NUR 6121 - Exam 3 | Actual Questions and Answers | 2026
Update | 100% Correct - William Paterson University. - 149
Questions
Section 1: Cardiovascular Disorders (Questions 1-15)
1 A patient with chronic heart failure (HFrEF) on optimal medical therapy presents with worsening dyspnea and a
new S3 gallop. Echocardiogram shows left ventricular ejection fraction (LVEF) of 35%, unchanged from 3
months ago. Which hemodynamic profile is most likely present?
A) Warm and dry (normal perfusion, no congestion)
B) Cold and dry (low perfusion, no congestion)
C) Warm and wet (normal perfusion, congestion)
D) Cold and wet (low perfusion, congestion)
Answer: D
Rationale: The presence of worsening dyspnea and S3 gallop indicates congestion (wet), while unchanged LVEF but
low perfusion signs (e.g., narrow pulse pressure, cool extremities) suggest cold profile. This is a classic
decompensated heart failure with low output and volume overload.
2 A patient with atrial fibrillation (AF) has a CHA2DS2-VASc score of 4. They are currently on warfarin with
therapeutic INR. A new medication is added that significantly increases the INR. Which of the following is the
most likely mechanism of this interaction?
A) Inhibition of CYP3A4 leading to reduced warfarin clearance
B) Displacement of warfarin from albumin binding sites
C) Induction of CYP2C9 increasing warfarin metabolism
D) Competitive antagonism of vitamin K epoxide reductase
Answer: B
Rationale: Warfarin is highly protein bound (99%). Displacement by another drug (e.g., sulfonamides, NSAIDs)
increases free warfarin, potentiating anticoagulation and raising INR. CYP3A4 inhibition is less significant for
warfarin; CYP2C9 is the major metabolizer. Vitamin K epoxide reductase is warfarin's target, not a mechanism of
interaction.
3 A patient with ST-elevation myocardial infarction (STEMI) undergoes primary percutaneous coronary
intervention (PCI) with drug-eluting stent placement. Which antiplatelet regimen is most appropriate for
long-term secondary prevention?
A) Aspirin 81 mg daily plus clopidogrel 75 mg daily for 1 month, then aspirin alone
B) Aspirin 325 mg daily plus ticagrelor 90 mg twice daily for 12 months, then aspirin alone
C) Aspirin 81 mg daily plus prasugrel 10 mg daily for 12 months, then aspirin alone
D) Aspirin 162 mg daily plus warfarin INR 2-3 for 12 months, then aspirin alone
Answer: C
Rationale: Current ACC/AHA guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and a P2Y12
inhibitor (prasugrel or ticagrelor) for 12 months after PCI for STEMI. Prasugrel is preferred over clopidogrel due to
more potent and consistent inhibition. Ticagrelor is also acceptable, but prasugrel is specifically indicated for ACS
patients undergoing PCI. Warfarin is not part of standard DAPT.
, 4 A patient presents with acute onset of chest pain and dyspnea. ECG shows sinus tachycardia with S1Q3T3
pattern. D-dimer is elevated. CT pulmonary angiography confirms a filling defect in the right main pulmonary
artery. Vital signs: BP 85/50 mmHg, HR 120 bpm, RR 28, SpO2 88% on room air. Which is the most
appropriate initial management?
A) Initiate therapeutic heparin infusion and admit to telemetry
B) Administer tissue plasminogen activator (tPA) and transfer to ICU
C) Start oral rivaroxaban and schedule echocardiogram
D) Place an inferior vena cava filter and observe
Answer: B
Rationale: This patient has massive pulmonary embolism (PE) with hemodynamic instability (hypotension,
hypoxia). Guidelines recommend immediate thrombolysis (tPA) in massive PE without contraindications. Heparin
alone is insufficient; rivaroxaban is not first-line in acute unstable PE; IVC filter is reserved for contraindications to
anticoagulation.
5 A patient with hypertension and diabetes is started on lisinopril. Two weeks later, serum creatinine rises from
0.9 to 1.4 mg/dL. Which of the following best explains this change?
A) Acute tubular necrosis from decreased renal perfusion
B) Reduced glomerular filtration pressure due to efferent arteriolar dilation
C) Interstitial nephritis from an allergic reaction
D) Volume depletion from concurrent diuretic use
Answer: B
Rationale: ACE inhibitors (like lisinopril) dilate the efferent arteriole, reducing intraglomerular pressure and GFR.
A mild rise in creatinine (up to 30%) is expected and usually stabilizes. Acute tubular necrosis would cause a
larger, progressive rise; interstitial nephritis is rare and often accompanied by fever, rash, eosinophilia.
6 A patient with hypertrophic cardiomyopathy (HCM) experiences exertional syncope. Which hemodynamic
mechanism most likely contributes to this symptom?
A) Increased left ventricular end-diastolic pressure causing pulmonary congestion
B) Dynamic left ventricular outflow tract obstruction exacerbated by increased contractility
C) Mitral regurgitation due to papillary muscle displacement
D) Coronary vasospasm leading to demand ischemia
Answer: B
Rationale: In HCM, hypertrophy of the septum and systolic anterior motion of the mitral valve can cause dynamic
LVOT obstruction. During exercise, increased contractility and decreased preload worsen obstruction, reducing
cardiac output and causing syncope. Pulmonary congestion is not typical; mitral regurgitation is secondary;
coronary vasospasm is not a primary mechanism.
7 A patient with aortic stenosis (valve area 0.8 cm²) is scheduled for surgical valve replacement. Preoperative
evaluation reveals left ventricular hypertrophy and a history of hypertension. Which of the following is a critical
consideration for anesthetic management?
A) Maintain sinus rhythm and avoid bradycardia
B) Induce hypotension to reduce afterload
C) Administer beta-blockers to prevent tachycardia
D) Use vasopressors cautiously to avoid increasing afterload
Answer: A
Rationale: In severe aortic stenosis, the left ventricle is pressure-overloaded and relies on preload and sinus rhythm
to maintain cardiac output. Bradycardia can reduce cardiac output; tachycardia is also poorly tolerated.
,Hypotension should be avoided as it reduces coronary perfusion. Beta-blockers are not first-line; vasopressors may
be needed but cautiously.
8 A patient with dilated cardiomyopathy (LVEF 25%) is started on carvedilol. After 3 months, LVEF improves to
35%. What is the most likely mechanism for this improvement?
A) Reduction in heart rate allowing increased diastolic filling time
B) Upregulation of beta-1 receptors in the myocardium
C) Inhibition of sympathetic nervous system overactivity causing reverse remodeling
D) Direct positive inotropic effect on cardiac myocytes
Answer: C
Rationale: Beta-blockers like carvedilol reduce the deleterious effects of chronic sympathetic activation, leading to
improved myocardial energetics, decreased apoptosis, and reverse remodeling. This results in improved LVEF over
months. Upregulation of beta-receptors occurs but is not the primary mechanism; carvedilol has no direct positive
inotropy; increased filling time is a minor factor.
9 A patient with acute decompensated heart failure has a pulmonary artery catheter placed. Hemodynamics:
PCWP 28 mm Hg, cardiac index 1.8 L/min/m², SVR 1800 dynes-s/cm. Which combination of therapies is most
appropriate?
A) Intravenous nitroglycerin and furosemide
B) Intravenous dobutamine and sodium nitroprusside
C) Intravenous milrinone and metoprolol
D) Intravenous norepinephrine and digoxin
Answer: B
Rationale: This profile shows low cardiac output (CI <2.2) with high filling pressures (PCWP >18) and high SVR
(vasoconstriction). Combination of an inotrope (dobutamine) and vasodilator (nitroprusside) can improve
contractility and reduce afterload, increasing cardiac output. Nitroglycerin is primarily venodilator; furosemide
alone insufficient. Milrinone plus beta-blocker is not recommended acutely; norepinephrine increases afterload.
10 A patient with chronic atrial fibrillation and a mechanical mitral valve is being anticoagulated with warfarin.
Their INR is 2.8. Which of the following dietary changes would most likely decrease the INR?
A) Increasing intake of leafy green vegetables
B) Switching from brand-name to generic warfarin
C) Starting a high-protein, low-carbohydrate diet
D) Adding a daily multivitamin containing vitamin K
Answer: A
Rationale: Leafy green vegetables are rich in vitamin K, which antagonizes warfarin's effect by providing substrate
for clotting factor synthesis. Increased vitamin K intake can lower INR. Generic warfarin is bioequivalent; protein
diets have minimal effect; multivitamins with vitamin K also lower INR, but the question asks for most likely, and
leafy greens are a common cause of INR fluctuation.
11 A patient with chronic heart failure (NYHA class III) on optimal medical therapy including an angiotensin
receptor-neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA) continues
to have symptoms and a left ventricular ejection fraction (LVEF) of 30%. Which of the following interventions
is most likely to improve survival and reduce hospitalizations based on current guidelines?
A) Addition of ivabradine
B) Initiation of digoxin
C) Cardiac resynchronization therapy with defibrillator (CRT-D)
, D) Up-titration of loop diuretic to achieve euvolemia
Answer: C
Rationale: For patients with HFrEF (LVEF "d35%), NYHA class II-IV, and wide QRS ("e130 ms), CRT-D reduces
mortality and hospitalizations. Ivabradine is reserved for those in sinus rhythm with heart rate 70 bpm despite
beta-blocker. Digoxin reduces hospitalizations but not mortality. Diuretics relieve symptoms but do not improve
survival.
12 In the management of acute decompensated heart failure (ADHF) with severe pulmonary congestion and
systolic blood pressure >100 mm Hg, which vasoactive agent is most appropriate as first-line therapy to
improve hemodynamics and symptoms?
A) Dobutamine
B) Milrinone
C) Nesiritide
D) Nitroglycerin
Answer: D
Rationale: Nitroglycerin is a venodilator that reduces preload and improves pulmonary congestion without
increasing myocardial oxygen demand; it is preferred in patients with adequate blood pressure. Dobutamine and
milrinone are inotropes reserved for hypotension or low cardiac output. Nesiritide is not recommended as first-line
due to lack of mortality benefit and potential renal harm.
13 A patient with atrial fibrillation (AF) and a CHADS-VASc score of 3 is started on apixaban. Which of the
following statements best describes the mechanism of action and monitoring requirements for this agent?
A) Direct thrombin inhibitor requiring periodic aPTT monitoring
B) Factor Xa inhibitor with no routine coagulation monitoring
C) Vitamin K antagonist requiring INR monitoring
D) Factor Xa inhibitor requiring anti-Xa level monitoring
Answer: B
Rationale: Apixaban is a direct oral factor Xa inhibitor with predictable pharmacokinetics; routine coagulation
monitoring is not required. Anti-Xa levels can be measured but are not standard. Direct thrombin inhibitors (e.g.,
dabigatran) do not require aPTT monitoring for efficacy. Vitamin K antagonists (e.g., warfarin) require INR
monitoring.
14 A patient with ST-segment elevation myocardial infarction (STEMI) presents 4 hours after symptom onset.
Primary percutaneous coronary intervention (PCI) is not available within 120 minutes. Which reperfusion
strategy is most appropriate?
A) Immediate administration of tenecteplase followed by transfer to a PCI-capable facility
B) Delayed PCI at 24 hours after heparin infusion
C) Conservative medical management with aspirin, heparin, and clopidogrel
D) Emergent coronary artery bypass grafting (CABG)
Answer: A
Rationale: When timely PCI is not feasible, fibrinolytic therapy (e.g., tenecteplase) should be given within 30
minutes of arrival, followed by routine early transfer for angiography. Delayed PCI or conservative management is
inferior. Emergent CABG is reserved for failed PCI or mechanical complications.
15 A patient with hypertrophic cardiomyopathy (HCM) and left ventricular outflow tract obstruction presents with
exertional syncope and dyspnea. Which medication is most appropriate to reduce obstruction and improve
symptoms?
Update | 100% Correct - William Paterson University. - 149
Questions
Section 1: Cardiovascular Disorders (Questions 1-15)
1 A patient with chronic heart failure (HFrEF) on optimal medical therapy presents with worsening dyspnea and a
new S3 gallop. Echocardiogram shows left ventricular ejection fraction (LVEF) of 35%, unchanged from 3
months ago. Which hemodynamic profile is most likely present?
A) Warm and dry (normal perfusion, no congestion)
B) Cold and dry (low perfusion, no congestion)
C) Warm and wet (normal perfusion, congestion)
D) Cold and wet (low perfusion, congestion)
Answer: D
Rationale: The presence of worsening dyspnea and S3 gallop indicates congestion (wet), while unchanged LVEF but
low perfusion signs (e.g., narrow pulse pressure, cool extremities) suggest cold profile. This is a classic
decompensated heart failure with low output and volume overload.
2 A patient with atrial fibrillation (AF) has a CHA2DS2-VASc score of 4. They are currently on warfarin with
therapeutic INR. A new medication is added that significantly increases the INR. Which of the following is the
most likely mechanism of this interaction?
A) Inhibition of CYP3A4 leading to reduced warfarin clearance
B) Displacement of warfarin from albumin binding sites
C) Induction of CYP2C9 increasing warfarin metabolism
D) Competitive antagonism of vitamin K epoxide reductase
Answer: B
Rationale: Warfarin is highly protein bound (99%). Displacement by another drug (e.g., sulfonamides, NSAIDs)
increases free warfarin, potentiating anticoagulation and raising INR. CYP3A4 inhibition is less significant for
warfarin; CYP2C9 is the major metabolizer. Vitamin K epoxide reductase is warfarin's target, not a mechanism of
interaction.
3 A patient with ST-elevation myocardial infarction (STEMI) undergoes primary percutaneous coronary
intervention (PCI) with drug-eluting stent placement. Which antiplatelet regimen is most appropriate for
long-term secondary prevention?
A) Aspirin 81 mg daily plus clopidogrel 75 mg daily for 1 month, then aspirin alone
B) Aspirin 325 mg daily plus ticagrelor 90 mg twice daily for 12 months, then aspirin alone
C) Aspirin 81 mg daily plus prasugrel 10 mg daily for 12 months, then aspirin alone
D) Aspirin 162 mg daily plus warfarin INR 2-3 for 12 months, then aspirin alone
Answer: C
Rationale: Current ACC/AHA guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and a P2Y12
inhibitor (prasugrel or ticagrelor) for 12 months after PCI for STEMI. Prasugrel is preferred over clopidogrel due to
more potent and consistent inhibition. Ticagrelor is also acceptable, but prasugrel is specifically indicated for ACS
patients undergoing PCI. Warfarin is not part of standard DAPT.
, 4 A patient presents with acute onset of chest pain and dyspnea. ECG shows sinus tachycardia with S1Q3T3
pattern. D-dimer is elevated. CT pulmonary angiography confirms a filling defect in the right main pulmonary
artery. Vital signs: BP 85/50 mmHg, HR 120 bpm, RR 28, SpO2 88% on room air. Which is the most
appropriate initial management?
A) Initiate therapeutic heparin infusion and admit to telemetry
B) Administer tissue plasminogen activator (tPA) and transfer to ICU
C) Start oral rivaroxaban and schedule echocardiogram
D) Place an inferior vena cava filter and observe
Answer: B
Rationale: This patient has massive pulmonary embolism (PE) with hemodynamic instability (hypotension,
hypoxia). Guidelines recommend immediate thrombolysis (tPA) in massive PE without contraindications. Heparin
alone is insufficient; rivaroxaban is not first-line in acute unstable PE; IVC filter is reserved for contraindications to
anticoagulation.
5 A patient with hypertension and diabetes is started on lisinopril. Two weeks later, serum creatinine rises from
0.9 to 1.4 mg/dL. Which of the following best explains this change?
A) Acute tubular necrosis from decreased renal perfusion
B) Reduced glomerular filtration pressure due to efferent arteriolar dilation
C) Interstitial nephritis from an allergic reaction
D) Volume depletion from concurrent diuretic use
Answer: B
Rationale: ACE inhibitors (like lisinopril) dilate the efferent arteriole, reducing intraglomerular pressure and GFR.
A mild rise in creatinine (up to 30%) is expected and usually stabilizes. Acute tubular necrosis would cause a
larger, progressive rise; interstitial nephritis is rare and often accompanied by fever, rash, eosinophilia.
6 A patient with hypertrophic cardiomyopathy (HCM) experiences exertional syncope. Which hemodynamic
mechanism most likely contributes to this symptom?
A) Increased left ventricular end-diastolic pressure causing pulmonary congestion
B) Dynamic left ventricular outflow tract obstruction exacerbated by increased contractility
C) Mitral regurgitation due to papillary muscle displacement
D) Coronary vasospasm leading to demand ischemia
Answer: B
Rationale: In HCM, hypertrophy of the septum and systolic anterior motion of the mitral valve can cause dynamic
LVOT obstruction. During exercise, increased contractility and decreased preload worsen obstruction, reducing
cardiac output and causing syncope. Pulmonary congestion is not typical; mitral regurgitation is secondary;
coronary vasospasm is not a primary mechanism.
7 A patient with aortic stenosis (valve area 0.8 cm²) is scheduled for surgical valve replacement. Preoperative
evaluation reveals left ventricular hypertrophy and a history of hypertension. Which of the following is a critical
consideration for anesthetic management?
A) Maintain sinus rhythm and avoid bradycardia
B) Induce hypotension to reduce afterload
C) Administer beta-blockers to prevent tachycardia
D) Use vasopressors cautiously to avoid increasing afterload
Answer: A
Rationale: In severe aortic stenosis, the left ventricle is pressure-overloaded and relies on preload and sinus rhythm
to maintain cardiac output. Bradycardia can reduce cardiac output; tachycardia is also poorly tolerated.
,Hypotension should be avoided as it reduces coronary perfusion. Beta-blockers are not first-line; vasopressors may
be needed but cautiously.
8 A patient with dilated cardiomyopathy (LVEF 25%) is started on carvedilol. After 3 months, LVEF improves to
35%. What is the most likely mechanism for this improvement?
A) Reduction in heart rate allowing increased diastolic filling time
B) Upregulation of beta-1 receptors in the myocardium
C) Inhibition of sympathetic nervous system overactivity causing reverse remodeling
D) Direct positive inotropic effect on cardiac myocytes
Answer: C
Rationale: Beta-blockers like carvedilol reduce the deleterious effects of chronic sympathetic activation, leading to
improved myocardial energetics, decreased apoptosis, and reverse remodeling. This results in improved LVEF over
months. Upregulation of beta-receptors occurs but is not the primary mechanism; carvedilol has no direct positive
inotropy; increased filling time is a minor factor.
9 A patient with acute decompensated heart failure has a pulmonary artery catheter placed. Hemodynamics:
PCWP 28 mm Hg, cardiac index 1.8 L/min/m², SVR 1800 dynes-s/cm. Which combination of therapies is most
appropriate?
A) Intravenous nitroglycerin and furosemide
B) Intravenous dobutamine and sodium nitroprusside
C) Intravenous milrinone and metoprolol
D) Intravenous norepinephrine and digoxin
Answer: B
Rationale: This profile shows low cardiac output (CI <2.2) with high filling pressures (PCWP >18) and high SVR
(vasoconstriction). Combination of an inotrope (dobutamine) and vasodilator (nitroprusside) can improve
contractility and reduce afterload, increasing cardiac output. Nitroglycerin is primarily venodilator; furosemide
alone insufficient. Milrinone plus beta-blocker is not recommended acutely; norepinephrine increases afterload.
10 A patient with chronic atrial fibrillation and a mechanical mitral valve is being anticoagulated with warfarin.
Their INR is 2.8. Which of the following dietary changes would most likely decrease the INR?
A) Increasing intake of leafy green vegetables
B) Switching from brand-name to generic warfarin
C) Starting a high-protein, low-carbohydrate diet
D) Adding a daily multivitamin containing vitamin K
Answer: A
Rationale: Leafy green vegetables are rich in vitamin K, which antagonizes warfarin's effect by providing substrate
for clotting factor synthesis. Increased vitamin K intake can lower INR. Generic warfarin is bioequivalent; protein
diets have minimal effect; multivitamins with vitamin K also lower INR, but the question asks for most likely, and
leafy greens are a common cause of INR fluctuation.
11 A patient with chronic heart failure (NYHA class III) on optimal medical therapy including an angiotensin
receptor-neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA) continues
to have symptoms and a left ventricular ejection fraction (LVEF) of 30%. Which of the following interventions
is most likely to improve survival and reduce hospitalizations based on current guidelines?
A) Addition of ivabradine
B) Initiation of digoxin
C) Cardiac resynchronization therapy with defibrillator (CRT-D)
, D) Up-titration of loop diuretic to achieve euvolemia
Answer: C
Rationale: For patients with HFrEF (LVEF "d35%), NYHA class II-IV, and wide QRS ("e130 ms), CRT-D reduces
mortality and hospitalizations. Ivabradine is reserved for those in sinus rhythm with heart rate 70 bpm despite
beta-blocker. Digoxin reduces hospitalizations but not mortality. Diuretics relieve symptoms but do not improve
survival.
12 In the management of acute decompensated heart failure (ADHF) with severe pulmonary congestion and
systolic blood pressure >100 mm Hg, which vasoactive agent is most appropriate as first-line therapy to
improve hemodynamics and symptoms?
A) Dobutamine
B) Milrinone
C) Nesiritide
D) Nitroglycerin
Answer: D
Rationale: Nitroglycerin is a venodilator that reduces preload and improves pulmonary congestion without
increasing myocardial oxygen demand; it is preferred in patients with adequate blood pressure. Dobutamine and
milrinone are inotropes reserved for hypotension or low cardiac output. Nesiritide is not recommended as first-line
due to lack of mortality benefit and potential renal harm.
13 A patient with atrial fibrillation (AF) and a CHADS-VASc score of 3 is started on apixaban. Which of the
following statements best describes the mechanism of action and monitoring requirements for this agent?
A) Direct thrombin inhibitor requiring periodic aPTT monitoring
B) Factor Xa inhibitor with no routine coagulation monitoring
C) Vitamin K antagonist requiring INR monitoring
D) Factor Xa inhibitor requiring anti-Xa level monitoring
Answer: B
Rationale: Apixaban is a direct oral factor Xa inhibitor with predictable pharmacokinetics; routine coagulation
monitoring is not required. Anti-Xa levels can be measured but are not standard. Direct thrombin inhibitors (e.g.,
dabigatran) do not require aPTT monitoring for efficacy. Vitamin K antagonists (e.g., warfarin) require INR
monitoring.
14 A patient with ST-segment elevation myocardial infarction (STEMI) presents 4 hours after symptom onset.
Primary percutaneous coronary intervention (PCI) is not available within 120 minutes. Which reperfusion
strategy is most appropriate?
A) Immediate administration of tenecteplase followed by transfer to a PCI-capable facility
B) Delayed PCI at 24 hours after heparin infusion
C) Conservative medical management with aspirin, heparin, and clopidogrel
D) Emergent coronary artery bypass grafting (CABG)
Answer: A
Rationale: When timely PCI is not feasible, fibrinolytic therapy (e.g., tenecteplase) should be given within 30
minutes of arrival, followed by routine early transfer for angiography. Delayed PCI or conservative management is
inferior. Emergent CABG is reserved for failed PCI or mechanical complications.
15 A patient with hypertrophic cardiomyopathy (HCM) and left ventricular outflow tract obstruction presents with
exertional syncope and dyspnea. Which medication is most appropriate to reduce obstruction and improve
symptoms?
