NR 603 Week 2 Case Discussion Pulmonary
Part One ACTUAL EXAM 2026/2027 | NR
603 Pulmonary Case Study | Verified Q&A |
Pass Guaranteed - A+ Graded
Section 1: Clinical Vignettes – COPD & Asthma
Q1: A 68-year-old male with a 40-pack-year history presents with progressive dyspnea and chronic
cough. Spirometry reveals FEV1/FVC ratio of 0.65. Post-bronchodilator FEV1 is 55% predicted. He has
had two moderate exacerbations in the past year treated with oral steroids. His CAT score is 18.
According to GOLD 2026 guidelines, what is his GOLD group classification?
A. Group B
B. Group C
C. Group D [CORRECT]
D. Group A
Correct Answer: C
Rationale: The patient has airflow limitation (FEV1 50-80% predicted, GOLD Stage 2). He has high
symptom burden (CAT ≥ 10) and a history of ≥ 2 moderate exacerbations or 1 leading to hospitalization,
placing him in the high-risk category for exacerbations. High symptoms + High risk = Group D. Distractor
A is low risk/high symptoms. Distractor B is high risk/low symptoms. Distractor D is low risk/low
symptoms.
Clinical Pearl: "GOLD groups are determined by symptoms (CAT/mMRC) and exacerbation history/risk,
not just spirometry stage."
Q2: A 22-year-old female presents with intermittent wheezing, chest tightness, and cough triggered by
exercise and cold air. She has no symptoms between episodes. Spirometry is normal. Her FeNO is
,elevated. She is not on daily medication. According to GINA 2026 guidelines, what is the most
appropriate initial step?
A. As-needed SABA (Short-Acting Beta-Agonist).
B. Daily low-dose ICS (Inhaled Corticosteroid).
C. As-needed low-dose ICS-Formoterol. [CORRECT]
D. Daily LTRA (Leukotriene Receptor Antagonist).
Correct Answer: C
Rationale: GINA Track 1 (preferred) for Step 1-2 asthma is as-needed low-dose ICS-Formoterol. This
approach reduces exacerbation risk compared to SABA alone (Distractor A) and is more flexible than
daily ICS (Distractor B) for mild intermittent asthma. SABA-only treatment is no longer preferred due to
safety concerns regarding exacerbation risk.
Clinical Pearl: "GINA no longer recommends SABA-only therapy for mild asthma due to the risk of severe
exacerbations; always combine with anti-inflammatory therapy (ICS-Formoterol preferred)."
Q3: A 65-year-old male with COPD (Group B) is currently on LAMA monotherapy but continues to have
significant dyspnea (mMRC 3). He has no history of exacerbations. His eosinophil count is 150 cells/µL.
What is the most appropriate escalation of therapy?
A. Add a LABA (LAMA/LABA dual bronchodilator). [CORRECT]
B. Add an ICS (LAMA/ICS).
C. Add a LABA/ICS (Triple therapy).
D. Add a PDE4 inhibitor.
Correct Answer: A
Rationale: For Group B patients with persistent symptoms on monotherapy, escalation to dual
bronchodilation (LAMA/LABA) is recommended. ICS (Distractor B and C) is indicated primarily for
patients with high exacerbation risk and eosinophils > 300 cells/µL. His eosinophil count is below the
threshold for ICS benefit.
Clinical Pearl: "ICS is not a first-line add-on for symptom relief in COPD unless there is a high
exacerbation risk (history) or high eosinophil count (usually >300)."
,Q4: A 45-year-old male with severe persistent asthma is currently on high-dose ICS-LABA but continues
to require oral steroids for exacerbations. His eosinophil count is 450 cells/µL. Which biologic agent
targets the IL-5 pathway and is indicated for severe eosinophilic asthma?
A. Omalizumab
B. Mepolizumab [CORRECT]
C. Dupilumab
D. Tezepelumab
Correct Answer: B
Rationale: Mepolizumab is an anti-IL-5 biologic used for severe eosinophilic asthma. Omalizumab (A)
targets IgE. Dupilumab (C) targets IL-4/IL-13. Tezepelumab (D) targets TSLP (upstream). While C and D
can also help eosinophilic asthma, Mepolizumab is the classic, specific answer for IL-5 pathway inhibition
often tested.
Clinical Pearl: "Mepolizumab and Reslizumab are anti-IL-5 agents; think 'M' and 'R' for Eosinophils."
Q5: A patient with an acute COPD exacerbation presents to the clinic. SpO2 is 88% on room air. He is
using accessory muscles but is alert. Which of the following is the MOST appropriate initial diagnostic
test?
A. Chest X-ray [CORRECT]
B. CT Angiography
C. Arterial Blood Gas (ABG)
D. BNP level
Correct Answer: A
Rationale: A chest X-ray is essential to rule out pneumonia or pneumothorax as the cause of the
exacerbation. While ABG (C) is useful for hypercapnia, it is not the initial screen in an office setting
before imaging if the patient is stable enough. CT Angiography (B) is for PE suspicion.
, Clinical Pearl: "Always image the chest in a COPD exacerbation to evaluate for precipitating causes like
pneumonia or effusion."
Q6: A 70-year-old patient with COPD is being discharged after an exacerbation. Which intervention has
been proven to reduce the risk of readmission and mortality?
A. Long-term azithromycin prophylaxis.
B. Pulmonary rehabilitation. [CORRECT]
C. Home oxygen therapy.
D. Daily oral steroids.
Correct Answer: B
Rationale: Pulmonary rehabilitation initiated soon after discharge improves exercise capacity, quality of
life, and reduces readmissions. Azithromycin (A) is for specific subsets. Oxygen (C) is for hypoxemia.
Daily steroids (D) are harmful in stable COPD.
Clinical Pearl: "Pulmonary rehab is the gold standard for recovery post-exacerbation; it addresses the
deconditioning spiral."
Q7: A 30-year-old presents with "asthma" that is difficult to control. She reports a cough that is worse
when lying down and after meals. She has no wheezing on exam today. Spirometry shows no
obstruction. What is the next best step?
A. Order a methacholine challenge test.
B. Start a PPI (Proton Pump Inhibitor) and monitor.
C. Evaluate for vocal cord dysfunction (VCD) with flow-volume loop. [CORRECT]
D. Increase ICS dose.
Correct Answer: C
Rationale: Symptoms worse lying down and post-prandial suggest GERD, but the lack of wheezing and
normal spirometry in a diagnosed asthmatic suggests the diagnosis may be wrong. VCD mimics asthma.
Part One ACTUAL EXAM 2026/2027 | NR
603 Pulmonary Case Study | Verified Q&A |
Pass Guaranteed - A+ Graded
Section 1: Clinical Vignettes – COPD & Asthma
Q1: A 68-year-old male with a 40-pack-year history presents with progressive dyspnea and chronic
cough. Spirometry reveals FEV1/FVC ratio of 0.65. Post-bronchodilator FEV1 is 55% predicted. He has
had two moderate exacerbations in the past year treated with oral steroids. His CAT score is 18.
According to GOLD 2026 guidelines, what is his GOLD group classification?
A. Group B
B. Group C
C. Group D [CORRECT]
D. Group A
Correct Answer: C
Rationale: The patient has airflow limitation (FEV1 50-80% predicted, GOLD Stage 2). He has high
symptom burden (CAT ≥ 10) and a history of ≥ 2 moderate exacerbations or 1 leading to hospitalization,
placing him in the high-risk category for exacerbations. High symptoms + High risk = Group D. Distractor
A is low risk/high symptoms. Distractor B is high risk/low symptoms. Distractor D is low risk/low
symptoms.
Clinical Pearl: "GOLD groups are determined by symptoms (CAT/mMRC) and exacerbation history/risk,
not just spirometry stage."
Q2: A 22-year-old female presents with intermittent wheezing, chest tightness, and cough triggered by
exercise and cold air. She has no symptoms between episodes. Spirometry is normal. Her FeNO is
,elevated. She is not on daily medication. According to GINA 2026 guidelines, what is the most
appropriate initial step?
A. As-needed SABA (Short-Acting Beta-Agonist).
B. Daily low-dose ICS (Inhaled Corticosteroid).
C. As-needed low-dose ICS-Formoterol. [CORRECT]
D. Daily LTRA (Leukotriene Receptor Antagonist).
Correct Answer: C
Rationale: GINA Track 1 (preferred) for Step 1-2 asthma is as-needed low-dose ICS-Formoterol. This
approach reduces exacerbation risk compared to SABA alone (Distractor A) and is more flexible than
daily ICS (Distractor B) for mild intermittent asthma. SABA-only treatment is no longer preferred due to
safety concerns regarding exacerbation risk.
Clinical Pearl: "GINA no longer recommends SABA-only therapy for mild asthma due to the risk of severe
exacerbations; always combine with anti-inflammatory therapy (ICS-Formoterol preferred)."
Q3: A 65-year-old male with COPD (Group B) is currently on LAMA monotherapy but continues to have
significant dyspnea (mMRC 3). He has no history of exacerbations. His eosinophil count is 150 cells/µL.
What is the most appropriate escalation of therapy?
A. Add a LABA (LAMA/LABA dual bronchodilator). [CORRECT]
B. Add an ICS (LAMA/ICS).
C. Add a LABA/ICS (Triple therapy).
D. Add a PDE4 inhibitor.
Correct Answer: A
Rationale: For Group B patients with persistent symptoms on monotherapy, escalation to dual
bronchodilation (LAMA/LABA) is recommended. ICS (Distractor B and C) is indicated primarily for
patients with high exacerbation risk and eosinophils > 300 cells/µL. His eosinophil count is below the
threshold for ICS benefit.
Clinical Pearl: "ICS is not a first-line add-on for symptom relief in COPD unless there is a high
exacerbation risk (history) or high eosinophil count (usually >300)."
,Q4: A 45-year-old male with severe persistent asthma is currently on high-dose ICS-LABA but continues
to require oral steroids for exacerbations. His eosinophil count is 450 cells/µL. Which biologic agent
targets the IL-5 pathway and is indicated for severe eosinophilic asthma?
A. Omalizumab
B. Mepolizumab [CORRECT]
C. Dupilumab
D. Tezepelumab
Correct Answer: B
Rationale: Mepolizumab is an anti-IL-5 biologic used for severe eosinophilic asthma. Omalizumab (A)
targets IgE. Dupilumab (C) targets IL-4/IL-13. Tezepelumab (D) targets TSLP (upstream). While C and D
can also help eosinophilic asthma, Mepolizumab is the classic, specific answer for IL-5 pathway inhibition
often tested.
Clinical Pearl: "Mepolizumab and Reslizumab are anti-IL-5 agents; think 'M' and 'R' for Eosinophils."
Q5: A patient with an acute COPD exacerbation presents to the clinic. SpO2 is 88% on room air. He is
using accessory muscles but is alert. Which of the following is the MOST appropriate initial diagnostic
test?
A. Chest X-ray [CORRECT]
B. CT Angiography
C. Arterial Blood Gas (ABG)
D. BNP level
Correct Answer: A
Rationale: A chest X-ray is essential to rule out pneumonia or pneumothorax as the cause of the
exacerbation. While ABG (C) is useful for hypercapnia, it is not the initial screen in an office setting
before imaging if the patient is stable enough. CT Angiography (B) is for PE suspicion.
, Clinical Pearl: "Always image the chest in a COPD exacerbation to evaluate for precipitating causes like
pneumonia or effusion."
Q6: A 70-year-old patient with COPD is being discharged after an exacerbation. Which intervention has
been proven to reduce the risk of readmission and mortality?
A. Long-term azithromycin prophylaxis.
B. Pulmonary rehabilitation. [CORRECT]
C. Home oxygen therapy.
D. Daily oral steroids.
Correct Answer: B
Rationale: Pulmonary rehabilitation initiated soon after discharge improves exercise capacity, quality of
life, and reduces readmissions. Azithromycin (A) is for specific subsets. Oxygen (C) is for hypoxemia.
Daily steroids (D) are harmful in stable COPD.
Clinical Pearl: "Pulmonary rehab is the gold standard for recovery post-exacerbation; it addresses the
deconditioning spiral."
Q7: A 30-year-old presents with "asthma" that is difficult to control. She reports a cough that is worse
when lying down and after meals. She has no wheezing on exam today. Spirometry shows no
obstruction. What is the next best step?
A. Order a methacholine challenge test.
B. Start a PPI (Proton Pump Inhibitor) and monitor.
C. Evaluate for vocal cord dysfunction (VCD) with flow-volume loop. [CORRECT]
D. Increase ICS dose.
Correct Answer: C
Rationale: Symptoms worse lying down and post-prandial suggest GERD, but the lack of wheezing and
normal spirometry in a diagnosed asthmatic suggests the diagnosis may be wrong. VCD mimics asthma.
