USMLE STEP 3 PRACTICE Exam LATEST 2026
UPDATE 100 QUESTIONS AND DETAILED VERIFIED
ANSWERS FROM ACTUAL EXAMS TEST GRADE A+
Question 1
A 65-year-old man with hypertension presents with sudden onset of right-sided
weakness and aphasia that began 45 minutes ago. CT scan of the head shows no
hemorrhage. What is the next best step in management?
A. Administer aspirin
B. Begin heparin infusion
C. Administer intravenous alteplase
D. Perform carotid endarterectomy
E. Observe and repeat CT in 24 hours
Answer: C. Administer intravenous alteplase
Rationale: The patient presents with an acute ischemic stroke within the
therapeutic window (≤4.5 hours). After ruling out hemorrhage on CT, intravenous
alteplase (tPA) is the recommended treatment to restore cerebral perfusion.
Question 2
A 58-year-old woman with type 2 diabetes presents with fever, flank pain, and
dysuria. Urinalysis shows numerous WBCs and bacteria. She is hypotensive and
tachycardic. What is the most appropriate initial management?
A. Oral ciprofloxacin
B. Intravenous fluids and broad-spectrum antibiotics
C. Immediate nephrectomy
,D. Observation
E. Nitrofurantoin therapy
Answer: B. Intravenous fluids and broad-spectrum antibiotics
Rationale: The patient has urosepsis. Initial management includes aggressive fluid
resuscitation and empiric broad-spectrum intravenous antibiotics to stabilize
hemodynamics and control infection.
Question 3
A 30-year-old pregnant woman at 32 weeks’ gestation presents with blood
pressure of 170/110 mm Hg and proteinuria. She complains of severe headache
and visual disturbances. What is the best next step?
A. Discharge with oral antihypertensives
B. Administer magnesium sulfate
C. Schedule cesarean delivery immediately
D. Start ACE inhibitors
E. Bed rest only
Answer: B. Administer magnesium sulfate
Rationale: This patient has severe preeclampsia. Magnesium sulfate is
administered to prevent eclamptic seizures. Delivery is ultimately required, but
seizure prophylaxis is the immediate priority.
Question 4
A 72-year-old man with atrial fibrillation presents with melena. His INR is 5.2.
What is the most appropriate management?
A. Continue warfarin
B. Administer vitamin K and prothrombin complex concentrate
C. Administer aspirin
,D. Start heparin
E. Observe only
Answer: B. Administer vitamin K and prothrombin complex concentrate
Rationale: The patient has life-threatening bleeding while on warfarin with a
supratherapeutic INR. Rapid reversal requires vitamin K and prothrombin complex
concentrate (PCC).
Question 5
A 45-year-old woman presents with sudden severe chest pain radiating to her
back. Blood pressure is higher in the right arm than the left. What is the most
appropriate next diagnostic test?
A. Chest X-ray
B. CT angiography of the chest
C. ECG
D. Cardiac enzymes
E. Ventilation-perfusion scan
Answer: B. CT angiography of the chest
Rationale: The presentation is classic for aortic dissection. CT angiography is the
diagnostic test of choice in hemodynamically stable patients.
Question 6
A hospitalized patient develops diarrhea after 5 days of clindamycin therapy. Stool
test is positive for Clostridioides difficile. What is the first-line treatment?
A. Metronidazole
B. Oral vancomycin
C. Ciprofloxacin
D. Loperamide
E. IV vancomycin
, Answer: B. Oral vancomycin
Rationale: Current guidelines recommend oral vancomycin (or fidaxomicin) as first-
line therapy for initial episodes of C. difficile infection.
Question 7
A 60-year-old smoker presents with hematuria. Imaging reveals a bladder mass.
What is the most appropriate next step?
A. Radical cystectomy
B. Transurethral resection of the bladder tumor (TURBT)
C. Chemotherapy alone
D. Radiation therapy
E. Observation
Answer: B. Transurethral resection of the bladder tumor (TURBT)
Rationale: TURBT is both diagnostic and therapeutic and is the initial management
for suspected bladder cancer.
Question 8
A 28-year-old woman presents with lower abdominal pain and cervical motion
tenderness. She has fever and leukocytosis. What is the most appropriate
treatment?
A. Oral azithromycin only
B. IV ceftriaxone, doxycycline, and metronidazole
C. Observation
D. Hysterectomy
E. Oral amoxicillin
Answer: B. IV ceftriaxone, doxycycline, and metronidazole
UPDATE 100 QUESTIONS AND DETAILED VERIFIED
ANSWERS FROM ACTUAL EXAMS TEST GRADE A+
Question 1
A 65-year-old man with hypertension presents with sudden onset of right-sided
weakness and aphasia that began 45 minutes ago. CT scan of the head shows no
hemorrhage. What is the next best step in management?
A. Administer aspirin
B. Begin heparin infusion
C. Administer intravenous alteplase
D. Perform carotid endarterectomy
E. Observe and repeat CT in 24 hours
Answer: C. Administer intravenous alteplase
Rationale: The patient presents with an acute ischemic stroke within the
therapeutic window (≤4.5 hours). After ruling out hemorrhage on CT, intravenous
alteplase (tPA) is the recommended treatment to restore cerebral perfusion.
Question 2
A 58-year-old woman with type 2 diabetes presents with fever, flank pain, and
dysuria. Urinalysis shows numerous WBCs and bacteria. She is hypotensive and
tachycardic. What is the most appropriate initial management?
A. Oral ciprofloxacin
B. Intravenous fluids and broad-spectrum antibiotics
C. Immediate nephrectomy
,D. Observation
E. Nitrofurantoin therapy
Answer: B. Intravenous fluids and broad-spectrum antibiotics
Rationale: The patient has urosepsis. Initial management includes aggressive fluid
resuscitation and empiric broad-spectrum intravenous antibiotics to stabilize
hemodynamics and control infection.
Question 3
A 30-year-old pregnant woman at 32 weeks’ gestation presents with blood
pressure of 170/110 mm Hg and proteinuria. She complains of severe headache
and visual disturbances. What is the best next step?
A. Discharge with oral antihypertensives
B. Administer magnesium sulfate
C. Schedule cesarean delivery immediately
D. Start ACE inhibitors
E. Bed rest only
Answer: B. Administer magnesium sulfate
Rationale: This patient has severe preeclampsia. Magnesium sulfate is
administered to prevent eclamptic seizures. Delivery is ultimately required, but
seizure prophylaxis is the immediate priority.
Question 4
A 72-year-old man with atrial fibrillation presents with melena. His INR is 5.2.
What is the most appropriate management?
A. Continue warfarin
B. Administer vitamin K and prothrombin complex concentrate
C. Administer aspirin
,D. Start heparin
E. Observe only
Answer: B. Administer vitamin K and prothrombin complex concentrate
Rationale: The patient has life-threatening bleeding while on warfarin with a
supratherapeutic INR. Rapid reversal requires vitamin K and prothrombin complex
concentrate (PCC).
Question 5
A 45-year-old woman presents with sudden severe chest pain radiating to her
back. Blood pressure is higher in the right arm than the left. What is the most
appropriate next diagnostic test?
A. Chest X-ray
B. CT angiography of the chest
C. ECG
D. Cardiac enzymes
E. Ventilation-perfusion scan
Answer: B. CT angiography of the chest
Rationale: The presentation is classic for aortic dissection. CT angiography is the
diagnostic test of choice in hemodynamically stable patients.
Question 6
A hospitalized patient develops diarrhea after 5 days of clindamycin therapy. Stool
test is positive for Clostridioides difficile. What is the first-line treatment?
A. Metronidazole
B. Oral vancomycin
C. Ciprofloxacin
D. Loperamide
E. IV vancomycin
, Answer: B. Oral vancomycin
Rationale: Current guidelines recommend oral vancomycin (or fidaxomicin) as first-
line therapy for initial episodes of C. difficile infection.
Question 7
A 60-year-old smoker presents with hematuria. Imaging reveals a bladder mass.
What is the most appropriate next step?
A. Radical cystectomy
B. Transurethral resection of the bladder tumor (TURBT)
C. Chemotherapy alone
D. Radiation therapy
E. Observation
Answer: B. Transurethral resection of the bladder tumor (TURBT)
Rationale: TURBT is both diagnostic and therapeutic and is the initial management
for suspected bladder cancer.
Question 8
A 28-year-old woman presents with lower abdominal pain and cervical motion
tenderness. She has fever and leukocytosis. What is the most appropriate
treatment?
A. Oral azithromycin only
B. IV ceftriaxone, doxycycline, and metronidazole
C. Observation
D. Hysterectomy
E. Oral amoxicillin
Answer: B. IV ceftriaxone, doxycycline, and metronidazole
