Barkley Emergency NP Comprehensive Review Exam | 100
Questions and Verified Answers 2026-2027
SECTION 1: ACUTE & CRITICAL CARE (Questions 1-30)
1. A 58-year-old male with a history of hypertension, type 2 diabetes, and a 40-
pack-year smoking history presents with 45 minutes of crushing substernal chest
pain radiating to his left shoulder, associated with diaphoresis and nausea. Vital
signs: BP 108/70, HR 52, RR 22, SpO₂ 94%. ECG reveals sinus bradycardia with 3
mm ST-segment elevations in leads II, III, and aVF, and 1 mm ST-segment
depression in leads I and aVL. Which is the MOST critical immediate next step?
A. Administer sublingual nitroglycerin 0.4 mg
B. Administer morphine sulfate 2-4 mg IV push
C. Administer a 600 mg loading dose of clopidogrel
D. Activate the cardiac catheterization laboratory for primary PCI
Answer: D
Rationale: This is an acute inferior STEMI. Primary PCI is the preferred reperfusion
strategy when it can be performed within 90-120 minutes. The presence of bradycardia
and borderline hypotension is a red flag for RV infarction, making nitroglycerin
potentially dangerous. Delaying reperfusion increases myocardial necrosis.
2. A 72-year-old female with HFpEF, hypertension, and atrial fibrillation on
rivaroxaban presents with acute dyspnea, orthopnea, and BP 210/120 mmHg.
Auscultation reveals an S3 gallop, bilateral crackles, and SpO₂ 82%. Which IV agent
is the MOST appropriate first-line therapy?
A. Sodium nitroprusside
B. Metoprolol
C. Nicardipine
D. Nitroglycerin
,Answer: D
Rationale: This is acute decompensated heart failure with pulmonary edema in a
hypertensive emergency. Nitroglycerin is a potent venodilator (reducing preload) and at
higher doses an arterial vasodilator (reducing afterload). Its rapid onset and titratability
make it ideal. Sodium nitroprusside can cause reflex tachycardia and cyanide toxicity.
3. A patient taking lisinopril arrives with sudden, asymmetrical swelling of the lips
and tongue. What biochemical mechanism causes this reaction?
A. Accumulation of bradykinin due to metabolic pathway inhibition
B. Direct IgE-mediated mast cell degranulation
C. Sudden loss of intravascular hydrostatic pressure
D. Complement activation
Answer: A
Rationale: ACE inhibitors prevent bradykinin breakdown. Excess bradykinin leads to
increased vascular permeability and angioedema. This is a medical emergency requiring
immediate airway assessment and ACE inhibitor discontinuation. This is not an IgE-
mediated reaction.
4. A 58-year-old patient with a history of MI has a current LDL of 95 mg/dL. What
is the appropriate clinical goal for secondary prevention?
A. Maintain current lifestyle modifications without drugs
B. Maximize high-intensity statin therapy to target LDL <55 mg/dL or at least 50%
reduction
C. Initiate low-intensity statin therapy daily
D. Target LDL <100 mg/dL
Answer: B
,Rationale: For secondary prevention in very high-risk ASCVD patients (history of MI),
aggressive lipid-lowering with high-intensity statins is required. Current guidelines
recommend LDL <55 mg/dL or at least 50% reduction from baseline.
5. A 55-year-old female presents with acute palpitations, dizziness, and SOB. ECG
shows narrow-complex tachycardia at 180 bpm with no visible P waves. BP is
100/70 mmHg. What is the most appropriate immediate management?
A. IV adenosine 6 mg rapid push
B. Synchronized cardioversion at 100 J
C. IV amiodarone 150 mg
D. Vagal maneuvers
Answer: A
Rationale: This is SVT presenting with narrow-complex tachycardia at 180 bpm.
Adenosine 6 mg IV rapid push is the first-line treatment for stable SVT.
6. A patient with HFrEF presents with worsening dyspnea, orthopnea, and 4+
pitting edema to the knees. Weight increased 8 pounds in 1 week. Current meds:
carvedilol, lisinopril, furosemide. What is the most appropriate initial adjustment?
A. Increase carvedilol to target dose
B. Increase lisinopril to maximum dose
C. Increase furosemide dose
D. Add spironolactone
Answer: C
Rationale: This patient is experiencing acute decompensated heart failure with
significant fluid overload. The initial intervention should be diuresis with increased loop
diuretic dose. GDMT adjustments should be made after decongestion.
7. Which medication could potentially exacerbate CHF in a susceptible individual?
, A. Naproxen
B. HCTZ
C. Lovastatin
D. Loratadine
Answer: A
Rationale: Naproxen is an NSAID. NSAIDs cause sodium and water retention, which can
exacerbate heart failure. This occurs through inhibition of prostaglandins that normally
promote renal vasodilation and sodium excretion.
8. An ACE inhibitor is specifically indicated in patients who have:
A. Hypertension, diabetes with proteinuria, heart failure
B. Hypertension only
C. Asthma and hypertension
D. Gout and hypertension
Answer: A
Rationale: ACE inhibitors are first-line therapy for hypertension, especially in patients
with diabetes with proteinuria (renal protective effects), and heart failure with reduced
ejection fraction (HFrEF) due to mortality benefit.
9. A child with septic shock has received three 20mL/kg fluid boluses and is now
on a norepinephrine drip. What is the NEXT appropriate intervention?
A. Initiate stress-dose hydrocortisone
B. Consider ECMO
C. Increase fluid boluses
D. Administer phenylephrine
Answer: A
Questions and Verified Answers 2026-2027
SECTION 1: ACUTE & CRITICAL CARE (Questions 1-30)
1. A 58-year-old male with a history of hypertension, type 2 diabetes, and a 40-
pack-year smoking history presents with 45 minutes of crushing substernal chest
pain radiating to his left shoulder, associated with diaphoresis and nausea. Vital
signs: BP 108/70, HR 52, RR 22, SpO₂ 94%. ECG reveals sinus bradycardia with 3
mm ST-segment elevations in leads II, III, and aVF, and 1 mm ST-segment
depression in leads I and aVL. Which is the MOST critical immediate next step?
A. Administer sublingual nitroglycerin 0.4 mg
B. Administer morphine sulfate 2-4 mg IV push
C. Administer a 600 mg loading dose of clopidogrel
D. Activate the cardiac catheterization laboratory for primary PCI
Answer: D
Rationale: This is an acute inferior STEMI. Primary PCI is the preferred reperfusion
strategy when it can be performed within 90-120 minutes. The presence of bradycardia
and borderline hypotension is a red flag for RV infarction, making nitroglycerin
potentially dangerous. Delaying reperfusion increases myocardial necrosis.
2. A 72-year-old female with HFpEF, hypertension, and atrial fibrillation on
rivaroxaban presents with acute dyspnea, orthopnea, and BP 210/120 mmHg.
Auscultation reveals an S3 gallop, bilateral crackles, and SpO₂ 82%. Which IV agent
is the MOST appropriate first-line therapy?
A. Sodium nitroprusside
B. Metoprolol
C. Nicardipine
D. Nitroglycerin
,Answer: D
Rationale: This is acute decompensated heart failure with pulmonary edema in a
hypertensive emergency. Nitroglycerin is a potent venodilator (reducing preload) and at
higher doses an arterial vasodilator (reducing afterload). Its rapid onset and titratability
make it ideal. Sodium nitroprusside can cause reflex tachycardia and cyanide toxicity.
3. A patient taking lisinopril arrives with sudden, asymmetrical swelling of the lips
and tongue. What biochemical mechanism causes this reaction?
A. Accumulation of bradykinin due to metabolic pathway inhibition
B. Direct IgE-mediated mast cell degranulation
C. Sudden loss of intravascular hydrostatic pressure
D. Complement activation
Answer: A
Rationale: ACE inhibitors prevent bradykinin breakdown. Excess bradykinin leads to
increased vascular permeability and angioedema. This is a medical emergency requiring
immediate airway assessment and ACE inhibitor discontinuation. This is not an IgE-
mediated reaction.
4. A 58-year-old patient with a history of MI has a current LDL of 95 mg/dL. What
is the appropriate clinical goal for secondary prevention?
A. Maintain current lifestyle modifications without drugs
B. Maximize high-intensity statin therapy to target LDL <55 mg/dL or at least 50%
reduction
C. Initiate low-intensity statin therapy daily
D. Target LDL <100 mg/dL
Answer: B
,Rationale: For secondary prevention in very high-risk ASCVD patients (history of MI),
aggressive lipid-lowering with high-intensity statins is required. Current guidelines
recommend LDL <55 mg/dL or at least 50% reduction from baseline.
5. A 55-year-old female presents with acute palpitations, dizziness, and SOB. ECG
shows narrow-complex tachycardia at 180 bpm with no visible P waves. BP is
100/70 mmHg. What is the most appropriate immediate management?
A. IV adenosine 6 mg rapid push
B. Synchronized cardioversion at 100 J
C. IV amiodarone 150 mg
D. Vagal maneuvers
Answer: A
Rationale: This is SVT presenting with narrow-complex tachycardia at 180 bpm.
Adenosine 6 mg IV rapid push is the first-line treatment for stable SVT.
6. A patient with HFrEF presents with worsening dyspnea, orthopnea, and 4+
pitting edema to the knees. Weight increased 8 pounds in 1 week. Current meds:
carvedilol, lisinopril, furosemide. What is the most appropriate initial adjustment?
A. Increase carvedilol to target dose
B. Increase lisinopril to maximum dose
C. Increase furosemide dose
D. Add spironolactone
Answer: C
Rationale: This patient is experiencing acute decompensated heart failure with
significant fluid overload. The initial intervention should be diuresis with increased loop
diuretic dose. GDMT adjustments should be made after decongestion.
7. Which medication could potentially exacerbate CHF in a susceptible individual?
, A. Naproxen
B. HCTZ
C. Lovastatin
D. Loratadine
Answer: A
Rationale: Naproxen is an NSAID. NSAIDs cause sodium and water retention, which can
exacerbate heart failure. This occurs through inhibition of prostaglandins that normally
promote renal vasodilation and sodium excretion.
8. An ACE inhibitor is specifically indicated in patients who have:
A. Hypertension, diabetes with proteinuria, heart failure
B. Hypertension only
C. Asthma and hypertension
D. Gout and hypertension
Answer: A
Rationale: ACE inhibitors are first-line therapy for hypertension, especially in patients
with diabetes with proteinuria (renal protective effects), and heart failure with reduced
ejection fraction (HFrEF) due to mortality benefit.
9. A child with septic shock has received three 20mL/kg fluid boluses and is now
on a norepinephrine drip. What is the NEXT appropriate intervention?
A. Initiate stress-dose hydrocortisone
B. Consider ECMO
C. Increase fluid boluses
D. Administer phenylephrine
Answer: A
