NUR 6121 Exam 2 | Questions and Answers | 2026 Update |
WPU - 149 Questions
Section 1: Cardiovascular Disorders (Questions 1-15)
1 A patient with chronic heart failure and a left ventricular ejection fraction (LVEF) of 35% develops worsening
dyspnea and peripheral edema despite optimal doses of lisinopril, carvedilol, and furosemide. Recent labs show
serum creatinine 1.8 mg/dL (baseline 1.2) and potassium 5.6 mEq/L. Which intervention is most appropriate to
reduce morbidity and mortality in this patient?
A) Add spironolactone 25 mg daily
B) Increase furosemide to 80 mg twice daily
C) Initiate sacubitril/valsartan 24/26 mg twice daily
D) Start digoxin 0.125 mg daily
Answer: C
Rationale: Sacubitril/valsartan is indicated to reduce morbidity and mortality in heart failure with reduced ejection
fraction (HFrEF), but its initiation requires careful monitoring of renal function and potassium. Option A is
contraindicated due to hyperkalemia (K >5.0). Option B addresses symptoms but not mortality. Option D is for
symptom control and hospitalization reduction, not mortality benefit.
2 A patient presents with acute-onset chest pressure, diaphoresis, and nausea. ECG shows 2 mm ST-segment
elevation in leads V1-V4 with reciprocal depression in II, III, aVF. High-sensitivity troponin I is 0.5 ng/mL
(99th percentile <0.04). Which combination of therapies is most appropriate before emergent percutaneous
coronary intervention?
A) Aspirin 324 mg chewed, ticagrelor 180 mg loading, and unfractionated heparin 60 U/kg bolus
B) Aspirin 81 mg, clopidogrel 600 mg, and enoxaparin 1 mg/kg subcutaneous
C) Aspirin 324 mg, abciximab bolus, and bivalirudin 0.75 mg/kg bolus
D) Aspirin 162 mg, prasugrel 60 mg, and fondaparinux 2.5 mg subcutaneous
Answer: A
Rationale: For STEMI, dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (ticagrelor preferred over
clopidogrel) plus anticoagulation (unfractionated heparin) is standard prior to PCI. Option B uses low-dose aspirin
and enoxaparin, which is less preferred. Option C includes abciximab, reserved for high-risk PCI with bailout.
Option D uses fondaparinux, which is not recommended alone in STEMI due to catheter thrombosis risk.
3 In a patient with hypertrophic cardiomyopathy (HCM) and symptomatic left ventricular outflow tract
obstruction, which of the following medications is most likely to exacerbate obstruction?
A) Metoprolol
B) Verapamil
C) Disopyramide
D) Nitroglycerin
Answer: D
Rationale: Nitroglycerin reduces preload and afterload, which can worsen LVOT obstruction in HCM. Beta-blockers
(metoprolol) and non-dihydropyridine calcium channel blockers (verapamil) reduce obstruction by decreasing
contractility and heart rate. Disopyramide has negative inotropic effects and is used to relieve obstruction.
,4 A patient with long-standing hypertension and type 2 diabetes mellitus presents with a blood pressure of
168/102 mm Hg. Serum creatinine is 1.4 mg/dL, and urine albumin-to-creatinine ratio is 350 mg/g. Which
antihypertensive regimen is most appropriate to slow progression of nephropathy?
A) Amlodipine 10 mg daily plus hydrochlorothiazide 25 mg daily
B) Lisinopril 20 mg daily plus amlodipine 5 mg daily
C) Losartan 50 mg daily plus chlorthalidone 12.5 mg daily
D) Metoprolol succinate 50 mg daily plus hydralazine 25 mg three times daily
Answer: B
Rationale: ACE inhibitors (like lisinopril) or ARBs are first-line for patients with diabetes and albuminuria to slow
nephropathy progression. Combination with a calcium channel blocker (amlodipine) is recommended if additional
BP lowering is needed. Option C uses an ARB but with a thiazide; however, chlorthalidone may worsen renal
function. Options A and D lack renin-angiotensin system blockade.
5 A patient with atrial fibrillation (AF) and a CHA2DS2-VASc score of 4 is started on apixaban. Which of the
following laboratory abnormalities would most significantly increase the risk of major bleeding with apixaban?
A) Platelet count 100,000/L
B) Serum creatinine 2.5 mg/dL
C) INR 1.5
D) Hemoglobin 11.0 g/dL
Answer: B
Rationale: Apixaban is partially renally excreted; significant renal impairment (CrCl <25 mL/min) increases drug
levels and bleeding risk. A platelet count of 100,000 is mild thrombocytopenia but not as critical. INR 1.5 is mildly
elevated but not a contraindication. Hemoglobin 11.0 is mild anemia but not a direct risk factor for
apixaban-related bleeding.
6 A patient with acute decompensated heart failure is started on intravenous nitroprusside. Which of the following
parameters requires the most vigilant monitoring?
A) Serum lactate
B) Serum thiocyanate levels
C) QT interval on ECG
D) Serum potassium
Answer: B
Rationale: Nitroprusside is metabolized to cyanide and then to thiocyanate, which can accumulate in renal
impairment and cause toxicity. Thiocyanate levels should be monitored, especially with prolonged infusion or renal
dysfunction. Lactate may indicate cyanide toxicity but thiocyanate is the direct metabolite. QT prolongation is not a
typical concern. Potassium monitoring is not specific.
7 A patient with severe aortic stenosis (valve area 0.8 cm², mean gradient 55 mm Hg) is being evaluated for
transcatheter aortic valve replacement (TAVR). Which of the following findings would most strongly
contraindicate the transfemoral approach?
A) Left ventricular ejection fraction 40%
B) Severe circumferential calcification of the iliofemoral arteries
C) Mild mitral regurgitation
D) Previous coronary artery bypass grafting with patent grafts
Answer: B
Rationale: Severe calcification or tortuosity of the iliofemoral arteries increases risk of vascular complications and
may preclude transfemoral access. Reduced LVEF is common and not a contraindication. Mild mitral regurgitation
,is not a concern. Prior CABG with patent grafts does not contraindicate transfemoral TAVR.
8 A patient with a dual-chamber pacemaker presents with palpitations. ECG shows pacing spikes at 60/min with
appropriate capture, but there are also intermittent narrow QRS complexes without preceding pacing spikes.
Which of the following is the most likely cause?
A) Pacemaker-mediated tachycardia
B) Undersensing of intrinsic P waves
C) Oversensing of T waves
D) Normal atrial sensing with ventricular inhibition
Answer: D
Rationale: In a dual-chamber pacemaker, intrinsic atrial activity can be sensed and inhibit ventricular pacing,
resulting in conducted QRS complexes. This is normal function. Pacemaker-mediated tachycardia is a reentrant
tachycardia involving the pacemaker. Undersensing would lead to inappropriate pacing. T-wave oversensing would
inhibit pacing inappropriately.
9 A patient with acute pericarditis is started on ibuprofen 800 mg three times daily and colchicine 0.6 mg twice
daily. After 3 days, the patient develops melena and a drop in hemoglobin from 14 to 10 g/dL. Which of the
following is the most appropriate next step?
A) Switch ibuprofen to prednisone 40 mg daily and continue colchicine
B) Discontinue ibuprofen, start indomethacin 50 mg three times daily
C) Discontinue both ibuprofen and colchicine, start aspirin 325 mg daily
D) Continue ibuprofen, add omeprazole 20 mg daily
Answer: A
Rationale: Gastrointestinal bleeding from NSAIDs requires discontinuation of the NSAID. Prednisone is an
alternative anti-inflammatory for pericarditis but should be used cautiously as it may increase recurrence risk.
Colchicine can be continued. Option B is inappropriate as it switches to another NSAID. Option C uses aspirin,
also an NSAID. Option D continues the offending agent despite bleeding.
10 A patient with pulmonary hypertension (World Health Organization group 1) has a mean pulmonary artery
pressure of 55 mm Hg, pulmonary capillary wedge pressure of 12 mm Hg, and cardiac index of 2.0 L/min/m².
Which of the following medications is most appropriate as first-line therapy?
A) Bosentan
B) Sildenafil
C) Epoprostenol
D) Riociguat
Answer: C
Rationale: Epoprostenol (continuous IV prostacyclin) is indicated for severe PAH (WHO functional class III-IV)
with low cardiac index. Bosentan (ERA) and sildenafil (PDE5 inhibitor) are oral options for milder disease.
Riociguat is used for CTEPH or PAH but not first-line for severe disease.
11 A patient presents with acute-onset chest pressure radiating to the left arm, diaphoresis, and nausea. ECG
shows ST-segment elevation in leads V1-V4. High-sensitivity cardiac troponin is elevated. Which of the
following pathophysiological mechanisms is most directly responsible for the observed electrical and
biomarker changes?
A) Plaque erosion leading to distal microembolization and subendocardial ischemia
B) Complete occlusion of the left anterior descending artery by a thrombus superimposed on a ruptured plaque
C) Severe three-vessel coronary artery spasm causing transient transmural ischemia
, D) Type 2 myocardial infarction due to supply-demand mismatch from tachycardia and hypotension
Answer: B
Rationale: ST-segment elevation myocardial infarction (STEMI) is typically caused by acute complete occlusion of
a coronary artery (here, LAD) due to plaque rupture and thrombosis. Plaque erosion (A) is more associated with
non-ST-elevation ACS. Coronary spasm (C) can cause transient ST elevation but not persistent elevation with
troponin rise. Type 2 MI (D) does not cause ST elevation from occlusion.
12 In a patient with chronic heart failure with reduced ejection fraction (HFrEF) on optimal medical therapy
including a beta-blocker, an ACE inhibitor, and a mineralocorticoid receptor antagonist, which additional
pharmacologic intervention has been shown in landmark trials to reduce mortality and hospitalizations by
directly inhibiting the combination of neprilysin and the angiotensin II type 1 receptor?
A) Ivabradine
B) Sacubitril/valsartan
C) Digoxin
D) Hydralazine/isosorbide dinitrate
Answer: B
Rationale: Sacubitril/valsartan (ARNI) inhibits neprilysin and blocks AT1 receptors, reducing mortality and HF
hospitalizations in HFrEF (PARADIGM-HF). Ivabradine (A) reduces heart rate but not via neprilysin/AT1. Digoxin
(C) reduces hospitalizations but not mortality. Hydralazine/ISDN (D) is reserved for African Americans or those
intolerant to ACE/ARB, not first-line in this scenario.
13 A 45-year-old male with no prior medical history presents with sudden-onset tearing chest pain radiating to the
back, hypertension (190/110 mm Hg), and a widened mediastinum on chest X-ray. Which of the following is
the most appropriate next diagnostic step to confirm the suspected diagnosis and guide emergent management?
A) CT angiography of the chest with intravenous contrast
B) Transesophageal echocardiography (TEE)
C) Magnetic resonance angiography (MRA) of the aorta
D) Aortography via cardiac catheterization
Answer: A
Rationale: Acute aortic dissection is suspected. CT angiography is rapid, widely available, and highly
sensitive/specific for dissection, making it the first-line imaging in stable patients. TEE (B) is useful in unstable
patients or intraoperatively. MRA (C) is time-consuming. Aortography (D) is invasive and rarely used for initial
diagnosis.
14 A patient with atrial fibrillation (AF) and a CHA2DS2-VASc score of 4 is started on warfarin. Three months
later, she presents with an INR of 1.8 and a new ischemic stroke. Which of the following best explains the
failure of warfarin to prevent thromboembolism in this patient?
A) Warfarin resistance due to a polymorphism in VKORC1
B) Subtherapeutic anticoagulation at the time of the thromboembolic event
C) Paradoxical embolism from a patent foramen ovale (PFO)
D) Warfarin-induced protein C deficiency leading to a hypercoagulable state
Answer: B
Rationale: The INR of 1.8 is below the therapeutic range (2.0–3.0) for AF, indicating subtherapeutic anticoagulation,
which increases stroke risk. Warfarin resistance (A) would cause persistently low INRs even with high doses. PFO
(C) is a possible cause but less likely given known AF. Warfarin-induced protein C deficiency (D) occurs early in
therapy and is not relevant months later.
WPU - 149 Questions
Section 1: Cardiovascular Disorders (Questions 1-15)
1 A patient with chronic heart failure and a left ventricular ejection fraction (LVEF) of 35% develops worsening
dyspnea and peripheral edema despite optimal doses of lisinopril, carvedilol, and furosemide. Recent labs show
serum creatinine 1.8 mg/dL (baseline 1.2) and potassium 5.6 mEq/L. Which intervention is most appropriate to
reduce morbidity and mortality in this patient?
A) Add spironolactone 25 mg daily
B) Increase furosemide to 80 mg twice daily
C) Initiate sacubitril/valsartan 24/26 mg twice daily
D) Start digoxin 0.125 mg daily
Answer: C
Rationale: Sacubitril/valsartan is indicated to reduce morbidity and mortality in heart failure with reduced ejection
fraction (HFrEF), but its initiation requires careful monitoring of renal function and potassium. Option A is
contraindicated due to hyperkalemia (K >5.0). Option B addresses symptoms but not mortality. Option D is for
symptom control and hospitalization reduction, not mortality benefit.
2 A patient presents with acute-onset chest pressure, diaphoresis, and nausea. ECG shows 2 mm ST-segment
elevation in leads V1-V4 with reciprocal depression in II, III, aVF. High-sensitivity troponin I is 0.5 ng/mL
(99th percentile <0.04). Which combination of therapies is most appropriate before emergent percutaneous
coronary intervention?
A) Aspirin 324 mg chewed, ticagrelor 180 mg loading, and unfractionated heparin 60 U/kg bolus
B) Aspirin 81 mg, clopidogrel 600 mg, and enoxaparin 1 mg/kg subcutaneous
C) Aspirin 324 mg, abciximab bolus, and bivalirudin 0.75 mg/kg bolus
D) Aspirin 162 mg, prasugrel 60 mg, and fondaparinux 2.5 mg subcutaneous
Answer: A
Rationale: For STEMI, dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (ticagrelor preferred over
clopidogrel) plus anticoagulation (unfractionated heparin) is standard prior to PCI. Option B uses low-dose aspirin
and enoxaparin, which is less preferred. Option C includes abciximab, reserved for high-risk PCI with bailout.
Option D uses fondaparinux, which is not recommended alone in STEMI due to catheter thrombosis risk.
3 In a patient with hypertrophic cardiomyopathy (HCM) and symptomatic left ventricular outflow tract
obstruction, which of the following medications is most likely to exacerbate obstruction?
A) Metoprolol
B) Verapamil
C) Disopyramide
D) Nitroglycerin
Answer: D
Rationale: Nitroglycerin reduces preload and afterload, which can worsen LVOT obstruction in HCM. Beta-blockers
(metoprolol) and non-dihydropyridine calcium channel blockers (verapamil) reduce obstruction by decreasing
contractility and heart rate. Disopyramide has negative inotropic effects and is used to relieve obstruction.
,4 A patient with long-standing hypertension and type 2 diabetes mellitus presents with a blood pressure of
168/102 mm Hg. Serum creatinine is 1.4 mg/dL, and urine albumin-to-creatinine ratio is 350 mg/g. Which
antihypertensive regimen is most appropriate to slow progression of nephropathy?
A) Amlodipine 10 mg daily plus hydrochlorothiazide 25 mg daily
B) Lisinopril 20 mg daily plus amlodipine 5 mg daily
C) Losartan 50 mg daily plus chlorthalidone 12.5 mg daily
D) Metoprolol succinate 50 mg daily plus hydralazine 25 mg three times daily
Answer: B
Rationale: ACE inhibitors (like lisinopril) or ARBs are first-line for patients with diabetes and albuminuria to slow
nephropathy progression. Combination with a calcium channel blocker (amlodipine) is recommended if additional
BP lowering is needed. Option C uses an ARB but with a thiazide; however, chlorthalidone may worsen renal
function. Options A and D lack renin-angiotensin system blockade.
5 A patient with atrial fibrillation (AF) and a CHA2DS2-VASc score of 4 is started on apixaban. Which of the
following laboratory abnormalities would most significantly increase the risk of major bleeding with apixaban?
A) Platelet count 100,000/L
B) Serum creatinine 2.5 mg/dL
C) INR 1.5
D) Hemoglobin 11.0 g/dL
Answer: B
Rationale: Apixaban is partially renally excreted; significant renal impairment (CrCl <25 mL/min) increases drug
levels and bleeding risk. A platelet count of 100,000 is mild thrombocytopenia but not as critical. INR 1.5 is mildly
elevated but not a contraindication. Hemoglobin 11.0 is mild anemia but not a direct risk factor for
apixaban-related bleeding.
6 A patient with acute decompensated heart failure is started on intravenous nitroprusside. Which of the following
parameters requires the most vigilant monitoring?
A) Serum lactate
B) Serum thiocyanate levels
C) QT interval on ECG
D) Serum potassium
Answer: B
Rationale: Nitroprusside is metabolized to cyanide and then to thiocyanate, which can accumulate in renal
impairment and cause toxicity. Thiocyanate levels should be monitored, especially with prolonged infusion or renal
dysfunction. Lactate may indicate cyanide toxicity but thiocyanate is the direct metabolite. QT prolongation is not a
typical concern. Potassium monitoring is not specific.
7 A patient with severe aortic stenosis (valve area 0.8 cm², mean gradient 55 mm Hg) is being evaluated for
transcatheter aortic valve replacement (TAVR). Which of the following findings would most strongly
contraindicate the transfemoral approach?
A) Left ventricular ejection fraction 40%
B) Severe circumferential calcification of the iliofemoral arteries
C) Mild mitral regurgitation
D) Previous coronary artery bypass grafting with patent grafts
Answer: B
Rationale: Severe calcification or tortuosity of the iliofemoral arteries increases risk of vascular complications and
may preclude transfemoral access. Reduced LVEF is common and not a contraindication. Mild mitral regurgitation
,is not a concern. Prior CABG with patent grafts does not contraindicate transfemoral TAVR.
8 A patient with a dual-chamber pacemaker presents with palpitations. ECG shows pacing spikes at 60/min with
appropriate capture, but there are also intermittent narrow QRS complexes without preceding pacing spikes.
Which of the following is the most likely cause?
A) Pacemaker-mediated tachycardia
B) Undersensing of intrinsic P waves
C) Oversensing of T waves
D) Normal atrial sensing with ventricular inhibition
Answer: D
Rationale: In a dual-chamber pacemaker, intrinsic atrial activity can be sensed and inhibit ventricular pacing,
resulting in conducted QRS complexes. This is normal function. Pacemaker-mediated tachycardia is a reentrant
tachycardia involving the pacemaker. Undersensing would lead to inappropriate pacing. T-wave oversensing would
inhibit pacing inappropriately.
9 A patient with acute pericarditis is started on ibuprofen 800 mg three times daily and colchicine 0.6 mg twice
daily. After 3 days, the patient develops melena and a drop in hemoglobin from 14 to 10 g/dL. Which of the
following is the most appropriate next step?
A) Switch ibuprofen to prednisone 40 mg daily and continue colchicine
B) Discontinue ibuprofen, start indomethacin 50 mg three times daily
C) Discontinue both ibuprofen and colchicine, start aspirin 325 mg daily
D) Continue ibuprofen, add omeprazole 20 mg daily
Answer: A
Rationale: Gastrointestinal bleeding from NSAIDs requires discontinuation of the NSAID. Prednisone is an
alternative anti-inflammatory for pericarditis but should be used cautiously as it may increase recurrence risk.
Colchicine can be continued. Option B is inappropriate as it switches to another NSAID. Option C uses aspirin,
also an NSAID. Option D continues the offending agent despite bleeding.
10 A patient with pulmonary hypertension (World Health Organization group 1) has a mean pulmonary artery
pressure of 55 mm Hg, pulmonary capillary wedge pressure of 12 mm Hg, and cardiac index of 2.0 L/min/m².
Which of the following medications is most appropriate as first-line therapy?
A) Bosentan
B) Sildenafil
C) Epoprostenol
D) Riociguat
Answer: C
Rationale: Epoprostenol (continuous IV prostacyclin) is indicated for severe PAH (WHO functional class III-IV)
with low cardiac index. Bosentan (ERA) and sildenafil (PDE5 inhibitor) are oral options for milder disease.
Riociguat is used for CTEPH or PAH but not first-line for severe disease.
11 A patient presents with acute-onset chest pressure radiating to the left arm, diaphoresis, and nausea. ECG
shows ST-segment elevation in leads V1-V4. High-sensitivity cardiac troponin is elevated. Which of the
following pathophysiological mechanisms is most directly responsible for the observed electrical and
biomarker changes?
A) Plaque erosion leading to distal microembolization and subendocardial ischemia
B) Complete occlusion of the left anterior descending artery by a thrombus superimposed on a ruptured plaque
C) Severe three-vessel coronary artery spasm causing transient transmural ischemia
, D) Type 2 myocardial infarction due to supply-demand mismatch from tachycardia and hypotension
Answer: B
Rationale: ST-segment elevation myocardial infarction (STEMI) is typically caused by acute complete occlusion of
a coronary artery (here, LAD) due to plaque rupture and thrombosis. Plaque erosion (A) is more associated with
non-ST-elevation ACS. Coronary spasm (C) can cause transient ST elevation but not persistent elevation with
troponin rise. Type 2 MI (D) does not cause ST elevation from occlusion.
12 In a patient with chronic heart failure with reduced ejection fraction (HFrEF) on optimal medical therapy
including a beta-blocker, an ACE inhibitor, and a mineralocorticoid receptor antagonist, which additional
pharmacologic intervention has been shown in landmark trials to reduce mortality and hospitalizations by
directly inhibiting the combination of neprilysin and the angiotensin II type 1 receptor?
A) Ivabradine
B) Sacubitril/valsartan
C) Digoxin
D) Hydralazine/isosorbide dinitrate
Answer: B
Rationale: Sacubitril/valsartan (ARNI) inhibits neprilysin and blocks AT1 receptors, reducing mortality and HF
hospitalizations in HFrEF (PARADIGM-HF). Ivabradine (A) reduces heart rate but not via neprilysin/AT1. Digoxin
(C) reduces hospitalizations but not mortality. Hydralazine/ISDN (D) is reserved for African Americans or those
intolerant to ACE/ARB, not first-line in this scenario.
13 A 45-year-old male with no prior medical history presents with sudden-onset tearing chest pain radiating to the
back, hypertension (190/110 mm Hg), and a widened mediastinum on chest X-ray. Which of the following is
the most appropriate next diagnostic step to confirm the suspected diagnosis and guide emergent management?
A) CT angiography of the chest with intravenous contrast
B) Transesophageal echocardiography (TEE)
C) Magnetic resonance angiography (MRA) of the aorta
D) Aortography via cardiac catheterization
Answer: A
Rationale: Acute aortic dissection is suspected. CT angiography is rapid, widely available, and highly
sensitive/specific for dissection, making it the first-line imaging in stable patients. TEE (B) is useful in unstable
patients or intraoperatively. MRA (C) is time-consuming. Aortography (D) is invasive and rarely used for initial
diagnosis.
14 A patient with atrial fibrillation (AF) and a CHA2DS2-VASc score of 4 is started on warfarin. Three months
later, she presents with an INR of 1.8 and a new ischemic stroke. Which of the following best explains the
failure of warfarin to prevent thromboembolism in this patient?
A) Warfarin resistance due to a polymorphism in VKORC1
B) Subtherapeutic anticoagulation at the time of the thromboembolic event
C) Paradoxical embolism from a patent foramen ovale (PFO)
D) Warfarin-induced protein C deficiency leading to a hypercoagulable state
Answer: B
Rationale: The INR of 1.8 is below the therapeutic range (2.0–3.0) for AF, indicating subtherapeutic anticoagulation,
which increases stroke risk. Warfarin resistance (A) would cause persistently low INRs even with high doses. PFO
(C) is a possible cause but less likely given known AF. Warfarin-induced protein C deficiency (D) occurs early in
therapy and is not relevant months later.
