NURS 5434 FNP III FINAL EXAM PREPARATION GUIDE
UNIVERSITY OF TEXAS AT ARLINGTON ADVANCED PRACTICE NURSING
2026 CLINICAL GUIDELINE ALIGNMENT
SECTION ONE: COMPLEX CARDIOVASCULAR MANAGEMENT
Question 1
A 68 year old patient with heart failure with reduced ejection fraction (HFrEF, EF 30
percent) is currently taking Lisinopril, Carvedilol, and Spironolactone. Her blood
pressure today is 105/65 mmHg, and her heart rate is 62 bpm. She denies dizziness but
reports mild ongoing dyspnea on exertion. According to the updated ACC/AHA
guidelines for heart failure, what is the most appropriate pharmacological addition to
improve her symptoms and reduce mortality?
A. Add amlodipine to further reduce afterload.
B. Add digoxin to increase her ejection fraction.
C. Add a Sodium Glucose Cotransporter 2 (SGLT2) inhibitor like Dapagliflozin.
D. Add hydralazine and isosorbide dinitrate only if she identifies as African American.
Answer: C
Rationale: The foundation of HFrEF management is the four pillars of guideline-
directed medical therapy (GDMT): an ACE inhibitor or ARNI, a beta blocker, an
aldosterone antagonist, and an SGLT2 inhibitor. Because this patient is tolerating the
first three medications without hypotension or bradycardia that would require dose
reduction, the addition of an SGLT2 inhibitor is strongly recommended regardless of
, whether the patient has diabetes, as it significantly reduces heart failure
hospitalizations and cardiovascular mortality. Hydralazine/isosorbide dinitrate is an
alternative add-on for self-identified African American patients who remain
symptomatic on optimal GDMT, but SGLT2 inhibitors are universally indicated earlier in
the algorithm.
Question 2
A 72 year old male presents with a 3 month history of progressive dyspnea on
exertion, orthopnea, and lower extremity edema. An echocardiogram shows a left
ventricular ejection fraction of 60 percent, left atrial enlargement, and concentric left
ventricular hypertrophy. What is the primary pathophysiologic defect in this patient,
and what medication class should be avoided?
A. Systolic dysfunction with impaired contractility; avoid beta blockers.
B. Diastolic dysfunction with impaired relaxation and filling; avoid non-dihydropyridine
calcium channel blockers like Diltiazem and Verapamil.
C. Diastolic dysfunction with impaired relaxation and filling; avoid loop diuretics like
Furosemide.
D. Right ventricular failure secondary to pulmonary hypertension; avoid ACE inhibitors.
Answer: B
Rationale: This patient has Heart Failure with Preserved Ejection Fraction (HFpEF),
also known as diastolic heart failure. The primary defect is stiff, non-compliant
ventricular myocardium that impairs filling. Hypertension is the most common cause.
While loop diuretics are actually indicated for symptom relief (volume overload), non-
dihydropyridine calcium channel blockers (like Diltiazem and Verapamil) should
generally be avoided or used with extreme caution. While they lower blood pressure
and slow heart rate (which allows more time for filling), their negative inotropic effect
can exacerbate diastolic dysfunction. Beta blockers and ACE inhibitors are standard for
blood pressure control in HFpEF.
Question 3
A patient with atrial fibrillation and a CHA2DS2-VASc score of 4 is taking Apixaban.
They present to the clinic with an acute mechanical fall and a large, localized
hematoma on their forehead. Their vital signs are stable, and a head CT is negative for
UNIVERSITY OF TEXAS AT ARLINGTON ADVANCED PRACTICE NURSING
2026 CLINICAL GUIDELINE ALIGNMENT
SECTION ONE: COMPLEX CARDIOVASCULAR MANAGEMENT
Question 1
A 68 year old patient with heart failure with reduced ejection fraction (HFrEF, EF 30
percent) is currently taking Lisinopril, Carvedilol, and Spironolactone. Her blood
pressure today is 105/65 mmHg, and her heart rate is 62 bpm. She denies dizziness but
reports mild ongoing dyspnea on exertion. According to the updated ACC/AHA
guidelines for heart failure, what is the most appropriate pharmacological addition to
improve her symptoms and reduce mortality?
A. Add amlodipine to further reduce afterload.
B. Add digoxin to increase her ejection fraction.
C. Add a Sodium Glucose Cotransporter 2 (SGLT2) inhibitor like Dapagliflozin.
D. Add hydralazine and isosorbide dinitrate only if she identifies as African American.
Answer: C
Rationale: The foundation of HFrEF management is the four pillars of guideline-
directed medical therapy (GDMT): an ACE inhibitor or ARNI, a beta blocker, an
aldosterone antagonist, and an SGLT2 inhibitor. Because this patient is tolerating the
first three medications without hypotension or bradycardia that would require dose
reduction, the addition of an SGLT2 inhibitor is strongly recommended regardless of
, whether the patient has diabetes, as it significantly reduces heart failure
hospitalizations and cardiovascular mortality. Hydralazine/isosorbide dinitrate is an
alternative add-on for self-identified African American patients who remain
symptomatic on optimal GDMT, but SGLT2 inhibitors are universally indicated earlier in
the algorithm.
Question 2
A 72 year old male presents with a 3 month history of progressive dyspnea on
exertion, orthopnea, and lower extremity edema. An echocardiogram shows a left
ventricular ejection fraction of 60 percent, left atrial enlargement, and concentric left
ventricular hypertrophy. What is the primary pathophysiologic defect in this patient,
and what medication class should be avoided?
A. Systolic dysfunction with impaired contractility; avoid beta blockers.
B. Diastolic dysfunction with impaired relaxation and filling; avoid non-dihydropyridine
calcium channel blockers like Diltiazem and Verapamil.
C. Diastolic dysfunction with impaired relaxation and filling; avoid loop diuretics like
Furosemide.
D. Right ventricular failure secondary to pulmonary hypertension; avoid ACE inhibitors.
Answer: B
Rationale: This patient has Heart Failure with Preserved Ejection Fraction (HFpEF),
also known as diastolic heart failure. The primary defect is stiff, non-compliant
ventricular myocardium that impairs filling. Hypertension is the most common cause.
While loop diuretics are actually indicated for symptom relief (volume overload), non-
dihydropyridine calcium channel blockers (like Diltiazem and Verapamil) should
generally be avoided or used with extreme caution. While they lower blood pressure
and slow heart rate (which allows more time for filling), their negative inotropic effect
can exacerbate diastolic dysfunction. Beta blockers and ACE inhibitors are standard for
blood pressure control in HFpEF.
Question 3
A patient with atrial fibrillation and a CHA2DS2-VASc score of 4 is taking Apixaban.
They present to the clinic with an acute mechanical fall and a large, localized
hematoma on their forehead. Their vital signs are stable, and a head CT is negative for
