FNP 652 Final Exam Version 2 Newest Actual Exam
With Complete Questions And Correct Detailed
Answers (Verified Answers) |Already Graded A+
1. A patient with type 2 diabetes and chronic kidney disease (eGFR 38 mL/min/1.73m²) is
currently on metformin 1000 mg BID and insulin glargine. HbA1c is 8.9%. Which of the following
changes to the pharmacotherapy regimen is most appropriate to improve glycemic control while
minimizing renal risk?
A. Discontinue metformin and add dapagliflozin 10 mg daily.
B. Continue metformin and add liraglutide 1.8 mg subcutaneously daily.
C. Discontinue metformin and add sitagliptin 50 mg daily.
D. Continue metformin and add glipizide 5 mg daily.
Answer: A
Rationale: Metformin is contraindicated when eGFR <45 due to lactic acidosis risk, so it should be
discontinued. Dapagliflozin (SGLT2 inhibitor) improves glycemic control and has renal protective
effects, making it a preferred add-on in CKD. Liraglutide is also an option but requires dose adjustment;
however, dapagliflozin is more directly renoprotective. Sitagliptin requires dose adjustment but does not
offer the same renal benefits. Glipizide increases hypoglycemia risk and lacks renal benefits.
2. A patient with atrial fibrillation (CHA2DS2-VASc score 4) and a mechanical mitral valve
requires anticoagulation. The patient develops heparin-induced thrombocytopenia (HIT) with
thrombosis. Which anticoagulant is most appropriate for long-term management?
A. Warfarin with a target INR of 2.5-3.5
B. Dabigatran 150 mg BID
C. Argatroban continuous infusion
D. Rivaroxaban 20 mg daily
Answer: A
Rationale: Mechanical mitral valves require warfarin with a higher INR target (2.5-3.5) because DOACs
are contraindicated in mechanical valves due to increased thromboembolic risk. HIT contraindicates
heparin use, but warfarin can be used once platelet count recovers, overlapping with a non-heparin
anticoagulant. Argatroban is for acute HIT, not long-term. Dabigatran and rivaroxaban are not
approved for mechanical valves.
3. A patient with major depressive disorder (MDD) and generalized anxiety disorder (GAD) has
failed adequate trials of sertraline and venlafaxine. The patient also has a history of prolonged QTc
interval (QTc 480 ms). Which of the following antidepressants is safest to initiate?
A. Citalopram 40 mg daily
B. Escitalopram 10 mg daily
Page 1
,C. Bupropion 150 mg BID
D. Amitriptyline 50 mg at bedtime
Answer: B
Rationale: Escitalopram has the least QTc prolongation among SSRIs and is safer in patients with
prolonged QTc. Citalopram carries a dose-dependent risk of QTc prolongation; 40 mg exceeds the
recommended limit for such patients. Bupropion is not first-line for GAD as it may worsen anxiety.
Amitriptyline is a tricyclic antidepressant that significantly prolongs QTc and is contraindicated.
4. A patient with HIV (CD4 count 350 cells/mm³, viral load 50,000 copies/mL) is started on
antiretroviral therapy with tenofovir disoproxil fumarate (TDF)/emtricitabine plus dolutegravir.
Three months later, serum creatinine increases from 0.9 to 1.4 mg/dL. Urinalysis shows proteinuria
and glycosuria with normal serum glucose. Which intervention is most appropriate?
A. Switch TDF to tenofovir alafenamide (TAF).
B. Reduce TDF dose to 150 mg daily.
C. Add probenecid to reduce tubular secretion of creatinine.
D. Discontinue antiretroviral therapy and monitor renal function.
Answer: A
Rationale: TDF is associated with proximal renal tubulopathy, presenting with proteinuria, glycosuria,
and rising creatinine. Switching to TAF, which has less renal toxicity, is recommended. Dose reduction
of TDF is not standard and may not resolve toxicity. Probenecid does not address the underlying
damage. Discontinuing ART would risk HIV progression.
5. A patient with rheumatoid arthritis on chronic prednisone 10 mg daily for 2 years develops
acute-onset severe mid-epigastric pain radiating to the back. Serum lipase is 850 U/L. CT shows
pancreatic necrosis. Which of the following medications is most likely to have contributed to this
complication?
A. Methotrexate
B. Hydroxychloroquine
C. Azathioprine
D. Adalimumab
Answer: C
Rationale: Azathioprine is known to cause acute pancreatitis, particularly in patients with inflammatory
bowel disease or rheumatoid arthritis. The presentation with pancreatic necrosis is classic.
Methotrexate can cause hepatotoxicity but not typically pancreatitis. Hydroxychloroquine rarely causes
pancreatitis. Adalimumab is not associated with pancreatitis.
6. A patient with cirrhosis (Child-Pugh class B) presents with spontaneous bacterial peritonitis
(SBP). Paracentesis reveals PMN count 350 cells/µL. The patient has a history of penicillin allergy
(urticaria). Which antibiotic regimen is most appropriate?
A. Ceftriaxone 2 g IV daily
B. Ciprofloxacin 400 mg IV every 12 hours
C. Cefotaxime 2 g IV every 8 hours
D. Trimethoprim-sulfamethoxazole 160/800 mg IV every 12 hours
Page 2
,Answer: C
Rationale: Cefotaxime is a third-generation cephalosporin and first-line for SBP. While cross-reactivity
with penicillin is low, in a patient with urticaria, a cephalosporin can be used with caution. Ceftriaxone
has higher protein binding and may be less effective in ascites. Ciprofloxacin is a second-line agent but
has increasing resistance. TMP-SMX is not standard for SBP treatment.
7. A patient with bipolar I disorder on lithium therapy for 5 years presents with polyuria,
polydipsia, and a serum creatinine of 1.3 mg/dL (baseline 0.8). Lithium level is 0.6 mEq/L. Urine
osmolality is 300 mOsm/kg after water deprivation. Which of the following is the most appropriate
next step?
A. Increase lithium dose to achieve therapeutic level of 1.0-1.2 mEq/L.
B. Discontinue lithium and start valproic acid.
C. Add amiloride 5 mg daily to counteract renal effects.
D. Start desmopressin to reduce polyuria.
Answer: C
Rationale: The presentation is consistent with lithium-induced nephrogenic diabetes insipidus (NDI).
Amiloride reduces lithium entry into collecting duct cells, ameliorating NDI. Increasing lithium would
worsen toxicity. Discontinuing lithium may be premature if the patient is stable; amiloride can allow
continuation. Desmopressin is ineffective in NDI because the kidney is resistant to ADH.
8. A patient with hypertension and heart failure with reduced ejection fraction (HFrEF, LVEF
35%) is on lisinopril 40 mg daily, carvedilol 25 mg BID, and furosemide 40 mg BID. Despite
adherence, blood pressure remains 148/92 mmHg and the patient has persistent dyspnea on
exertion. Which medication addition is most likely to improve both blood pressure and heart
failure outcomes?
A. Hydrochlorothiazide 25 mg daily
B. Spironolactone 25 mg daily
C. Amlodipine 5 mg daily
D. Clonidine 0.1 mg BID
Answer: B
Rationale: Spironolactone is a mineralocorticoid receptor antagonist indicated in HFrEF to reduce
mortality and hospitalizations. It also provides modest BP reduction. Hydrochlorothiazide is not
recommended in HFrEF due to electrolyte disturbances and lack of mortality benefit. Amlodipine can be
used but does not have the same mortality benefit. Clonidine is not preferred due to side effects and lack
of HF benefit.
9. A patient with severe asthma (eosinophilic phenotype) on high-dose inhaled corticosteroids and
long-acting beta-agonist (ICS/LABA) continues to have exacerbations. Which of the following
biologic therapies targets the interleukin-5 (IL-5) pathway and is most appropriate for this
patient?
A. Omalizumab
B. Mepolizumab
C. Dupilumab
Page 3
, D. Benralizumab
Answer: B
Rationale: Mepolizumab is a monoclonal antibody against IL-5, reducing eosinophil production and is
indicated for severe eosinophilic asthma. Omalizumab targets IgE. Dupilumab blocks IL-4/IL-13.
Benralizumab targets IL-5 receptor, but mepolizumab is the classic IL-5 inhibitor. All are biologics, but
mepolizumab specifically inhibits IL-5.
10. A patient with chronic migraine (15 headache days/month) has failed topiramate, propranolol,
and amitriptyline. The patient has a history of depression and is currently on venlafaxine. Which
of the following preventive medications is most appropriate?
A. Valproic acid 500 mg BID
B. OnabotulinumtoxinA 155 units every 12 weeks
C. Erenumab 70 mg subcutaneously monthly
D. Verapamil 240 mg daily
Answer: C
Rationale: Erenumab is a CGRP antagonist approved for chronic migraine prevention. It is effective and
has no drug interactions with venlafaxine. Valproic acid is teratogenic and may worsen depression.
OnabotulinumtoxinA is indicated for chronic migraine but requires prior failure of multiple oral
preventives; however, CGRP antagonists are often preferred due to better tolerability. Verapamil is used
for cluster headache, not migraine.
11. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with acute
onset of severe right-sided flank pain radiating to the groin, associated with nausea. Urinalysis
shows microscopic hematuria. Which of the following is the most appropriate next step in
management, considering current guidelines for nephrolithiasis?
A. Obtain a non-contrast CT scan of the abdomen and pelvis
B. Prescribe tamsulosin 0.4 mg daily and schedule follow-up in 2 weeks
C. Admit for intravenous hydration and pain control with NSAIDs
D. Perform a renal ultrasound and order a 24-hour urine collection for metabolic evaluation
Answer: A
Rationale: Non-contrast CT is the gold standard for diagnosing ureteral stones in acute flank pain with
hematuria, as it provides precise stone location, size, and density. Tamsulosin may be used for medical
expulsive therapy but requires confirmation of stone presence. Admission is reserved for refractory pain,
obstruction, or infection. Metabolic evaluation is indicated after stone passage or removal.
12. A 30-year-old woman with no significant medical history presents with a 3-week history of
fatigue, arthralgias, and a malar rash. Laboratory studies show positive ANA (1:640, speckled
pattern), positive anti-Smith antibodies, and low C3 and C4. Which of the following is the most
likely diagnosis?
A. Systemic lupus erythematosus
B. Rheumatoid arthritis
C. Sjögren's syndrome
D. Mixed connective tissue disease
Page 4
With Complete Questions And Correct Detailed
Answers (Verified Answers) |Already Graded A+
1. A patient with type 2 diabetes and chronic kidney disease (eGFR 38 mL/min/1.73m²) is
currently on metformin 1000 mg BID and insulin glargine. HbA1c is 8.9%. Which of the following
changes to the pharmacotherapy regimen is most appropriate to improve glycemic control while
minimizing renal risk?
A. Discontinue metformin and add dapagliflozin 10 mg daily.
B. Continue metformin and add liraglutide 1.8 mg subcutaneously daily.
C. Discontinue metformin and add sitagliptin 50 mg daily.
D. Continue metformin and add glipizide 5 mg daily.
Answer: A
Rationale: Metformin is contraindicated when eGFR <45 due to lactic acidosis risk, so it should be
discontinued. Dapagliflozin (SGLT2 inhibitor) improves glycemic control and has renal protective
effects, making it a preferred add-on in CKD. Liraglutide is also an option but requires dose adjustment;
however, dapagliflozin is more directly renoprotective. Sitagliptin requires dose adjustment but does not
offer the same renal benefits. Glipizide increases hypoglycemia risk and lacks renal benefits.
2. A patient with atrial fibrillation (CHA2DS2-VASc score 4) and a mechanical mitral valve
requires anticoagulation. The patient develops heparin-induced thrombocytopenia (HIT) with
thrombosis. Which anticoagulant is most appropriate for long-term management?
A. Warfarin with a target INR of 2.5-3.5
B. Dabigatran 150 mg BID
C. Argatroban continuous infusion
D. Rivaroxaban 20 mg daily
Answer: A
Rationale: Mechanical mitral valves require warfarin with a higher INR target (2.5-3.5) because DOACs
are contraindicated in mechanical valves due to increased thromboembolic risk. HIT contraindicates
heparin use, but warfarin can be used once platelet count recovers, overlapping with a non-heparin
anticoagulant. Argatroban is for acute HIT, not long-term. Dabigatran and rivaroxaban are not
approved for mechanical valves.
3. A patient with major depressive disorder (MDD) and generalized anxiety disorder (GAD) has
failed adequate trials of sertraline and venlafaxine. The patient also has a history of prolonged QTc
interval (QTc 480 ms). Which of the following antidepressants is safest to initiate?
A. Citalopram 40 mg daily
B. Escitalopram 10 mg daily
Page 1
,C. Bupropion 150 mg BID
D. Amitriptyline 50 mg at bedtime
Answer: B
Rationale: Escitalopram has the least QTc prolongation among SSRIs and is safer in patients with
prolonged QTc. Citalopram carries a dose-dependent risk of QTc prolongation; 40 mg exceeds the
recommended limit for such patients. Bupropion is not first-line for GAD as it may worsen anxiety.
Amitriptyline is a tricyclic antidepressant that significantly prolongs QTc and is contraindicated.
4. A patient with HIV (CD4 count 350 cells/mm³, viral load 50,000 copies/mL) is started on
antiretroviral therapy with tenofovir disoproxil fumarate (TDF)/emtricitabine plus dolutegravir.
Three months later, serum creatinine increases from 0.9 to 1.4 mg/dL. Urinalysis shows proteinuria
and glycosuria with normal serum glucose. Which intervention is most appropriate?
A. Switch TDF to tenofovir alafenamide (TAF).
B. Reduce TDF dose to 150 mg daily.
C. Add probenecid to reduce tubular secretion of creatinine.
D. Discontinue antiretroviral therapy and monitor renal function.
Answer: A
Rationale: TDF is associated with proximal renal tubulopathy, presenting with proteinuria, glycosuria,
and rising creatinine. Switching to TAF, which has less renal toxicity, is recommended. Dose reduction
of TDF is not standard and may not resolve toxicity. Probenecid does not address the underlying
damage. Discontinuing ART would risk HIV progression.
5. A patient with rheumatoid arthritis on chronic prednisone 10 mg daily for 2 years develops
acute-onset severe mid-epigastric pain radiating to the back. Serum lipase is 850 U/L. CT shows
pancreatic necrosis. Which of the following medications is most likely to have contributed to this
complication?
A. Methotrexate
B. Hydroxychloroquine
C. Azathioprine
D. Adalimumab
Answer: C
Rationale: Azathioprine is known to cause acute pancreatitis, particularly in patients with inflammatory
bowel disease or rheumatoid arthritis. The presentation with pancreatic necrosis is classic.
Methotrexate can cause hepatotoxicity but not typically pancreatitis. Hydroxychloroquine rarely causes
pancreatitis. Adalimumab is not associated with pancreatitis.
6. A patient with cirrhosis (Child-Pugh class B) presents with spontaneous bacterial peritonitis
(SBP). Paracentesis reveals PMN count 350 cells/µL. The patient has a history of penicillin allergy
(urticaria). Which antibiotic regimen is most appropriate?
A. Ceftriaxone 2 g IV daily
B. Ciprofloxacin 400 mg IV every 12 hours
C. Cefotaxime 2 g IV every 8 hours
D. Trimethoprim-sulfamethoxazole 160/800 mg IV every 12 hours
Page 2
,Answer: C
Rationale: Cefotaxime is a third-generation cephalosporin and first-line for SBP. While cross-reactivity
with penicillin is low, in a patient with urticaria, a cephalosporin can be used with caution. Ceftriaxone
has higher protein binding and may be less effective in ascites. Ciprofloxacin is a second-line agent but
has increasing resistance. TMP-SMX is not standard for SBP treatment.
7. A patient with bipolar I disorder on lithium therapy for 5 years presents with polyuria,
polydipsia, and a serum creatinine of 1.3 mg/dL (baseline 0.8). Lithium level is 0.6 mEq/L. Urine
osmolality is 300 mOsm/kg after water deprivation. Which of the following is the most appropriate
next step?
A. Increase lithium dose to achieve therapeutic level of 1.0-1.2 mEq/L.
B. Discontinue lithium and start valproic acid.
C. Add amiloride 5 mg daily to counteract renal effects.
D. Start desmopressin to reduce polyuria.
Answer: C
Rationale: The presentation is consistent with lithium-induced nephrogenic diabetes insipidus (NDI).
Amiloride reduces lithium entry into collecting duct cells, ameliorating NDI. Increasing lithium would
worsen toxicity. Discontinuing lithium may be premature if the patient is stable; amiloride can allow
continuation. Desmopressin is ineffective in NDI because the kidney is resistant to ADH.
8. A patient with hypertension and heart failure with reduced ejection fraction (HFrEF, LVEF
35%) is on lisinopril 40 mg daily, carvedilol 25 mg BID, and furosemide 40 mg BID. Despite
adherence, blood pressure remains 148/92 mmHg and the patient has persistent dyspnea on
exertion. Which medication addition is most likely to improve both blood pressure and heart
failure outcomes?
A. Hydrochlorothiazide 25 mg daily
B. Spironolactone 25 mg daily
C. Amlodipine 5 mg daily
D. Clonidine 0.1 mg BID
Answer: B
Rationale: Spironolactone is a mineralocorticoid receptor antagonist indicated in HFrEF to reduce
mortality and hospitalizations. It also provides modest BP reduction. Hydrochlorothiazide is not
recommended in HFrEF due to electrolyte disturbances and lack of mortality benefit. Amlodipine can be
used but does not have the same mortality benefit. Clonidine is not preferred due to side effects and lack
of HF benefit.
9. A patient with severe asthma (eosinophilic phenotype) on high-dose inhaled corticosteroids and
long-acting beta-agonist (ICS/LABA) continues to have exacerbations. Which of the following
biologic therapies targets the interleukin-5 (IL-5) pathway and is most appropriate for this
patient?
A. Omalizumab
B. Mepolizumab
C. Dupilumab
Page 3
, D. Benralizumab
Answer: B
Rationale: Mepolizumab is a monoclonal antibody against IL-5, reducing eosinophil production and is
indicated for severe eosinophilic asthma. Omalizumab targets IgE. Dupilumab blocks IL-4/IL-13.
Benralizumab targets IL-5 receptor, but mepolizumab is the classic IL-5 inhibitor. All are biologics, but
mepolizumab specifically inhibits IL-5.
10. A patient with chronic migraine (15 headache days/month) has failed topiramate, propranolol,
and amitriptyline. The patient has a history of depression and is currently on venlafaxine. Which
of the following preventive medications is most appropriate?
A. Valproic acid 500 mg BID
B. OnabotulinumtoxinA 155 units every 12 weeks
C. Erenumab 70 mg subcutaneously monthly
D. Verapamil 240 mg daily
Answer: C
Rationale: Erenumab is a CGRP antagonist approved for chronic migraine prevention. It is effective and
has no drug interactions with venlafaxine. Valproic acid is teratogenic and may worsen depression.
OnabotulinumtoxinA is indicated for chronic migraine but requires prior failure of multiple oral
preventives; however, CGRP antagonists are often preferred due to better tolerability. Verapamil is used
for cluster headache, not migraine.
11. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with acute
onset of severe right-sided flank pain radiating to the groin, associated with nausea. Urinalysis
shows microscopic hematuria. Which of the following is the most appropriate next step in
management, considering current guidelines for nephrolithiasis?
A. Obtain a non-contrast CT scan of the abdomen and pelvis
B. Prescribe tamsulosin 0.4 mg daily and schedule follow-up in 2 weeks
C. Admit for intravenous hydration and pain control with NSAIDs
D. Perform a renal ultrasound and order a 24-hour urine collection for metabolic evaluation
Answer: A
Rationale: Non-contrast CT is the gold standard for diagnosing ureteral stones in acute flank pain with
hematuria, as it provides precise stone location, size, and density. Tamsulosin may be used for medical
expulsive therapy but requires confirmation of stone presence. Admission is reserved for refractory pain,
obstruction, or infection. Metabolic evaluation is indicated after stone passage or removal.
12. A 30-year-old woman with no significant medical history presents with a 3-week history of
fatigue, arthralgias, and a malar rash. Laboratory studies show positive ANA (1:640, speckled
pattern), positive anti-Smith antibodies, and low C3 and C4. Which of the following is the most
likely diagnosis?
A. Systemic lupus erythematosus
B. Rheumatoid arthritis
C. Sjögren's syndrome
D. Mixed connective tissue disease
Page 4
