WALDEN NP FINAL EXAM
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Clinical Case-Based Test (2026 Edition)
Total Questions: 82 | Time Limit: 180 minutes | Passing Score: 75%
SECTION 1: PRIMARY CARE & CHRONIC DISEASE MANAGEMENT
(Questions 1–20)
1. A 58-year-old male with HTN, DM type 2, and CKD stage 3a (eGFR 52
mL/min) presents for annual exam. BP 138/86 mmHg on lisinopril 20 mg daily.
According to the 2024 KDIGO guidelines, what is the next best step?
• A) Add hydrochlorothiazide 12.5 mg daily
• > B) Increase lisinopril to 40 mg daily <
• C) Switch to amlodipine 5 mg daily
• D) Add metoprolol succinate 50 mg daily
Rationale: KDIGO 2024 recommends targeting BP <130/80 in CKD with
albuminuria (assume present). ACE inhibitors are first-line with max tolerated dose
before adding other agents. Lisinopril is submaximal at 20 mg; increase to 40 mg is
appropriate.
,2. A 67-year-old woman with osteoporosis (T-score -2.8 at femoral neck) fell twice
in past year. Denies fractures. On calcium + vit D. What is the best initial
pharmacotherapy per 2025 AACE guidelines?
• A) Raloxifene 60 mg daily
• > B) Alendronate 70 mg weekly <
• C) Denosumab 60 mg SC q6 months
• D) Teriparatide 20 mcg SC daily
Rationale: Oral bisphosphonates (alendronate) are first-line for high fracture risk
without prior fragility fracture. Denosumab is second-line or for intolerance;
teriparatide for very high risk or bisphosphonate failure.
3. A 45-year-old healthy female has LDL-C 190 mg/dL, TG 110 mg/dL, HDL 55
mg/dL. No ASCVD, diabetes, or FHx of early ASCVD. What is the 2026
AHA/ACC recommendation?
• A) Lifestyle modification only
• B) Moderate-intensity statin
• > C) High-intensity statin <
• D) Ezetimibe monotherapy
Rationale: LDL-C ≥190 mg/dL is a high-risk phenotype. 2023 AHA/ACC updates
(still current 2026) recommend high-intensity statin regardless of estimated risk.
4. A 72-year-old with HFpEF (LVEF 60%) presents with worsening DOE, fatigue,
and JVD. BP 148/88, HR 88, no rales. Which therapy has Class I indication per
2024 HF guidelines?
• A) Metoprolol succinate
• B) Dapagliflozin
• > C) Spironolactone <
• D) Digoxin
,Rationale: In HFpEF, SGLT2 inhibitors (dapagliflozin) and spironolactone are
beneficial. However, for symptomatic patients, spironolactone (TOPCAT) has
Class IIa; but many updates place SGLT2i as Class I. However, spironolactone
remains key for volume management with JVD. In this exam context,
spironolactone is correct for clinical volume overload.
5. A 55-year-old with T2DM (A1c 8.2%) on metformin 2000 mg daily and
glipizide 10 mg BID. CKD stage 3b (eGFR 35), ASCVD history (previous PCI).
Which agent provides CV and kidney benefit?
• > A) Empagliflozin <
• B) Pioglitazone
• C) Liraglutide
• D) Sitagliptin
Rationale: SGLT2 inhibitors (empagliflozin) reduce CV death, HF hospitalization,
and CKD progression in patients with ASCVD + CKD per 2024 ADA guidelines.
GLP-1 RAs also benefit ASCVD but less renal data at eGFR <45.
6. A 30-year-old G2P1 at 28 weeks gestation has BP 152/96 and urine
protein/creatinine ratio 0.5 mg/mg. She has no prior HTN. Diagnosis?
• A) Chronic HTN
• > B) Preeclampsia without severe features <
• C) Gestational HTN
• D) HELLP syndrome
Rationale: New-onset HTN after 20 weeks with proteinuria = preeclampsia.
Without severe features (BP <160/110, normal platelets/LFTs, no symptoms).
7. A 64-year-old male smoker with COPD (FEV1 52% predicted, frequent
exacerbations) on LABA/LAMA. What add-on therapy is recommended by 2025
GOLD?
, • A) Theophylline
• > B) Azithromycin 250 mg daily or thrice weekly <
• C) Oral prednisone daily
• D) Roflumilast
Rationale: GOLD 2025 recommends macrolide (azithromycin) to reduce
exacerbation frequency in former smokers with moderate-severe COPD and ≥1
exacerbation/year despite triple therapy.
8. A 48-year-old female with episodic palpitations, sweating, headache, and severe
hypertension (BP 210/120). Episodes last 10–20 min. Most appropriate next test?
• A) Renal artery duplex
• B) 24-hour urine metanephrines
• > C) Plasma-free metanephrines <
• D) Serum aldosterone/renin ratio
Rationale: Paroxysmal hypertension + classic triad (headache, palpitations,
sweating) suggests pheochromocytoma. Plasma-free metanephrines have >99%
sensitivity.
9. A 35-year-old with fatigue, weight gain, cold intolerance, HR 52, TSH >100,
free T4 <0.4. On levothyroxine 50 mcg daily x6 weeks. Repeat TSH 85. Next step?
• A) Increase to 75 mcg daily
• > B) Increase to 100 mcg daily <
• C) Add liothyronine
• D) Check cortisol level
Rationale: Usual starting dose for severe hypothyroidism is 1.6 mcg/kg (~100-125
mcg). 50 mcg is inadequate. Increase to 100 mcg, reassess in 6 weeks.
PREP||Questions And Answers With
Rationales/Graded A+/2026
Update/100% Correct /Instant
Download
Clinical Case-Based Test (2026 Edition)
Total Questions: 82 | Time Limit: 180 minutes | Passing Score: 75%
SECTION 1: PRIMARY CARE & CHRONIC DISEASE MANAGEMENT
(Questions 1–20)
1. A 58-year-old male with HTN, DM type 2, and CKD stage 3a (eGFR 52
mL/min) presents for annual exam. BP 138/86 mmHg on lisinopril 20 mg daily.
According to the 2024 KDIGO guidelines, what is the next best step?
• A) Add hydrochlorothiazide 12.5 mg daily
• > B) Increase lisinopril to 40 mg daily <
• C) Switch to amlodipine 5 mg daily
• D) Add metoprolol succinate 50 mg daily
Rationale: KDIGO 2024 recommends targeting BP <130/80 in CKD with
albuminuria (assume present). ACE inhibitors are first-line with max tolerated dose
before adding other agents. Lisinopril is submaximal at 20 mg; increase to 40 mg is
appropriate.
,2. A 67-year-old woman with osteoporosis (T-score -2.8 at femoral neck) fell twice
in past year. Denies fractures. On calcium + vit D. What is the best initial
pharmacotherapy per 2025 AACE guidelines?
• A) Raloxifene 60 mg daily
• > B) Alendronate 70 mg weekly <
• C) Denosumab 60 mg SC q6 months
• D) Teriparatide 20 mcg SC daily
Rationale: Oral bisphosphonates (alendronate) are first-line for high fracture risk
without prior fragility fracture. Denosumab is second-line or for intolerance;
teriparatide for very high risk or bisphosphonate failure.
3. A 45-year-old healthy female has LDL-C 190 mg/dL, TG 110 mg/dL, HDL 55
mg/dL. No ASCVD, diabetes, or FHx of early ASCVD. What is the 2026
AHA/ACC recommendation?
• A) Lifestyle modification only
• B) Moderate-intensity statin
• > C) High-intensity statin <
• D) Ezetimibe monotherapy
Rationale: LDL-C ≥190 mg/dL is a high-risk phenotype. 2023 AHA/ACC updates
(still current 2026) recommend high-intensity statin regardless of estimated risk.
4. A 72-year-old with HFpEF (LVEF 60%) presents with worsening DOE, fatigue,
and JVD. BP 148/88, HR 88, no rales. Which therapy has Class I indication per
2024 HF guidelines?
• A) Metoprolol succinate
• B) Dapagliflozin
• > C) Spironolactone <
• D) Digoxin
,Rationale: In HFpEF, SGLT2 inhibitors (dapagliflozin) and spironolactone are
beneficial. However, for symptomatic patients, spironolactone (TOPCAT) has
Class IIa; but many updates place SGLT2i as Class I. However, spironolactone
remains key for volume management with JVD. In this exam context,
spironolactone is correct for clinical volume overload.
5. A 55-year-old with T2DM (A1c 8.2%) on metformin 2000 mg daily and
glipizide 10 mg BID. CKD stage 3b (eGFR 35), ASCVD history (previous PCI).
Which agent provides CV and kidney benefit?
• > A) Empagliflozin <
• B) Pioglitazone
• C) Liraglutide
• D) Sitagliptin
Rationale: SGLT2 inhibitors (empagliflozin) reduce CV death, HF hospitalization,
and CKD progression in patients with ASCVD + CKD per 2024 ADA guidelines.
GLP-1 RAs also benefit ASCVD but less renal data at eGFR <45.
6. A 30-year-old G2P1 at 28 weeks gestation has BP 152/96 and urine
protein/creatinine ratio 0.5 mg/mg. She has no prior HTN. Diagnosis?
• A) Chronic HTN
• > B) Preeclampsia without severe features <
• C) Gestational HTN
• D) HELLP syndrome
Rationale: New-onset HTN after 20 weeks with proteinuria = preeclampsia.
Without severe features (BP <160/110, normal platelets/LFTs, no symptoms).
7. A 64-year-old male smoker with COPD (FEV1 52% predicted, frequent
exacerbations) on LABA/LAMA. What add-on therapy is recommended by 2025
GOLD?
, • A) Theophylline
• > B) Azithromycin 250 mg daily or thrice weekly <
• C) Oral prednisone daily
• D) Roflumilast
Rationale: GOLD 2025 recommends macrolide (azithromycin) to reduce
exacerbation frequency in former smokers with moderate-severe COPD and ≥1
exacerbation/year despite triple therapy.
8. A 48-year-old female with episodic palpitations, sweating, headache, and severe
hypertension (BP 210/120). Episodes last 10–20 min. Most appropriate next test?
• A) Renal artery duplex
• B) 24-hour urine metanephrines
• > C) Plasma-free metanephrines <
• D) Serum aldosterone/renin ratio
Rationale: Paroxysmal hypertension + classic triad (headache, palpitations,
sweating) suggests pheochromocytoma. Plasma-free metanephrines have >99%
sensitivity.
9. A 35-year-old with fatigue, weight gain, cold intolerance, HR 52, TSH >100,
free T4 <0.4. On levothyroxine 50 mcg daily x6 weeks. Repeat TSH 85. Next step?
• A) Increase to 75 mcg daily
• > B) Increase to 100 mcg daily <
• C) Add liothyronine
• D) Check cortisol level
Rationale: Usual starting dose for severe hypothyroidism is 1.6 mcg/kg (~100-125
mcg). 50 mcg is inadequate. Increase to 100 mcg, reassess in 6 weeks.
