MSN 621 Final Exam UPDATED QUESTIONS
AND CORRECT ANSWERS
A decrease in the forced expiratory volume in one second (FEV1) to forced vital capacity
(FVC) ratio is most likely to be seen in a patient with which of the following? - CORRECT
ANSWER Asthma
A middle-aged male presents to the emergency department with an exacerbation of his
chronic obstructive pulmonary disease (COPD). He has been coughing and been moderately
short of breath for the past 2 days. He says that his inhalers do work, but he ran out of
supplies. He complains of general malaise. After examining him, you decide to start him on
antibiotics. However, you first decide to send the sputum for gram stain and culture.
According to the 2015 Global Initiative for Chronic Obstructive Lung Disease report, which
of the following organisms is most likely to be involved in COPD exacerbation? - CORRECT
ANSWER Moraxella catarrhalis
A 65-year-old male is evaluated for worsening shortness of breath and a productive cough for
6 months. He is a current smoker with a 30-pack-year smoking history. His other medical
history includes hypertension and chronic kidney disease. On examination, his blood pressure
is 145/95 mmHg, pulse 88/min, and oxygen saturation of 92% on room air. He does not have
accessory muscle use. On lung auscultation, there is decreased air movement and prolonged
expiration. There are no wheezes detected. No S3 or S4 auscultated. There is no jugular vein
distention. He has no lower extremity edema and denies chest pain or calf tenderness. Chest
x-ray reveals bilateral hyperinflated lung fields. Which of the following is the next best step
in the diagnosis of this patient's condition? - CORRECT ANSWER Spirometry
A 65-year-old male patient presents to the hospital with the complaint of increasing shortness
of breath. His condition has been progressively worsening over the past six months. He is a
smoker and a bird keeper. He has one son and one daughter with asthma. On examination,
there is a wheeze and coarse end-inspiratory crackles in the chest. A chest radiograph reveals
diffuse non-specific changes consistent with lung disease. What investigation is most likely to
yield the diagnosis in this case? - CORRECT ANSWER Spirometry with reversibility
A 65-year-old male patient presents to the clinic with complaints of a dry cough and
wheezing, particularly at night. He has had asthma. Six months ago, his symptoms were well-
controlled on inhaled fomoterol and low dose budesonide twice a day and occasional use of
an albuterol inhaler as required. However, now he is more short of breath with morning
dipping of his peak flow readings. On examination, he is mildly dyspneic but able to
,complete sentences. On auscultation, there are wheezes scattered in his chest. His peak
expiratory flow rate is 70% of predicted. What is the most appropriate next step in the
management of this patient? - CORRECT ANSWER Inhaled budesonide dose
A patient with mild, persistent asthma has been well controlled with low-dose inhaled
corticosteroids. He presents for follow up complaining of some limitation with normal
activities and needing albuterol for symptom relief 3 to 4 days per week over the past month.
Which of the following is the preferred next step? - CORRECT ANSWER Medium
dose inhaled corticosteroid
A 37-year-old woman presents with complaints of intermittent dry cough and chest tightness
since she started a new job as a chambermaid at a hotel 5-weeks ago. Her symptoms are
worst at night. She does not have any rhinitis, postnasal drip, or history of allergic rhinitis.
She has never smoked and doe not take any medicine. On physical examination, the patient
appears comfortable and speaks full sentences without any problem. Oral and nasal mucosa
appears normal. On auscultation of lungs, wheeze is reported in the left lung. The chest x-ray
report comes out normal. Which of the following is the next best step in identifying the cause
of the patient's current symptoms? - CORRECT ANSWER Spirometry with pre and
post bronchodilator testing
A 40-year-old male patient comes in with a chief complaint of difficulty breathing. His
cardiac function test results are normal. He shows airway hyperresponsiveness to the
methacholine challenge test. His lung spirometry test reveals a lower-than-predicted level of
forced expiratory volume in the first second (FEV1). Based on the most likely diagnosis,
what is the most appropriate first-line therapy for a patient with infrequent episodes of mild
symptoms? - CORRECT ANSWER Albuterol alone
A 78-year-old male presents to the clinic with complaints of a cough that started three days
ago. The cough is associated with sputum, which is scanty in volume and yellow in color. He
also complains of mild headaches and a stuffy nose for the last two days. On further
questioning, he reveals that he has had two similar episodes previously, which subsided
within a week. A detailed medical history reveals that he was diagnosed with diabetes
mellitus twenty years ago and is on metformin. His vital signs show a blood pressure of
100/80 mmHg, a respiratory rate of 14/min, a heart rate of 88/min, and a temperature of 99 F
(37.1 C). Auscultation of the chest was performed, which reveals bilateral coarse rhonchi,
whereas a chest x-ray is normal. What is the most appropriate next step in the management of
his condition? - CORRECT ANSWER Abx and antitussives
,A 17-year-old male presents with a two-day history of fever, runny nose, and cough
productive of clear sputum. His past medical history is unremarkable, and he takes no
medication. His blood pressure is 110/70 mmHg, respiratory rate 16 breaths per minute, heart
rate 102 beats per minute, temperature 101.8 F (38.8 C), and oxygen saturation 98% on room
air. The lung examination demonstrates clear breath sounds bilaterally. In addition to an
antipyretic, what is the most appropriate treatment for this patient? - CORRECT
ANSWER Guaifensen
A 28-year-old male patient with a past medical history significant for asthma presents to the
primary care office for complaints of cough, shortness of breath for 24 hours duration. His
symptoms started abruptly and are progressively worsening. He denies fevers or chills and
has had no known exposure to sick contacts. Vital signs are within normal limits. Physical
examination is significant for mild expiratory wheezing. His asthma is well controlled, and he
has not used any inhalers for a few years. What is the next best step in the management of
this patient? - CORRECT ANSWER Prescribe albuterol
A 35-year-old female presents to the out-patient department with complaints of cough with
whitish sputum production for the past three months. She mentions that the cough worsens at
night. She has no other complaints. The patient mentions that she has tried chlorpheniramine
for a week, and no improvement was noted. She has a history of gastroesophageal reflux
disease, for which she takes famotidine. She has been smoking a pack of cigarettes a day for
the past seven years and drinks alcohol socially. Vitals show a blood pressure of 133/85 mm
Hg, pulse of 79/min, respiratory rate of 14/min, and temperature of 98.6 F (37 C). Pulmonary
examination reveals normal breath sounds bilaterally. A chest x-ray is normal. Which of the
following is the best next step in the management of the patient's condition? - CORRECT
ANSWER Pulm fxn tests
A 20-year-old man presents to the clinic with two months history of cough and right-sided
chest pain. On examination, his chest movement on the right side is diminished, the trachea is
shifted to the left, and a stony dull percussion note is present on the right side. His breath
sounds are impaired, and vocal fremitus is present. Which of the following is the most likely
diagnosis? - CORRECT ANSWER Right pleural effusion
A 62-year-old man presents with general malaise, occasional cough, and weight loss of 10 lbs
(4.5 kg) over the last two months. History is significant for prediabetes managed with diet
and cigarette smoking. Physical examination findings include mild edema in the extremities
and clubbing bilaterally. Blood work shows mild anemia and sodium of 122 mg/dL. What test
should be done next? - CORRECT ANSWER Chest radiograph
, A patient with chronic obstructive pulmonary disease (COPD) and chronic carbon dioxide
retention in a nursing home is wheezing. The oxygen saturation drops from 93 to 90. Which
of the following would be most appropriate? - CORRECT ANSWER Albuterol by neb
A 70-year-old man with severe chronic obstructive pulmonary disease (COPD) has had
multiple hospital admission for exacerbations. He is an ex-smoker of 40 pack years. He takes
budesonide/formoterol combination and tiotropium inhalers. He is up-to-date with his
Influenza and pneumococcal vaccine. What should be advised to decrease his COPD
exacerbations? - CORRECT ANSWER Start on roflumilast
A 65-year-old female is evaluated for shortness of breath with exertion and a chronic cough.
She is often unable to walk farther than 200 feet without stopping to catch her breath. She is a
current smoker with a 33-pack-year smoking history. She has no prior hospitalizations. On
physical examination, her vital signs are within normal limits at rest. Auscultation of her
lungs reveals bilateral expiratory wheezes. The remainder of her physical examination is
normal. Spirometry is performed and shows an FEV1 of 72% of predicted. Her post-
bronchodilator FEV1/FVC ratio is 60%. Her modified medical research council (mMRC)
dyspnea score is 3. She is counseled on smoking cessation. Which of the following is the
most appropriate pharmacological treatment for this patient? - CORRECT
ANSWER Short acting bronchodilator as needed and a long acting bronchodilator
A 56-year-old man with a past medical history of uncontrolled hypertension, poorly
controlled diabetes mellitus and hyperlipidemia presents with a 1-hour history of sudden
onset, sharp left shoulder pain. He states that the pain is exacerbated by deep breathing, and
coughing. The patient is diaphoretic. He does not take any medication except aspirin which
he took today when the chest pain began. On examination, his oxygen saturation is 99% on
room air, respiratory rate 20/minute, heart rate 88/min, and blood pressure 110/50 mmHg. A
chest x-ray is unremarkable. Which of the following is the next best step in the management
of this patient? - CORRECT ANSWER EKG
A 26-year-old woman G1P0000 at 24 weeks gestation presents to the clinic in October for
evaluation of cough, rhinorrhea, and subjective fever for 24 hours. The patient has no
significant past medical history and takes only a prenatal vitamin daily. Vital signs show oral
temperature 38 C (100.4 F), blood pressure 120/80 mmHg, pulse 90/minute, respirations
18/minute, and oxygen saturation 96% on room air. Physical exam reveals a mildly ill-
appearing gravid female in no acute distress with lung fields that are clear to auscultation
bilaterally. Continuous fetal monitoring is normal. Nasal swab ELISA is positive for
AND CORRECT ANSWERS
A decrease in the forced expiratory volume in one second (FEV1) to forced vital capacity
(FVC) ratio is most likely to be seen in a patient with which of the following? - CORRECT
ANSWER Asthma
A middle-aged male presents to the emergency department with an exacerbation of his
chronic obstructive pulmonary disease (COPD). He has been coughing and been moderately
short of breath for the past 2 days. He says that his inhalers do work, but he ran out of
supplies. He complains of general malaise. After examining him, you decide to start him on
antibiotics. However, you first decide to send the sputum for gram stain and culture.
According to the 2015 Global Initiative for Chronic Obstructive Lung Disease report, which
of the following organisms is most likely to be involved in COPD exacerbation? - CORRECT
ANSWER Moraxella catarrhalis
A 65-year-old male is evaluated for worsening shortness of breath and a productive cough for
6 months. He is a current smoker with a 30-pack-year smoking history. His other medical
history includes hypertension and chronic kidney disease. On examination, his blood pressure
is 145/95 mmHg, pulse 88/min, and oxygen saturation of 92% on room air. He does not have
accessory muscle use. On lung auscultation, there is decreased air movement and prolonged
expiration. There are no wheezes detected. No S3 or S4 auscultated. There is no jugular vein
distention. He has no lower extremity edema and denies chest pain or calf tenderness. Chest
x-ray reveals bilateral hyperinflated lung fields. Which of the following is the next best step
in the diagnosis of this patient's condition? - CORRECT ANSWER Spirometry
A 65-year-old male patient presents to the hospital with the complaint of increasing shortness
of breath. His condition has been progressively worsening over the past six months. He is a
smoker and a bird keeper. He has one son and one daughter with asthma. On examination,
there is a wheeze and coarse end-inspiratory crackles in the chest. A chest radiograph reveals
diffuse non-specific changes consistent with lung disease. What investigation is most likely to
yield the diagnosis in this case? - CORRECT ANSWER Spirometry with reversibility
A 65-year-old male patient presents to the clinic with complaints of a dry cough and
wheezing, particularly at night. He has had asthma. Six months ago, his symptoms were well-
controlled on inhaled fomoterol and low dose budesonide twice a day and occasional use of
an albuterol inhaler as required. However, now he is more short of breath with morning
dipping of his peak flow readings. On examination, he is mildly dyspneic but able to
,complete sentences. On auscultation, there are wheezes scattered in his chest. His peak
expiratory flow rate is 70% of predicted. What is the most appropriate next step in the
management of this patient? - CORRECT ANSWER Inhaled budesonide dose
A patient with mild, persistent asthma has been well controlled with low-dose inhaled
corticosteroids. He presents for follow up complaining of some limitation with normal
activities and needing albuterol for symptom relief 3 to 4 days per week over the past month.
Which of the following is the preferred next step? - CORRECT ANSWER Medium
dose inhaled corticosteroid
A 37-year-old woman presents with complaints of intermittent dry cough and chest tightness
since she started a new job as a chambermaid at a hotel 5-weeks ago. Her symptoms are
worst at night. She does not have any rhinitis, postnasal drip, or history of allergic rhinitis.
She has never smoked and doe not take any medicine. On physical examination, the patient
appears comfortable and speaks full sentences without any problem. Oral and nasal mucosa
appears normal. On auscultation of lungs, wheeze is reported in the left lung. The chest x-ray
report comes out normal. Which of the following is the next best step in identifying the cause
of the patient's current symptoms? - CORRECT ANSWER Spirometry with pre and
post bronchodilator testing
A 40-year-old male patient comes in with a chief complaint of difficulty breathing. His
cardiac function test results are normal. He shows airway hyperresponsiveness to the
methacholine challenge test. His lung spirometry test reveals a lower-than-predicted level of
forced expiratory volume in the first second (FEV1). Based on the most likely diagnosis,
what is the most appropriate first-line therapy for a patient with infrequent episodes of mild
symptoms? - CORRECT ANSWER Albuterol alone
A 78-year-old male presents to the clinic with complaints of a cough that started three days
ago. The cough is associated with sputum, which is scanty in volume and yellow in color. He
also complains of mild headaches and a stuffy nose for the last two days. On further
questioning, he reveals that he has had two similar episodes previously, which subsided
within a week. A detailed medical history reveals that he was diagnosed with diabetes
mellitus twenty years ago and is on metformin. His vital signs show a blood pressure of
100/80 mmHg, a respiratory rate of 14/min, a heart rate of 88/min, and a temperature of 99 F
(37.1 C). Auscultation of the chest was performed, which reveals bilateral coarse rhonchi,
whereas a chest x-ray is normal. What is the most appropriate next step in the management of
his condition? - CORRECT ANSWER Abx and antitussives
,A 17-year-old male presents with a two-day history of fever, runny nose, and cough
productive of clear sputum. His past medical history is unremarkable, and he takes no
medication. His blood pressure is 110/70 mmHg, respiratory rate 16 breaths per minute, heart
rate 102 beats per minute, temperature 101.8 F (38.8 C), and oxygen saturation 98% on room
air. The lung examination demonstrates clear breath sounds bilaterally. In addition to an
antipyretic, what is the most appropriate treatment for this patient? - CORRECT
ANSWER Guaifensen
A 28-year-old male patient with a past medical history significant for asthma presents to the
primary care office for complaints of cough, shortness of breath for 24 hours duration. His
symptoms started abruptly and are progressively worsening. He denies fevers or chills and
has had no known exposure to sick contacts. Vital signs are within normal limits. Physical
examination is significant for mild expiratory wheezing. His asthma is well controlled, and he
has not used any inhalers for a few years. What is the next best step in the management of
this patient? - CORRECT ANSWER Prescribe albuterol
A 35-year-old female presents to the out-patient department with complaints of cough with
whitish sputum production for the past three months. She mentions that the cough worsens at
night. She has no other complaints. The patient mentions that she has tried chlorpheniramine
for a week, and no improvement was noted. She has a history of gastroesophageal reflux
disease, for which she takes famotidine. She has been smoking a pack of cigarettes a day for
the past seven years and drinks alcohol socially. Vitals show a blood pressure of 133/85 mm
Hg, pulse of 79/min, respiratory rate of 14/min, and temperature of 98.6 F (37 C). Pulmonary
examination reveals normal breath sounds bilaterally. A chest x-ray is normal. Which of the
following is the best next step in the management of the patient's condition? - CORRECT
ANSWER Pulm fxn tests
A 20-year-old man presents to the clinic with two months history of cough and right-sided
chest pain. On examination, his chest movement on the right side is diminished, the trachea is
shifted to the left, and a stony dull percussion note is present on the right side. His breath
sounds are impaired, and vocal fremitus is present. Which of the following is the most likely
diagnosis? - CORRECT ANSWER Right pleural effusion
A 62-year-old man presents with general malaise, occasional cough, and weight loss of 10 lbs
(4.5 kg) over the last two months. History is significant for prediabetes managed with diet
and cigarette smoking. Physical examination findings include mild edema in the extremities
and clubbing bilaterally. Blood work shows mild anemia and sodium of 122 mg/dL. What test
should be done next? - CORRECT ANSWER Chest radiograph
, A patient with chronic obstructive pulmonary disease (COPD) and chronic carbon dioxide
retention in a nursing home is wheezing. The oxygen saturation drops from 93 to 90. Which
of the following would be most appropriate? - CORRECT ANSWER Albuterol by neb
A 70-year-old man with severe chronic obstructive pulmonary disease (COPD) has had
multiple hospital admission for exacerbations. He is an ex-smoker of 40 pack years. He takes
budesonide/formoterol combination and tiotropium inhalers. He is up-to-date with his
Influenza and pneumococcal vaccine. What should be advised to decrease his COPD
exacerbations? - CORRECT ANSWER Start on roflumilast
A 65-year-old female is evaluated for shortness of breath with exertion and a chronic cough.
She is often unable to walk farther than 200 feet without stopping to catch her breath. She is a
current smoker with a 33-pack-year smoking history. She has no prior hospitalizations. On
physical examination, her vital signs are within normal limits at rest. Auscultation of her
lungs reveals bilateral expiratory wheezes. The remainder of her physical examination is
normal. Spirometry is performed and shows an FEV1 of 72% of predicted. Her post-
bronchodilator FEV1/FVC ratio is 60%. Her modified medical research council (mMRC)
dyspnea score is 3. She is counseled on smoking cessation. Which of the following is the
most appropriate pharmacological treatment for this patient? - CORRECT
ANSWER Short acting bronchodilator as needed and a long acting bronchodilator
A 56-year-old man with a past medical history of uncontrolled hypertension, poorly
controlled diabetes mellitus and hyperlipidemia presents with a 1-hour history of sudden
onset, sharp left shoulder pain. He states that the pain is exacerbated by deep breathing, and
coughing. The patient is diaphoretic. He does not take any medication except aspirin which
he took today when the chest pain began. On examination, his oxygen saturation is 99% on
room air, respiratory rate 20/minute, heart rate 88/min, and blood pressure 110/50 mmHg. A
chest x-ray is unremarkable. Which of the following is the next best step in the management
of this patient? - CORRECT ANSWER EKG
A 26-year-old woman G1P0000 at 24 weeks gestation presents to the clinic in October for
evaluation of cough, rhinorrhea, and subjective fever for 24 hours. The patient has no
significant past medical history and takes only a prenatal vitamin daily. Vital signs show oral
temperature 38 C (100.4 F), blood pressure 120/80 mmHg, pulse 90/minute, respirations
18/minute, and oxygen saturation 96% on room air. Physical exam reveals a mildly ill-
appearing gravid female in no acute distress with lung fields that are clear to auscultation
bilaterally. Continuous fetal monitoring is normal. Nasal swab ELISA is positive for
