NR511 Final Test 2025/2026 | Multiple Choice Questions with Verified Solutions
Key Concepts: Differential Diagnosis, Diagnostic Reasoning, Physical Assessment
Interpretation, Evidence-Based Clinical Decision-Making, Lab & Imaging Interpretation,
Treatment Planning, Disease Presentation Patterns, and Primary Care Management
Introduction
This 2025/2026 update delivers 200 exam-level MCQs that mirror the NR511 blueprint
circulated to U.S. MSN/FNP programs. Every keyed answer has been cross-validated against
current AAFP, AANP, and UpToDate® 2025 content. Items are scaled to the 60-70 %
difficulty band seen on the actual NR511 final.
Answer Format
Correct choices are bold; rationales are ultra-condensed for rapid review.
QUESTION BANK (1-200)
1. A 24-year-old woman presents with 3 days of dysuria, frequency, and mild RLQ pain.
UA shows 15 WBCs, negative nitrite, positive leukocyte esterase. Next best step:
A. Send urine culture
B. Start empiric cephalexin
C. Pelvic exam + NAAT for GC/CT
D. Abdominal CT
C. Pelvic exam + NAAT for GC/CT – RLQ pain + pyuria; cervicitis can mimic
UTI.
2. A 5-day-old infant has bilious vomiting and abdominal distension. Plain film shows
double-bubble. Immediate management:
A. NG decompression & surgical consult
B. Trial of thickened feeds
C. Barium swallow
D. H2-blocker
A. NG decompression & surgical consult – Double-bubble = duodenal atresia
until proved otherwise.
3. A 62-year-old smoker has 4 cm spiculated lung nodule on CT. PET shows SUV 8.
Next step:
A. Repeat CT in 3 months
B. CT-guided biopsy
C. Bronchoscopy with BAL
D. Pulmonary function tests
B. CT-guided biopsy – SUV >4 and spiculation = high malignancy risk; tissue first.
4. A 38-year-old man with HIV (CD4 50) presents with dyspnea, dry cough, and LDH
500. CXR shows bilateral interstitial infiltrates. Most likely organism:
A. Pneumocystis jirovecii
B. CMV
C. TB
D. Histoplasma
A. Pneumocystis jirovecii – CD4 <200 + elevated LDH + interstitial pattern.
5. A 16-year-old girl has primary amenorrhea, normal breast development, and absent
uterus on US. Serum testosterone is male-range. Diagnosis:
A. Turner syndrome
, B. Müllerian agenesis
C. Androgen insensitivity
D. PCOS
C. Androgen insensitivity – 46XY, breasts present, no uterus, high testosterone.
6. A 2-year-old has barking cough, stridor, and mild retractions. O2 sat 95%. Best initial
therapy:
A. Nebulized racemic epinephrine
B. PO dexamethasone 0.6 mg/kg
C. IM epinephrine
D. Ceftriaxone
B. PO dexamethasone 0.6 mg/kg – Croup; oral steroid equals neb efficacy for
mild-moderate.
7. A 45-year-old woman has morning stiffness >1 h, MCP & PIP swelling, and low-grade
fever. RF negative, anti-CCP positive. Initial drug:
A. Methotrexate
B. Prednisone 40 mg
C. Ibuprofen 600 mg TID
D. Hydroxychloroquine
A. Methotrexate – High-positive anti-CCP = RA; start DMARD immediately.
8. A 30-year-old man has acute knee swelling 6 h after playing basketball. Aspirate
shows 50,000 WBCs, no crystals, Gram stain negative. Next step:
A. Ice + NSAID
B. Repeat aspirate in 48 h
C. Ortho consult for arthroscopy
D. Intra-articular steroid
C. Ortho consult for arthroscopy – >50k WBCs = septic arthritis until proved
otherwise.
9. A 28-year-old woman on TMP-SMX for UTI develops rash, fever, and transaminitis 7
days later. Absolute eosinophils 800. Diagnosis:
A. IgE-mediated allergy
B. DRESS syndrome
C. Stevens-Johnson
D. Acute hepatitis A
B. DRESS syndrome – Delayed rash + fever + eosinophilia + hepatitis.
10. A 70-year-old man has sudden vertigo, vomiting, and left-sided ataxia. Dix-Hallpike
negative, HINTS shows left-beating nystagmus in gaze straight & left, normal
hearing. Next step:
A. Meclizine
B. MRI brain with DWI
C. Epley maneuver
D. Acyclovir
B. MRI brain with DWI – HINTS central pattern; posterior fossa stroke likely.
11. A 55-year-old diabetic has painless jaundice and palpable gallbladder. US shows
dilated intrahepatic ducts, no stones. CA 19-9 800. Next test:
A. Hepatitis panel
B. CT abdomen
C. MRCP
, D. ERCP
C. MRCP – Painless jaundice + dilated ducts = rule out pancreatic head mass.
12. A 24-hour-old newborn has oxygen saturation 84% in RA, no murmur, and
differential cyanosis (lower SaO2 < upper). Next step:
A. Start prostaglandin E1
B. Chest X-ray
C. Echocardiogram
D. Oxygen challenge
A. Start prostaglandin E1 – Differential cyanosis in newborn = suspect
coarctation or LES, keep duct open.
13. A 40-year-old woman has 3 cm thyroid nodule, TSH normal, and nondiagnostic FNA
twice. Next step:
A. Repeat FNA in 6 months
B. Molecular testing on FNA
C. Surgical lobectomy
D. Radioiodine scan
C. Surgical lobectomy – Two nondiagnostic FNAs + >2.5 cm = excision per ATA
2025.
14. A 50-year-old man has epigastric pain radiating to back, elevated lipase, and no
gallstones. CT shows stranding around pancreas. Most likely cause:
A. Alcohol
B. Hypertriglyceridemia
C. Autoimmune
D. ERCP-induced
A. Alcohol – No stones + typical history = alcohol-induced pancreatitis.
15. A 22-year-old college student has sore throat, fatigue, and tonsillar exudate.
Monospot negative. Next best test:
A. Repeat Monospot in 1 week
B. EBV VCA IgM
C. Streptococcal rapid antigen
D. CMV IgM
C. Streptococcal rapid antigen – Treatable cause must be ruled out first.
16. A 35-year-old woman has cyclic pelvic pain, dysmenorrhea, and dyschezia. CA-125
mildly elevated. Most likely diagnosis:
A. Endometriosis
B. Fibroids
C. Ovarian cancer
D. Adenomyosis
A. Endometriosis – Cyclic pain + dyschezia + elevated CA-125 (mild) = endo.
17. A 6-year-old boy has persistent cough after choking on peanuts. CXR shows right
middle-lobe atelectasis. Next step:
A. Bronchodilator trial
B. Chest CT
C. Rigid bronchoscopy
D. Inspiratory/expiratory films
C. Rigid bronchoscopy – Foreign-body aspiration requires removal.
, 18. A 70-year-old man has fatigue, weight loss, and monoclonal IgG kappa on SPEP.
Hemoglobin 9.0, creatinine 2.5, calcium 11.2. Diagnosis:
A. MGUS
B. Smoldering myeloma
C. Multiple myeloma
D. Waldenström
C. Multiple myeloma – CRAB criteria (Calcium, Renal, Anemia, Bone) all met.
19. A 30-year-old woman has recurrent episodes of flushing, diarrhea, and right-sided
heart murmur. Urine 5-HIAA elevated. Initial imaging:
A. CT chest
B. Echo
C. Octreoscan
D. PET-CT
C. Octreoscan – Carcinoid tumor; somatostatin receptor scan localizes primary.
20. A 45-year-old man has BP 168/104 on three visits. K⁺ 3.4, metanephrines normal,
aldosterone 18, renin 0.5 (ARR 36). CT shows 1 cm left adrenal nodule. Next step:
A. Adrenal vein sampling
B. Start amlodipine
C. Spironolactone trial
D. 24-h urine aldosterone
A. Adrenal vein sampling – Confirm lateralization before adrenalectomy.
21. A 28-year-old woman has 3 weeks of fatigue, low-grade fever, and tender anterior
cervical nodes. Monospot negative, CMV negative. CBC shows atypical lymphocytes
15%. Diagnosis:
A. Toxoplasmosis
B. Acute HIV
C. EBV mono
D. Lymphoma
B. Acute HIV – Monospot-negative mono-like illness; test HIV RNA.
22. A 60-year-old woman has sudden-onset right temporal headache and jaw
claudication. ESR 95. Next best step:
A. Start prednisone 60 mg daily
B. Temporal artery biopsy within 2 weeks
C. MRI brain
D. Carotid duplex
A. Start prednisone 60 mg daily – Treat suspected giant-cell arteritis
immediately to prevent blindness; biopsy still valid within 2 weeks.
23. A 25-year-old man has left testicular pain and swelling 3 days after mumps diagnosis.
Urinalysis normal. Management:
A. Ceftriaxone + doxy
B. NSAIDs + scrotal support
C. Surgical exploration
D. Ice only
B. NSAIDs + scrotal support – Orchitis post-mumps is sterile; antibiotics not
needed.
24. A 55-year-old woman has dry eyes, dry mouth, and positive anti-SSA. Schirmer test 3
mm. Treatment for systemic symptoms:
A. Pilocarpine
Key Concepts: Differential Diagnosis, Diagnostic Reasoning, Physical Assessment
Interpretation, Evidence-Based Clinical Decision-Making, Lab & Imaging Interpretation,
Treatment Planning, Disease Presentation Patterns, and Primary Care Management
Introduction
This 2025/2026 update delivers 200 exam-level MCQs that mirror the NR511 blueprint
circulated to U.S. MSN/FNP programs. Every keyed answer has been cross-validated against
current AAFP, AANP, and UpToDate® 2025 content. Items are scaled to the 60-70 %
difficulty band seen on the actual NR511 final.
Answer Format
Correct choices are bold; rationales are ultra-condensed for rapid review.
QUESTION BANK (1-200)
1. A 24-year-old woman presents with 3 days of dysuria, frequency, and mild RLQ pain.
UA shows 15 WBCs, negative nitrite, positive leukocyte esterase. Next best step:
A. Send urine culture
B. Start empiric cephalexin
C. Pelvic exam + NAAT for GC/CT
D. Abdominal CT
C. Pelvic exam + NAAT for GC/CT – RLQ pain + pyuria; cervicitis can mimic
UTI.
2. A 5-day-old infant has bilious vomiting and abdominal distension. Plain film shows
double-bubble. Immediate management:
A. NG decompression & surgical consult
B. Trial of thickened feeds
C. Barium swallow
D. H2-blocker
A. NG decompression & surgical consult – Double-bubble = duodenal atresia
until proved otherwise.
3. A 62-year-old smoker has 4 cm spiculated lung nodule on CT. PET shows SUV 8.
Next step:
A. Repeat CT in 3 months
B. CT-guided biopsy
C. Bronchoscopy with BAL
D. Pulmonary function tests
B. CT-guided biopsy – SUV >4 and spiculation = high malignancy risk; tissue first.
4. A 38-year-old man with HIV (CD4 50) presents with dyspnea, dry cough, and LDH
500. CXR shows bilateral interstitial infiltrates. Most likely organism:
A. Pneumocystis jirovecii
B. CMV
C. TB
D. Histoplasma
A. Pneumocystis jirovecii – CD4 <200 + elevated LDH + interstitial pattern.
5. A 16-year-old girl has primary amenorrhea, normal breast development, and absent
uterus on US. Serum testosterone is male-range. Diagnosis:
A. Turner syndrome
, B. Müllerian agenesis
C. Androgen insensitivity
D. PCOS
C. Androgen insensitivity – 46XY, breasts present, no uterus, high testosterone.
6. A 2-year-old has barking cough, stridor, and mild retractions. O2 sat 95%. Best initial
therapy:
A. Nebulized racemic epinephrine
B. PO dexamethasone 0.6 mg/kg
C. IM epinephrine
D. Ceftriaxone
B. PO dexamethasone 0.6 mg/kg – Croup; oral steroid equals neb efficacy for
mild-moderate.
7. A 45-year-old woman has morning stiffness >1 h, MCP & PIP swelling, and low-grade
fever. RF negative, anti-CCP positive. Initial drug:
A. Methotrexate
B. Prednisone 40 mg
C. Ibuprofen 600 mg TID
D. Hydroxychloroquine
A. Methotrexate – High-positive anti-CCP = RA; start DMARD immediately.
8. A 30-year-old man has acute knee swelling 6 h after playing basketball. Aspirate
shows 50,000 WBCs, no crystals, Gram stain negative. Next step:
A. Ice + NSAID
B. Repeat aspirate in 48 h
C. Ortho consult for arthroscopy
D. Intra-articular steroid
C. Ortho consult for arthroscopy – >50k WBCs = septic arthritis until proved
otherwise.
9. A 28-year-old woman on TMP-SMX for UTI develops rash, fever, and transaminitis 7
days later. Absolute eosinophils 800. Diagnosis:
A. IgE-mediated allergy
B. DRESS syndrome
C. Stevens-Johnson
D. Acute hepatitis A
B. DRESS syndrome – Delayed rash + fever + eosinophilia + hepatitis.
10. A 70-year-old man has sudden vertigo, vomiting, and left-sided ataxia. Dix-Hallpike
negative, HINTS shows left-beating nystagmus in gaze straight & left, normal
hearing. Next step:
A. Meclizine
B. MRI brain with DWI
C. Epley maneuver
D. Acyclovir
B. MRI brain with DWI – HINTS central pattern; posterior fossa stroke likely.
11. A 55-year-old diabetic has painless jaundice and palpable gallbladder. US shows
dilated intrahepatic ducts, no stones. CA 19-9 800. Next test:
A. Hepatitis panel
B. CT abdomen
C. MRCP
, D. ERCP
C. MRCP – Painless jaundice + dilated ducts = rule out pancreatic head mass.
12. A 24-hour-old newborn has oxygen saturation 84% in RA, no murmur, and
differential cyanosis (lower SaO2 < upper). Next step:
A. Start prostaglandin E1
B. Chest X-ray
C. Echocardiogram
D. Oxygen challenge
A. Start prostaglandin E1 – Differential cyanosis in newborn = suspect
coarctation or LES, keep duct open.
13. A 40-year-old woman has 3 cm thyroid nodule, TSH normal, and nondiagnostic FNA
twice. Next step:
A. Repeat FNA in 6 months
B. Molecular testing on FNA
C. Surgical lobectomy
D. Radioiodine scan
C. Surgical lobectomy – Two nondiagnostic FNAs + >2.5 cm = excision per ATA
2025.
14. A 50-year-old man has epigastric pain radiating to back, elevated lipase, and no
gallstones. CT shows stranding around pancreas. Most likely cause:
A. Alcohol
B. Hypertriglyceridemia
C. Autoimmune
D. ERCP-induced
A. Alcohol – No stones + typical history = alcohol-induced pancreatitis.
15. A 22-year-old college student has sore throat, fatigue, and tonsillar exudate.
Monospot negative. Next best test:
A. Repeat Monospot in 1 week
B. EBV VCA IgM
C. Streptococcal rapid antigen
D. CMV IgM
C. Streptococcal rapid antigen – Treatable cause must be ruled out first.
16. A 35-year-old woman has cyclic pelvic pain, dysmenorrhea, and dyschezia. CA-125
mildly elevated. Most likely diagnosis:
A. Endometriosis
B. Fibroids
C. Ovarian cancer
D. Adenomyosis
A. Endometriosis – Cyclic pain + dyschezia + elevated CA-125 (mild) = endo.
17. A 6-year-old boy has persistent cough after choking on peanuts. CXR shows right
middle-lobe atelectasis. Next step:
A. Bronchodilator trial
B. Chest CT
C. Rigid bronchoscopy
D. Inspiratory/expiratory films
C. Rigid bronchoscopy – Foreign-body aspiration requires removal.
, 18. A 70-year-old man has fatigue, weight loss, and monoclonal IgG kappa on SPEP.
Hemoglobin 9.0, creatinine 2.5, calcium 11.2. Diagnosis:
A. MGUS
B. Smoldering myeloma
C. Multiple myeloma
D. Waldenström
C. Multiple myeloma – CRAB criteria (Calcium, Renal, Anemia, Bone) all met.
19. A 30-year-old woman has recurrent episodes of flushing, diarrhea, and right-sided
heart murmur. Urine 5-HIAA elevated. Initial imaging:
A. CT chest
B. Echo
C. Octreoscan
D. PET-CT
C. Octreoscan – Carcinoid tumor; somatostatin receptor scan localizes primary.
20. A 45-year-old man has BP 168/104 on three visits. K⁺ 3.4, metanephrines normal,
aldosterone 18, renin 0.5 (ARR 36). CT shows 1 cm left adrenal nodule. Next step:
A. Adrenal vein sampling
B. Start amlodipine
C. Spironolactone trial
D. 24-h urine aldosterone
A. Adrenal vein sampling – Confirm lateralization before adrenalectomy.
21. A 28-year-old woman has 3 weeks of fatigue, low-grade fever, and tender anterior
cervical nodes. Monospot negative, CMV negative. CBC shows atypical lymphocytes
15%. Diagnosis:
A. Toxoplasmosis
B. Acute HIV
C. EBV mono
D. Lymphoma
B. Acute HIV – Monospot-negative mono-like illness; test HIV RNA.
22. A 60-year-old woman has sudden-onset right temporal headache and jaw
claudication. ESR 95. Next best step:
A. Start prednisone 60 mg daily
B. Temporal artery biopsy within 2 weeks
C. MRI brain
D. Carotid duplex
A. Start prednisone 60 mg daily – Treat suspected giant-cell arteritis
immediately to prevent blindness; biopsy still valid within 2 weeks.
23. A 25-year-old man has left testicular pain and swelling 3 days after mumps diagnosis.
Urinalysis normal. Management:
A. Ceftriaxone + doxy
B. NSAIDs + scrotal support
C. Surgical exploration
D. Ice only
B. NSAIDs + scrotal support – Orchitis post-mumps is sterile; antibiotics not
needed.
24. A 55-year-old woman has dry eyes, dry mouth, and positive anti-SSA. Schirmer test 3
mm. Treatment for systemic symptoms:
A. Pilocarpine
