NRNP 6531 Midterm Exam (Version 2) | Questions
And Answers With Rationales | Latest 2026/27 |
Digital Download Pdf | Graded A
Cardiovascular & Hypertension
1. A 60-year-old Black man with hypertension and no other comorbidities has
BP 146/90. What is the preferred initial antihypertensive?
a) Lisinopril
b) Amlodipine
c) Metoprolol
d) Clonidine
Rationale: In Black patients without CKD or heart failure, initial therapy should
be a CCB (amlodipine) or thiazide diuretic based on ACCOMPLISH and ALLHAT
trials.
2. A patient with heart failure with reduced ejection fraction (HFrEF) is on
sacubitril/valsartan. Which lab finding requires immediate holding of the
medication?
a) Potassium 6.1 mEq/L
b) Sodium 135 mEq/L
c) BUN 25 mg/dL
d) Creatinine 1.3 mg/dL
*Rationale: Sacubitril/valsartan (ARBNI) can cause hyperkalemia. Potassium
>5.5 mEq/L warrants dose reduction or holding.*
3. Which medication for atrial fibrillation requires INR monitoring at least
every 4 weeks?
a) Apixaban
b) Dabigatran
c) Warfarin
d) Rivaroxaban
Rationale: Warfarin requires frequent INR monitoring (goal 2–3 for most AF);
DOACs do not require routine monitoring.
4. A patient with hypertension has a serum creatinine increase of 35% after
starting lisinopril. What is the most appropriate action?
a) Continue lisinopril; repeat creatinine in 2 weeks
b) Discontinue lisinopril immediately
,c) Add hydrochlorothiazide
d) Switch to clonidine
*Rationale: ACE inhibitor-induced increase in creatinine up to 30% is expected
due to efferent arteriolar dilation; continue if stable and <30–35%.*
5. A 72-year-old with systolic BP 162/78. Heart rate 52. Which antihypertensive
should be avoided?
a) Amlodipine
b) Chlorthalidone
c) Metoprolol
d) Losartan
*Rationale: Beta-blockers (metoprolol) lower heart rate; bradycardia (HR <60)
is a relative contraindication unless pacemaker.*
Diabetes & Endocrinology
6. A 55-year-old with type 2 diabetes, BMI 36, and history of stroke is on
metformin and glipizide. HbA1c 8.2%. Which agent adds the greatest reduction
in recurrent stroke risk?
a) Liraglutide
b) Pioglitazone
c) Sitagliptin
d) Insulin glargine
*Rationale: GLP-1 receptor agonists (liraglutide, semaglutide) reduce major
adverse CV events including stroke in high-risk patients.*
7. A patient with type 2 diabetes and CKD (eGFR 25) has HbA1c 7.8% on
metformin. What change is needed?
a) Stop metformin
b) Increase metformin to 2000 mg
c) Add pioglitazone
d) Add SGLT2 inhibitor
Rationale: Metformin is contraindicated if eGFR <30. Stop metformin; consider
SGLT2 inhibitor (empagliflozin) if eGFR ≥20, or insulin.
8. Which statement about insulin glargine U-100 is correct?
a) It has a peak effect at 8–12 hours
b) It should be given twice daily
c) It is a rapid-acting insulin
d) It can be mixed with regular insulin in the same syringe
, *Rationale: Insulin glargine is long-acting, peakless (flat profile), duration
~24h; do not mix with other insulins due to pH incompatibility.*
9. A 45-year-old with type 2 diabetes on metformin reports no hypoglycemia
but HbA1c 7.2%. Labs: AST 80, ALT 90, platelets 180, INR 1.0. Next step?
a) FibroScan or liver biopsy
b) Stop metformin
c) Add insulin
d) Repeat LFTs in 6 months
Rationale: Elevated LFTs with metabolic syndrome suggests non-alcoholic
steatohepatitis (NASH). Assess fibrosis; metformin is not hepatotoxic.
10. A patient with diabetes has a foot ulcer with no erythema or purulence, but
probe-to-bone testing is positive. What is the most likely diagnosis?
a) Osteomyelitis
b) Neuropathic ulcer
c) Cellulitis
d) Charcot foot
Rationale: Probe-to-bone positive has high sensitivity for osteomyelitis in
diabetic foot ulcers.
Respiratory (COPD/Asthma)
11. A 65-year-old with COPD GOLD stage 2 (FEV1 65%) has 2 exacerbations in
past year. He is on tiotropium. What is next step?
a) Add LABA alone
b) Add LABA/ICS combination
c) Add roflumilast
d) Add theophylline
*Rationale: Frequent exacerbations despite LAMA → add LABA/ICS (triple
therapy). Roflumilast for FEV1 <50% and chronic bronchitis.*
12. An asthmatic patient on ICS-formoterol as maintenance and reliever
therapy reports using the reliever 4 times per week. What is appropriate?
a) Step up to medium-dose ICS-formoterol
b) Add montelukast
c) Switch to daily ICS + SABA
d) Add oral prednisone
*Rationale: GINA step 3: low-dose ICS-formoterol as MART. If symptoms
>2x/week, step up to medium-dose ICS-formoterol.*
And Answers With Rationales | Latest 2026/27 |
Digital Download Pdf | Graded A
Cardiovascular & Hypertension
1. A 60-year-old Black man with hypertension and no other comorbidities has
BP 146/90. What is the preferred initial antihypertensive?
a) Lisinopril
b) Amlodipine
c) Metoprolol
d) Clonidine
Rationale: In Black patients without CKD or heart failure, initial therapy should
be a CCB (amlodipine) or thiazide diuretic based on ACCOMPLISH and ALLHAT
trials.
2. A patient with heart failure with reduced ejection fraction (HFrEF) is on
sacubitril/valsartan. Which lab finding requires immediate holding of the
medication?
a) Potassium 6.1 mEq/L
b) Sodium 135 mEq/L
c) BUN 25 mg/dL
d) Creatinine 1.3 mg/dL
*Rationale: Sacubitril/valsartan (ARBNI) can cause hyperkalemia. Potassium
>5.5 mEq/L warrants dose reduction or holding.*
3. Which medication for atrial fibrillation requires INR monitoring at least
every 4 weeks?
a) Apixaban
b) Dabigatran
c) Warfarin
d) Rivaroxaban
Rationale: Warfarin requires frequent INR monitoring (goal 2–3 for most AF);
DOACs do not require routine monitoring.
4. A patient with hypertension has a serum creatinine increase of 35% after
starting lisinopril. What is the most appropriate action?
a) Continue lisinopril; repeat creatinine in 2 weeks
b) Discontinue lisinopril immediately
,c) Add hydrochlorothiazide
d) Switch to clonidine
*Rationale: ACE inhibitor-induced increase in creatinine up to 30% is expected
due to efferent arteriolar dilation; continue if stable and <30–35%.*
5. A 72-year-old with systolic BP 162/78. Heart rate 52. Which antihypertensive
should be avoided?
a) Amlodipine
b) Chlorthalidone
c) Metoprolol
d) Losartan
*Rationale: Beta-blockers (metoprolol) lower heart rate; bradycardia (HR <60)
is a relative contraindication unless pacemaker.*
Diabetes & Endocrinology
6. A 55-year-old with type 2 diabetes, BMI 36, and history of stroke is on
metformin and glipizide. HbA1c 8.2%. Which agent adds the greatest reduction
in recurrent stroke risk?
a) Liraglutide
b) Pioglitazone
c) Sitagliptin
d) Insulin glargine
*Rationale: GLP-1 receptor agonists (liraglutide, semaglutide) reduce major
adverse CV events including stroke in high-risk patients.*
7. A patient with type 2 diabetes and CKD (eGFR 25) has HbA1c 7.8% on
metformin. What change is needed?
a) Stop metformin
b) Increase metformin to 2000 mg
c) Add pioglitazone
d) Add SGLT2 inhibitor
Rationale: Metformin is contraindicated if eGFR <30. Stop metformin; consider
SGLT2 inhibitor (empagliflozin) if eGFR ≥20, or insulin.
8. Which statement about insulin glargine U-100 is correct?
a) It has a peak effect at 8–12 hours
b) It should be given twice daily
c) It is a rapid-acting insulin
d) It can be mixed with regular insulin in the same syringe
, *Rationale: Insulin glargine is long-acting, peakless (flat profile), duration
~24h; do not mix with other insulins due to pH incompatibility.*
9. A 45-year-old with type 2 diabetes on metformin reports no hypoglycemia
but HbA1c 7.2%. Labs: AST 80, ALT 90, platelets 180, INR 1.0. Next step?
a) FibroScan or liver biopsy
b) Stop metformin
c) Add insulin
d) Repeat LFTs in 6 months
Rationale: Elevated LFTs with metabolic syndrome suggests non-alcoholic
steatohepatitis (NASH). Assess fibrosis; metformin is not hepatotoxic.
10. A patient with diabetes has a foot ulcer with no erythema or purulence, but
probe-to-bone testing is positive. What is the most likely diagnosis?
a) Osteomyelitis
b) Neuropathic ulcer
c) Cellulitis
d) Charcot foot
Rationale: Probe-to-bone positive has high sensitivity for osteomyelitis in
diabetic foot ulcers.
Respiratory (COPD/Asthma)
11. A 65-year-old with COPD GOLD stage 2 (FEV1 65%) has 2 exacerbations in
past year. He is on tiotropium. What is next step?
a) Add LABA alone
b) Add LABA/ICS combination
c) Add roflumilast
d) Add theophylline
*Rationale: Frequent exacerbations despite LAMA → add LABA/ICS (triple
therapy). Roflumilast for FEV1 <50% and chronic bronchitis.*
12. An asthmatic patient on ICS-formoterol as maintenance and reliever
therapy reports using the reliever 4 times per week. What is appropriate?
a) Step up to medium-dose ICS-formoterol
b) Add montelukast
c) Switch to daily ICS + SABA
d) Add oral prednisone
*Rationale: GINA step 3: low-dose ICS-formoterol as MART. If symptoms
>2x/week, step up to medium-dose ICS-formoterol.*
