BARKLEY ENP-C DIAGNOSTIC READINESS TEST (DRT) #3
100 Practice Questions with Detailed Rationales
1. A 68-year-old man presents with acute-onset tearing chest pain
radiating to the back. Blood pressure is 170/95 mmHg in the right
arm and 135/80 mmHg in the left arm. Chest X-ray shows a widened
mediastinum. What is the most likely diagnosis?
A) Acute myocardial infarction
B) Aortic dissection
C) Pulmonary embolism
D) Tension pneumothorax
Correct Answer: B) Aortic dissection
Explanation: The classic presentation of aortic dissection is sudden,
severe "tearing" or "ripping" chest pain, often radiating to the back.
A difference in systolic blood pressure >15–20 mmHg between arms
is a key physical finding. Widened mediastinum on chest X-ray
supports the diagnosis. This is a surgical emergency requiring
immediate blood pressure control and vascular surgery
consultation. Acute MI typically has crushing chest pain with ST-
segment changes; pulmonary embolism causes dyspnea and
tachycardia; tension pneumothorax causes tracheal deviation and
absent breath sounds.
,2. A 55-year-old male with a history of hypertension and
dyslipidemia presents with substernal chest pressure, diaphoresis,
and nausea. ECG shows ST-segment elevation of 3 mm in leads II, III,
and aVF. Which coronary artery is most likely occluded?
A) Left anterior descending (LAD)
B) Left circumflex (LCx)
C) Right coronary artery (RCA)
D) Left main coronary artery
Correct Answer: C) Right coronary artery (RCA)
Explanation: ST-segment elevation in leads II, III, and aVF indicates an
inferior wall myocardial infarction. The inferior wall is typically
supplied by the right coronary artery (RCA) in the majority of
patients (right-dominant circulation). The LAD supplies the anterior
wall and septum (V1–V4). The LCx supplies the lateral wall (I, aVL,
V5–V6). Left main occlusion would cause widespread ischemia and
often fatal arrhythmias.
3. A patient with an acute STEMI is being prepared for percutaneous
coronary intervention (PCI). The nurse practitioner is reviewing the
medications. Which antiplatelet agent is most critical to administer
as a loading dose prior to PCI?
A) Aspirin 81 mg
B) Clopidogrel 600 mg or ticagrelor 180 mg (P2Y12 inhibitor)
C) Warfarin
D) Heparin only
,Correct Answer: B) Clopidogrel 600 mg or ticagrelor 180 mg (P2Y12
inhibitor)
Explanation: Dual antiplatelet therapy (DAPT) with aspirin and a
P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) is essential
before and after PCI to prevent stent thrombosis. A loading dose of
a P2Y12 inhibitor is given as soon as possible. Aspirin 324 mg
(chewed) is also given, but the P2Y12 inhibitor is the specific loading
dose question. Unfractionated heparin or bivalirudin is used for
anticoagulation during the procedure.
4. A 70-year-old female with atrial fibrillation on warfarin presents
with acute-onset left-sided weakness, facial droop, and aphasia.
Onset was 2 hours ago. CT head is negative for hemorrhage. INR is
2.8. Can she receive IV alteplase?
A) Yes, because CT is negative
B) No, because INR >1.7 is a contraindication to thrombolysis
C) Yes, after reversing warfarin with vitamin K and PCC
D) Only if she has a large vessel occlusion
Correct Answer: B) No, because INR >1.7 is a contraindication to
thrombolysis
Explanation: Current guidelines list INR >1.7 as a contraindication to
IV alteplase for acute ischemic stroke. Even though the CT is
negative for hemorrhage, the elevated INR increases the risk of
hemorrhagic transformation. Reversal could be considered, but
would delay treatment beyond the window. Mechanical
, thrombectomy may be an option if a large vessel occlusion is
present.
5. A 62-year-old male with heart failure with reduced ejection
fraction (HFrEF) presents with worsening dyspnea, orthopnea, and
bilateral lower extremity edema. He is on lisinopril, carvedilol, and
furosemide. Vital signs: BP 100/60, HR 90, SpO2 92%. On exam, JVD
is present and crackles are heard in the bases. Which of the
following additional therapies has a mortality benefit?
A) Digoxin
B) Spironolactone
C) Amlodipine
D) Isosorbide dinitrate/hydralazine
Correct Answer: B) Spironolactone
Explanation: Mineralocorticoid receptor antagonists
(spironolactone, eplerenone) have been shown to reduce mortality
and heart failure hospitalizations in patients with HFrEF (LVEF ≤35%)
who are already on standard therapy. The RALES trial demonstrated
a 30% reduction in mortality with spironolactone. Digoxin reduces
hospitalizations but not mortality. Amlodipine is safe but does not
improve mortality. Isosorbide dinitrate/hydralazine is an alternative
for patients who cannot tolerate ACEi/ARBs, but spironolactone is
the best answer here.
6. A patient with acute decompensated heart failure is placed on
nitroglycerin infusion. The nurse practitioner understands that the
100 Practice Questions with Detailed Rationales
1. A 68-year-old man presents with acute-onset tearing chest pain
radiating to the back. Blood pressure is 170/95 mmHg in the right
arm and 135/80 mmHg in the left arm. Chest X-ray shows a widened
mediastinum. What is the most likely diagnosis?
A) Acute myocardial infarction
B) Aortic dissection
C) Pulmonary embolism
D) Tension pneumothorax
Correct Answer: B) Aortic dissection
Explanation: The classic presentation of aortic dissection is sudden,
severe "tearing" or "ripping" chest pain, often radiating to the back.
A difference in systolic blood pressure >15–20 mmHg between arms
is a key physical finding. Widened mediastinum on chest X-ray
supports the diagnosis. This is a surgical emergency requiring
immediate blood pressure control and vascular surgery
consultation. Acute MI typically has crushing chest pain with ST-
segment changes; pulmonary embolism causes dyspnea and
tachycardia; tension pneumothorax causes tracheal deviation and
absent breath sounds.
,2. A 55-year-old male with a history of hypertension and
dyslipidemia presents with substernal chest pressure, diaphoresis,
and nausea. ECG shows ST-segment elevation of 3 mm in leads II, III,
and aVF. Which coronary artery is most likely occluded?
A) Left anterior descending (LAD)
B) Left circumflex (LCx)
C) Right coronary artery (RCA)
D) Left main coronary artery
Correct Answer: C) Right coronary artery (RCA)
Explanation: ST-segment elevation in leads II, III, and aVF indicates an
inferior wall myocardial infarction. The inferior wall is typically
supplied by the right coronary artery (RCA) in the majority of
patients (right-dominant circulation). The LAD supplies the anterior
wall and septum (V1–V4). The LCx supplies the lateral wall (I, aVL,
V5–V6). Left main occlusion would cause widespread ischemia and
often fatal arrhythmias.
3. A patient with an acute STEMI is being prepared for percutaneous
coronary intervention (PCI). The nurse practitioner is reviewing the
medications. Which antiplatelet agent is most critical to administer
as a loading dose prior to PCI?
A) Aspirin 81 mg
B) Clopidogrel 600 mg or ticagrelor 180 mg (P2Y12 inhibitor)
C) Warfarin
D) Heparin only
,Correct Answer: B) Clopidogrel 600 mg or ticagrelor 180 mg (P2Y12
inhibitor)
Explanation: Dual antiplatelet therapy (DAPT) with aspirin and a
P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) is essential
before and after PCI to prevent stent thrombosis. A loading dose of
a P2Y12 inhibitor is given as soon as possible. Aspirin 324 mg
(chewed) is also given, but the P2Y12 inhibitor is the specific loading
dose question. Unfractionated heparin or bivalirudin is used for
anticoagulation during the procedure.
4. A 70-year-old female with atrial fibrillation on warfarin presents
with acute-onset left-sided weakness, facial droop, and aphasia.
Onset was 2 hours ago. CT head is negative for hemorrhage. INR is
2.8. Can she receive IV alteplase?
A) Yes, because CT is negative
B) No, because INR >1.7 is a contraindication to thrombolysis
C) Yes, after reversing warfarin with vitamin K and PCC
D) Only if she has a large vessel occlusion
Correct Answer: B) No, because INR >1.7 is a contraindication to
thrombolysis
Explanation: Current guidelines list INR >1.7 as a contraindication to
IV alteplase for acute ischemic stroke. Even though the CT is
negative for hemorrhage, the elevated INR increases the risk of
hemorrhagic transformation. Reversal could be considered, but
would delay treatment beyond the window. Mechanical
, thrombectomy may be an option if a large vessel occlusion is
present.
5. A 62-year-old male with heart failure with reduced ejection
fraction (HFrEF) presents with worsening dyspnea, orthopnea, and
bilateral lower extremity edema. He is on lisinopril, carvedilol, and
furosemide. Vital signs: BP 100/60, HR 90, SpO2 92%. On exam, JVD
is present and crackles are heard in the bases. Which of the
following additional therapies has a mortality benefit?
A) Digoxin
B) Spironolactone
C) Amlodipine
D) Isosorbide dinitrate/hydralazine
Correct Answer: B) Spironolactone
Explanation: Mineralocorticoid receptor antagonists
(spironolactone, eplerenone) have been shown to reduce mortality
and heart failure hospitalizations in patients with HFrEF (LVEF ≤35%)
who are already on standard therapy. The RALES trial demonstrated
a 30% reduction in mortality with spironolactone. Digoxin reduces
hospitalizations but not mortality. Amlodipine is safe but does not
improve mortality. Isosorbide dinitrate/hydralazine is an alternative
for patients who cannot tolerate ACEi/ARBs, but spironolactone is
the best answer here.
6. A patient with acute decompensated heart failure is placed on
nitroglycerin infusion. The nurse practitioner understands that the
