NRNP 6531 – PRIMARY CARE OF ADULTS ACROSS THE LIFESPAN
(QUARTER 5/11-WEEK) EXAM BANK
It contains multiple-choice questions with answers and rationales in italics.
Cardiology (25 questions)
1. A 58-year-old man with hypertension reports substernal chest pressure with exertion,
relieved by rest. What is the most appropriate next step?
A. Order a stress echocardiogram
B. Prescribe nitroglycerin PRN
C. Start high-intensity statin
D. Refer to ER for troponin
Answer: A
Rationale: This is stable angina. Stress testing (echocardiogram or nuclear) is indicated to
assess for ischemia. Nitroglycerin is symptomatic relief but not diagnostic. Statin is
indicated but not the next step. ER referral is for unstable angina.
2. Which ACE inhibitor side effect is most characteristic and requires monitoring in a 72-
year-old with CKD?
A. Dry cough
B. Angioedema
C. Hyperkalemia
D. Hypotension
Answer: C
Rationale: In CKD, ACE inhibitors reduce aldosterone → potassium retention →
,hyperkalemia. Dry cough is common but not unique to CKD. Angioedema is rare.
Hypotension can occur but is not the most characteristic lab finding.
3. A 45-year-old female has a blood pressure of 148/92 mmHg on two visits. No
diabetes or CKD. What is first-line monotherapy?
A. HCTZ
B. Lisinopril
C. Amlodipine
D. Metoprolol
Answer: B
Rationale: ACE inhibitors (lisinopril) are first-line for non-Black patients without
compelling indications. Thiazides are also acceptable but ACEi is preferred in younger
patients. CCB (amlodipine) is alternative. Beta-blockers not first-line.
4. ECG shows irregularly irregular rhythm with no P waves. Rate is 110-130 bpm. What is
the best initial pharmacotherapy for rate control?
A. Amiodarone
B. Metoprolol
C. Aspirin
D. Diltiazem IV
Answer: D
Rationale: Atrial fibrillation with rapid ventricular response. IV diltiazem
(nondihydropyridine CCB) is first-line for acute rate control. Metoprolol is also used but
diltiazem is often preferred in acute setting. Amiodarone is for rhythm control or unstable
patients.
,5. A 62-year-old with heart failure with reduced ejection fraction (HFrEF, EF 35%) is on
metoprolol succinate, lisinopril, and furosemide. What medication should be added to
reduce mortality?
A. Digoxin
B. Spironolactone
C. Hydralazine
D. Diltiazem
Answer: B
Rationale: Mineralocorticoid receptor antagonist (spironolactone) improves mortality in
HFrEF (RALES trial). Digoxin reduces symptoms not mortality. Hydralazine/nitrate for
African Americans or intolerant to ACE/ARB. Diltiazem contraindicated in HFrEF.
6. Which EKG finding is most specific for prior myocardial infarction?
A. ST elevation
B. Pathologic Q waves
C. T wave inversion
D. Left bundle branch block
Answer: B
*Rationale: Pathologic Q waves (≥0.04 sec wide, >1/3 R wave height) indicate transmural
scar from prior MI. ST elevation is acute. T wave inversion is nonspecific. LBBB can mimic
ischemia but not specific for prior MI.*
7. A 55-year-old has BP 162/98, HR 82, and complains of headaches and palpitations.
On exam, you note pallor and tremors. What is the most appropriate next test?
A. Renal artery doppler
B. Plasma metanephrines
C. Serum aldosterone/renin ratio
D. 24-hour urine cortisol
Answer: B
Rationale: Suspect pheochromocytoma (paroxysmal hypertension, headache, palpitations,
diaphoresis). Plasma metanephrines is best screening test. Aldosterone/renin for
hyperaldosteronism (hypokalemia). Cortisol for Cushing's.
8. A 68-year-old with hypertension and diabetes has a BP of 134/78 mmHg on
amlodipine 10 mg, lisinopril 40 mg, and HCTZ 25 mg. What is the recommended next
step?
A. Add metoprolol
B. Increase amlodipine to 15 mg
C. Add spironolactone
D. Continue current regimen
Answer: D
, *Rationale: Target BP for diabetics is <130/80. Current BP 134/78 is at goal per recent
SPRINT and ACC/AHA guidelines (<130/80). No need to intensify. Spironolactone is
fourth-line for resistant hypertension.*
9. A 72-year-old reports syncope while walking. ECG shows heart rate 38 bpm, regular,
with P waves not associated with QRS complexes. What is the diagnosis?
A. Wenckebach (Mobitz I)
B. Complete heart block (Mobitz III)
C. Sinus bradycardia
D. Atrial fibrillation with slow response
Answer: B
*Rationale: Third-degree AV block: no relationship between P waves and QRS.
Ventricular escape rhythm. Mobitz I has progressive PR prolongation. Sinus bradycardia
has 1:1 conduction. A-fib has no P waves.*
10. What is the most common cause of acute pericarditis?
A. Viral infection (Coxsackie, echo)
B. Myocardial infarction
C. Uremia
D. Tuberculosis
Answer: A
Rationale: Idiopathic (likely viral) is most common. Post-MI (Dressler's) is rare now. Uremia
is cause but less frequent. TB pericarditis is rare in developed countries.
11. A 48-year-old obese female has dyspnea on exertion, orthopnea, and JVD. Echo
shows preserved EF (65%) and concentric LV hypertrophy. What is the most likely
diagnosis?
A. Constrictive pericarditis
B. Hypertrophic cardiomyopathy
C. HFpEF
D. Cardiac amyloidosis
Answer: C
Rationale: Heart failure with preserved ejection fraction (HFpEF) presents with diastolic
dysfunction. Common risk factors: obesity, hypertension, diabetes. Concentric LVH is
typical. Constrictive pericarditis has septal bounce. HCM has asymmetric septal
hypertrophy.
12. Which lipid-lowering medication has been shown to reduce cardiovascular events
and all-cause mortality in statin-intolerant patients?
A. Ezetimibe
B. Bempedoic acid
(QUARTER 5/11-WEEK) EXAM BANK
It contains multiple-choice questions with answers and rationales in italics.
Cardiology (25 questions)
1. A 58-year-old man with hypertension reports substernal chest pressure with exertion,
relieved by rest. What is the most appropriate next step?
A. Order a stress echocardiogram
B. Prescribe nitroglycerin PRN
C. Start high-intensity statin
D. Refer to ER for troponin
Answer: A
Rationale: This is stable angina. Stress testing (echocardiogram or nuclear) is indicated to
assess for ischemia. Nitroglycerin is symptomatic relief but not diagnostic. Statin is
indicated but not the next step. ER referral is for unstable angina.
2. Which ACE inhibitor side effect is most characteristic and requires monitoring in a 72-
year-old with CKD?
A. Dry cough
B. Angioedema
C. Hyperkalemia
D. Hypotension
Answer: C
Rationale: In CKD, ACE inhibitors reduce aldosterone → potassium retention →
,hyperkalemia. Dry cough is common but not unique to CKD. Angioedema is rare.
Hypotension can occur but is not the most characteristic lab finding.
3. A 45-year-old female has a blood pressure of 148/92 mmHg on two visits. No
diabetes or CKD. What is first-line monotherapy?
A. HCTZ
B. Lisinopril
C. Amlodipine
D. Metoprolol
Answer: B
Rationale: ACE inhibitors (lisinopril) are first-line for non-Black patients without
compelling indications. Thiazides are also acceptable but ACEi is preferred in younger
patients. CCB (amlodipine) is alternative. Beta-blockers not first-line.
4. ECG shows irregularly irregular rhythm with no P waves. Rate is 110-130 bpm. What is
the best initial pharmacotherapy for rate control?
A. Amiodarone
B. Metoprolol
C. Aspirin
D. Diltiazem IV
Answer: D
Rationale: Atrial fibrillation with rapid ventricular response. IV diltiazem
(nondihydropyridine CCB) is first-line for acute rate control. Metoprolol is also used but
diltiazem is often preferred in acute setting. Amiodarone is for rhythm control or unstable
patients.
,5. A 62-year-old with heart failure with reduced ejection fraction (HFrEF, EF 35%) is on
metoprolol succinate, lisinopril, and furosemide. What medication should be added to
reduce mortality?
A. Digoxin
B. Spironolactone
C. Hydralazine
D. Diltiazem
Answer: B
Rationale: Mineralocorticoid receptor antagonist (spironolactone) improves mortality in
HFrEF (RALES trial). Digoxin reduces symptoms not mortality. Hydralazine/nitrate for
African Americans or intolerant to ACE/ARB. Diltiazem contraindicated in HFrEF.
6. Which EKG finding is most specific for prior myocardial infarction?
A. ST elevation
B. Pathologic Q waves
C. T wave inversion
D. Left bundle branch block
Answer: B
*Rationale: Pathologic Q waves (≥0.04 sec wide, >1/3 R wave height) indicate transmural
scar from prior MI. ST elevation is acute. T wave inversion is nonspecific. LBBB can mimic
ischemia but not specific for prior MI.*
7. A 55-year-old has BP 162/98, HR 82, and complains of headaches and palpitations.
On exam, you note pallor and tremors. What is the most appropriate next test?
A. Renal artery doppler
B. Plasma metanephrines
C. Serum aldosterone/renin ratio
D. 24-hour urine cortisol
Answer: B
Rationale: Suspect pheochromocytoma (paroxysmal hypertension, headache, palpitations,
diaphoresis). Plasma metanephrines is best screening test. Aldosterone/renin for
hyperaldosteronism (hypokalemia). Cortisol for Cushing's.
8. A 68-year-old with hypertension and diabetes has a BP of 134/78 mmHg on
amlodipine 10 mg, lisinopril 40 mg, and HCTZ 25 mg. What is the recommended next
step?
A. Add metoprolol
B. Increase amlodipine to 15 mg
C. Add spironolactone
D. Continue current regimen
Answer: D
, *Rationale: Target BP for diabetics is <130/80. Current BP 134/78 is at goal per recent
SPRINT and ACC/AHA guidelines (<130/80). No need to intensify. Spironolactone is
fourth-line for resistant hypertension.*
9. A 72-year-old reports syncope while walking. ECG shows heart rate 38 bpm, regular,
with P waves not associated with QRS complexes. What is the diagnosis?
A. Wenckebach (Mobitz I)
B. Complete heart block (Mobitz III)
C. Sinus bradycardia
D. Atrial fibrillation with slow response
Answer: B
*Rationale: Third-degree AV block: no relationship between P waves and QRS.
Ventricular escape rhythm. Mobitz I has progressive PR prolongation. Sinus bradycardia
has 1:1 conduction. A-fib has no P waves.*
10. What is the most common cause of acute pericarditis?
A. Viral infection (Coxsackie, echo)
B. Myocardial infarction
C. Uremia
D. Tuberculosis
Answer: A
Rationale: Idiopathic (likely viral) is most common. Post-MI (Dressler's) is rare now. Uremia
is cause but less frequent. TB pericarditis is rare in developed countries.
11. A 48-year-old obese female has dyspnea on exertion, orthopnea, and JVD. Echo
shows preserved EF (65%) and concentric LV hypertrophy. What is the most likely
diagnosis?
A. Constrictive pericarditis
B. Hypertrophic cardiomyopathy
C. HFpEF
D. Cardiac amyloidosis
Answer: C
Rationale: Heart failure with preserved ejection fraction (HFpEF) presents with diastolic
dysfunction. Common risk factors: obesity, hypertension, diabetes. Concentric LVH is
typical. Constrictive pericarditis has septal bounce. HCM has asymmetric septal
hypertrophy.
12. Which lipid-lowering medication has been shown to reduce cardiovascular events
and all-cause mortality in statin-intolerant patients?
A. Ezetimibe
B. Bempedoic acid
