NURS 5434 FNP III Final Exam – Family Nurse
Practitioner 2026 Updated NCLEX-Style
Questions | Answers & Rationales
1. A 45-year-old female presents with fatigue, weight gain, cold intolerance, and
constipation. Thyroid-stimulating hormone (TSH) is 12.5 mIU/mL (normal 0.4–4.0).
What is the most appropriate initial treatment?
A. Methimazole 10 mg daily
B. Levothyroxine 1.6 mcg/kg/day
C. Radioactive iodine ablation
D. Levothyroxine 50 mcg daily with gradual titration
Answer: D
Rationale: This patient has hypothyroidism. Levothyroxine should be started at a low
dose (25–50 mcg) in older adults or those with cardiac history, then titrated. Younger
healthy adults may start at 1.6 mcg/kg. Methimazole is for hyperthyroidism.
2. A 60-year-old male with type 2 diabetes has a BP of 145/90 mmHg and urine albumin-
to-creatinine ratio of 80 mg/g. Which antihypertensive is preferred?
A. Hydrochlorothiazide
B. Amlodipine
C. Lisinopril
D. Metoprolol
Answer: C
Rationale: ACE inhibitors (lisinopril) are preferred in diabetics with albuminuria for renal
protection. They slow progression of diabetic nephropathy.
3. A 32-year-old pregnant woman at 28 weeks gestation presents with headache, blurred
vision, and BP 160/100 mmHg. Urine dipstick shows 3+ protein. What is the most
appropriate next step?
A. Prescribe labetalol and send home
B. Admit for magnesium sulfate and fetal monitoring
C. Prescribe methyldopa and follow up in 1 week
D. Recommend bed rest at home
,Answer: B
Rationale: This is severe preeclampsia (BP ≥160/110 with proteinuria). Requires hospital
admission for magnesium sulfate seizure prophylaxis and fetal monitoring.
4. A 55-year-old male presents with acute onset of tearing chest pain radiating to the
back. BP is 180/100 mmHg in the right arm and 140/80 mmHg in the left arm. What is the
most likely diagnosis?
A. Myocardial infarction
B. Pulmonary embolism
C. Aortic dissection
D. Pericarditis
Answer: C
Rationale: Aortic dissection presents with tearing chest pain radiating to the back and
asymmetric blood pressures between arms. Requires immediate imaging (CT
angiography).
5. A 70-year-old female with osteoporosis is started on alendronate. Which instruction is
most important?
A. Take with food to prevent nausea
B. Take on an empty stomach with a full glass of water and remain upright for 30 minutes
C. Take at bedtime with a small snack
D. Take with calcium supplements for better absorption
Answer: B
Rationale: Alendronate (bisphosphonate) must be taken on an empty stomach with full
water, and the patient must remain upright for 30 minutes to prevent esophagitis.
6. A 25-year-old male presents with knee swelling after a twisting injury. Lachman test is
positive. What is the most likely diagnosis?
A. Medial meniscus tear
B. Anterior cruciate ligament (ACL) tear
C. Posterior cruciate ligament (PCL) tear
D. Patellar dislocation
Answer: B
Rationale: A positive Lachman test is highly sensitive and specific for ACL tear. McMurray
test is for meniscus.
,7. A 65-year-old male with COPD has an FEV1/FVC ratio of 0.65 and FEV1 45% of
predicted. According to GOLD guidelines, what is the severity classification?
A. GOLD 1 (Mild)
B. GOLD 2 (Moderate)
C. GOLD 3 (Severe)
D. GOLD 4 (Very Severe)
Answer: C
Rationale: GOLD classification: FEV1 ≥80% = GOLD 1; 50–79% = GOLD 2; 30–49% =
GOLD 3; <30% = GOLD 4.
8. A 48-year-old female presents with episodic palpitations, sweating, headache, and
hypertension. Which test is most helpful in diagnosis?
A. Thyroid function tests
B. 24-hour urinary metanephrines
C. Serum cortisol
D. ECG
Answer: B
Rationale: Symptoms suggest pheochromocytoma. 24-hour urinary metanephrines and
fractionated catecholamines are the best screening tests.
9. A 2-year-old child presents with fever, cough, and inspiratory stridor that worsens at
night. The child is sitting upright with drooling. What is the most appropriate next step?
A. Oral antibiotics and discharge
B. Nebulized epinephrine and observation
C. Immediate airway assessment in a controlled setting (OR)
D. Chest X-ray
Answer: C
Rationale: Stridor + drooling + sitting upright suggest epiglottitis (now rare due to Hib
vaccine). This is an airway emergency requiring immediate ENT/anesthesia evaluation.
10. A 50-year-old female presents with a 3-cm thyroid nodule found incidentally on CT.
TSH is normal. What is the next best step?
A. Repeat TSH in 6 months
B. Thyroid ultrasound with risk stratification
C. Fine-needle aspiration biopsy
D. Thyroid scan
, Answer: B
Rationale: For a thyroid nodule with normal TSH, ultrasound with risk stratification (TI-
RADS) is the first step. FNA is done for nodules >1 cm with suspicious features.
11. A 35-year-old male presents with acute-onset severe testicular pain, nausea, and
vomiting. The testis is tender and elevated. Cremasteric reflex is absent. What is the most
appropriate next step?
A. Scrotal ultrasound
B. Emergent surgical consultation for possible testicular torsion
C. Urinalysis and antibiotics
D. Ice and scrotal elevation
Answer: B
Rationale: Sudden severe testicular pain with absent cremasteric reflex is testicular
torsion until proven otherwise. Emergent surgical exploration is needed within 6 hours.
12. A 68-year-old female with atrial fibrillation is on warfarin. Her INR is 4.5. She has no
bleeding. What is the most appropriate management?
A. Hold warfarin for 1 day and recheck INR
B. Administer vitamin K 10 mg orally
C. Administer fresh frozen plasma
D. Hold warfarin and give vitamin K 2.5 mg orally
Answer: A
Rationale: For INR 4.5–5.0 without bleeding, hold warfarin for 1 day and recheck. Vitamin
K is given for INR >10 or bleeding.
13. A 22-year-old female presents with dysuria, frequency, and urgency. Urinalysis shows
positive leukocyte esterase and nitrites. What is the first-line treatment?
A. Ciprofloxacin 500 mg BID for 3 days
B. Nitrofurantoin 100 mg BID for 5 days
C. Doxycycline 100 mg BID for 7 days
D. Cephalexin 500 mg BID for 7 days
Answer: B
Rationale: First-line for uncomplicated UTI in women: nitrofurantoin 5 days or
trimethoprim-sulfamethoxazole 3 days. Fluoroquinolones are reserved for complicated
UTI.
Practitioner 2026 Updated NCLEX-Style
Questions | Answers & Rationales
1. A 45-year-old female presents with fatigue, weight gain, cold intolerance, and
constipation. Thyroid-stimulating hormone (TSH) is 12.5 mIU/mL (normal 0.4–4.0).
What is the most appropriate initial treatment?
A. Methimazole 10 mg daily
B. Levothyroxine 1.6 mcg/kg/day
C. Radioactive iodine ablation
D. Levothyroxine 50 mcg daily with gradual titration
Answer: D
Rationale: This patient has hypothyroidism. Levothyroxine should be started at a low
dose (25–50 mcg) in older adults or those with cardiac history, then titrated. Younger
healthy adults may start at 1.6 mcg/kg. Methimazole is for hyperthyroidism.
2. A 60-year-old male with type 2 diabetes has a BP of 145/90 mmHg and urine albumin-
to-creatinine ratio of 80 mg/g. Which antihypertensive is preferred?
A. Hydrochlorothiazide
B. Amlodipine
C. Lisinopril
D. Metoprolol
Answer: C
Rationale: ACE inhibitors (lisinopril) are preferred in diabetics with albuminuria for renal
protection. They slow progression of diabetic nephropathy.
3. A 32-year-old pregnant woman at 28 weeks gestation presents with headache, blurred
vision, and BP 160/100 mmHg. Urine dipstick shows 3+ protein. What is the most
appropriate next step?
A. Prescribe labetalol and send home
B. Admit for magnesium sulfate and fetal monitoring
C. Prescribe methyldopa and follow up in 1 week
D. Recommend bed rest at home
,Answer: B
Rationale: This is severe preeclampsia (BP ≥160/110 with proteinuria). Requires hospital
admission for magnesium sulfate seizure prophylaxis and fetal monitoring.
4. A 55-year-old male presents with acute onset of tearing chest pain radiating to the
back. BP is 180/100 mmHg in the right arm and 140/80 mmHg in the left arm. What is the
most likely diagnosis?
A. Myocardial infarction
B. Pulmonary embolism
C. Aortic dissection
D. Pericarditis
Answer: C
Rationale: Aortic dissection presents with tearing chest pain radiating to the back and
asymmetric blood pressures between arms. Requires immediate imaging (CT
angiography).
5. A 70-year-old female with osteoporosis is started on alendronate. Which instruction is
most important?
A. Take with food to prevent nausea
B. Take on an empty stomach with a full glass of water and remain upright for 30 minutes
C. Take at bedtime with a small snack
D. Take with calcium supplements for better absorption
Answer: B
Rationale: Alendronate (bisphosphonate) must be taken on an empty stomach with full
water, and the patient must remain upright for 30 minutes to prevent esophagitis.
6. A 25-year-old male presents with knee swelling after a twisting injury. Lachman test is
positive. What is the most likely diagnosis?
A. Medial meniscus tear
B. Anterior cruciate ligament (ACL) tear
C. Posterior cruciate ligament (PCL) tear
D. Patellar dislocation
Answer: B
Rationale: A positive Lachman test is highly sensitive and specific for ACL tear. McMurray
test is for meniscus.
,7. A 65-year-old male with COPD has an FEV1/FVC ratio of 0.65 and FEV1 45% of
predicted. According to GOLD guidelines, what is the severity classification?
A. GOLD 1 (Mild)
B. GOLD 2 (Moderate)
C. GOLD 3 (Severe)
D. GOLD 4 (Very Severe)
Answer: C
Rationale: GOLD classification: FEV1 ≥80% = GOLD 1; 50–79% = GOLD 2; 30–49% =
GOLD 3; <30% = GOLD 4.
8. A 48-year-old female presents with episodic palpitations, sweating, headache, and
hypertension. Which test is most helpful in diagnosis?
A. Thyroid function tests
B. 24-hour urinary metanephrines
C. Serum cortisol
D. ECG
Answer: B
Rationale: Symptoms suggest pheochromocytoma. 24-hour urinary metanephrines and
fractionated catecholamines are the best screening tests.
9. A 2-year-old child presents with fever, cough, and inspiratory stridor that worsens at
night. The child is sitting upright with drooling. What is the most appropriate next step?
A. Oral antibiotics and discharge
B. Nebulized epinephrine and observation
C. Immediate airway assessment in a controlled setting (OR)
D. Chest X-ray
Answer: C
Rationale: Stridor + drooling + sitting upright suggest epiglottitis (now rare due to Hib
vaccine). This is an airway emergency requiring immediate ENT/anesthesia evaluation.
10. A 50-year-old female presents with a 3-cm thyroid nodule found incidentally on CT.
TSH is normal. What is the next best step?
A. Repeat TSH in 6 months
B. Thyroid ultrasound with risk stratification
C. Fine-needle aspiration biopsy
D. Thyroid scan
, Answer: B
Rationale: For a thyroid nodule with normal TSH, ultrasound with risk stratification (TI-
RADS) is the first step. FNA is done for nodules >1 cm with suspicious features.
11. A 35-year-old male presents with acute-onset severe testicular pain, nausea, and
vomiting. The testis is tender and elevated. Cremasteric reflex is absent. What is the most
appropriate next step?
A. Scrotal ultrasound
B. Emergent surgical consultation for possible testicular torsion
C. Urinalysis and antibiotics
D. Ice and scrotal elevation
Answer: B
Rationale: Sudden severe testicular pain with absent cremasteric reflex is testicular
torsion until proven otherwise. Emergent surgical exploration is needed within 6 hours.
12. A 68-year-old female with atrial fibrillation is on warfarin. Her INR is 4.5. She has no
bleeding. What is the most appropriate management?
A. Hold warfarin for 1 day and recheck INR
B. Administer vitamin K 10 mg orally
C. Administer fresh frozen plasma
D. Hold warfarin and give vitamin K 2.5 mg orally
Answer: A
Rationale: For INR 4.5–5.0 without bleeding, hold warfarin for 1 day and recheck. Vitamin
K is given for INR >10 or bleeding.
13. A 22-year-old female presents with dysuria, frequency, and urgency. Urinalysis shows
positive leukocyte esterase and nitrites. What is the first-line treatment?
A. Ciprofloxacin 500 mg BID for 3 days
B. Nitrofurantoin 100 mg BID for 5 days
C. Doxycycline 100 mg BID for 7 days
D. Cephalexin 500 mg BID for 7 days
Answer: B
Rationale: First-line for uncomplicated UTI in women: nitrofurantoin 5 days or
trimethoprim-sulfamethoxazole 3 days. Fluoroquinolones are reserved for complicated
UTI.
