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ANCC AGACNP-BC study materials
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ANCC AGACNP-BC practice questions

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Question 1Assessment and Diagnosis

A patient presents with sudden severe chest pain. Which finding most suggests aortic dissection rather than acute myocardial infarction?

  1. Sharp pain that worsens with inspiration and coughing
  2. Burning epigastric pain that occurs after meals
  3. Tearing pain radiating to the back with a blood pressure difference between arms Correct answer.
  4. Substernal pressure relieved by rest and nitroglycerin

Explanation

Aortic dissection classically produces abrupt tearing pain that radiates to the back and may cause pulse deficits or interarm blood pressure differences. Ischemic cardiac pain is more often exertional pressure, while pleuritic and postprandial pain suggest other causes.

Question 2Assessment and Diagnosis

Orthostatic hypotension is best defined as which change after standing?

  1. Diastolic rise ≥20 mm Hg or systolic rise ≥10 mm Hg by 5 minutes
  2. Systolic fall ≥10 mm Hg or diastolic fall ≥5 mm Hg by 1 minute
  3. Systolic fall ≥20 mm Hg or diastolic fall ≥10 mm Hg by 3 minutes Correct answer.
  4. Systolic rise ≥30 mm Hg or diastolic rise ≥15 mm Hg by 10 minutes

Explanation

Orthostatic hypotension is a systolic decrease of at least 20 mm Hg or a diastolic decrease of at least 10 mm Hg within 3 minutes of standing or head-up tilt. Smaller falls or pressure rises do not meet the definition.

Question 3Assessment and Diagnosis

A positive Murphy sign during abdominal examination is most consistent with which diagnosis?

  1. Acute diverticulitis
  2. Acute cholecystitis Correct answer.
  3. Acute appendicitis
  4. Acute pancreatitis

Explanation

Murphy sign is inspiratory arrest during deep palpation of the right upper quadrant, reflecting an inflamed gallbladder. It is classically associated with acute cholecystitis.

Question 4Assessment and Diagnosis

A Babinski sign in an adult, consisting of dorsiflexion of the great toe and fanning of the other toes, indicates which process?

  1. A normal finding at any age
  2. An upper motor neuron lesion Correct answer.
  3. A lower motor neuron lesion
  4. A peripheral sensory neuropathy

Explanation

The Babinski response is a pathologic plantar reflex caused by corticospinal tract dysfunction. In adults it indicates an upper motor neuron lesion.

Question 5Assessment and Diagnosis

A microcytic anemia with a low ferritin level is most consistent with which diagnosis?

  1. Vitamin B12 deficiency
  2. Acute hemolytic anemia
  3. Anemia of chronic inflammation
  4. Iron deficiency anemia Correct answer.

Explanation

Iron deficiency produces microcytosis and low ferritin, reflecting depleted iron stores. Ferritin is an acute-phase reactant and is typically normal or elevated in anemia of chronic inflammation.

Question 6Assessment and Diagnosis

ST-segment elevation in contiguous leads on a 12-lead ECG most directly indicates which condition?

  1. Left ventricular hypertrophy
  2. Hyperkalemia
  3. Acute transmural myocardial ischemia Correct answer.
  4. Pericardial effusion

Explanation

ST elevation in anatomically contiguous leads reflects acute transmural injury and is the hallmark of STEMI. Pericarditis may cause diffuse ST elevation, but contiguous focal elevation is treated as acute coronary occlusion.

Question 7Assessment and Diagnosis

Which colorectal cancer screening option is appropriate for an average-risk adult beginning at age 45?

  1. Colonoscopy every 10 years Correct answer.
  2. Bone density testing every 2 years
  3. Annual prostate-specific antigen testing
  4. Screening mammography every 2 years

Explanation

Average-risk colorectal cancer screening may begin at age 45 and includes colonoscopy every 10 years or other accepted stool- or imaging-based strategies. Prostate, breast, and bone density screening address different cancers and conditions.

Question 8Assessment and Diagnosis

Transient monocular vision loss described as a curtain descending over one eye is most consistent with which diagnosis?

  1. Migraine with aura
  2. Transient ischemic attack Correct answer.
  3. Acute angle-closure glaucoma
  4. Retinal detachment

Explanation

Amaurosis fugax is transient monocular vision loss caused by retinal ischemia, often from a carotid or cardiac embolic source. It is a transient ischemic attack and warrants urgent vascular assessment.

Question 9Assessment and Diagnosis

An arterial blood gas shows pH 7.30, PaCO2 30 mm Hg, and HCO3 15 mEq/L. Which acid-base disorder is present?

  1. Metabolic alkalosis with respiratory compensation
  2. Respiratory alkalosis with metabolic compensation
  3. Metabolic acidosis with respiratory compensation Correct answer.
  4. Mixed metabolic acidosis and respiratory acidosis

Explanation

The low pH and low bicarbonate indicate metabolic acidosis. The low PaCO2 represents appropriate respiratory compensation, with the expected PaCO2 near 30 mm Hg by Winter formula.

Question 10Assessment and Diagnosis

Which electrolyte abnormality most commonly prolongs the QT interval?

  1. Hypernatremia
  2. Hyperkalemia
  3. Metabolic alkalosis
  4. Hypocalcemia Correct answer.

Explanation

Hypocalcemia prolongs the plateau phase of the cardiac action potential and therefore lengthens the QT interval. Hyperkalemia typically produces peaked T waves and QRS widening.

Question 11Assessment and Diagnosis

An AST/ALT ratio greater than 2 is most suggestive of which cause of liver injury?

  1. Wilson disease
  2. Alcohol-associated liver disease Correct answer.
  3. Ischemic hepatitis
  4. Acute viral hepatitis

Explanation

Alcohol-associated liver disease often produces an AST/ALT ratio above 2 because of mitochondrial injury and pyridoxine deficiency. Viral and ischemic hepatitis more often raise ALT above AST.

Question 12Assessment and Diagnosis

Pleural fluid analysis shows a pleural-to-serum protein ratio of 0.6 and a pleural-to-serum LDH ratio of 0.7. This fluid is classified as which type?

  1. Chylothorax
  2. Empyema
  3. Exudate Correct answer.
  4. Transudate

Explanation

Light criteria classify pleural fluid as exudative when the protein ratio exceeds 0.5 or the LDH ratio exceeds 0.6. Either criterion alone is sufficient.

Question 13Assessment and Diagnosis

A patient has a high TSH and a low free T4. Which diagnosis best fits these results?

  1. Subclinical hyperthyroidism
  2. Central hypothyroidism
  3. Graves disease
  4. Primary hypothyroidism Correct answer.

Explanation

Primary hypothyroidism causes failure of the thyroid gland, producing low free T4 with a compensatory rise in TSH. Central hypothyroidism would show low or inappropriately normal TSH.

Question 14Assessment and Diagnosis

A patient has BUN 40 mg/dL, creatinine 1.0 mg/dL, urine sodium 10 mEq/L, and FENa less than 1%. Which condition is most likely?

  1. Acute interstitial nephritis
  2. Postrenal obstruction
  3. Prerenal azotemia Correct answer.
  4. Acute tubular necrosis

Explanation

A BUN-to-creatinine ratio above 20 with low urine sodium and FENa below 1% suggests prerenal azotemia from hypoperfusion. Intrinsic renal injury usually shows higher urine sodium and FENa.

Question 15Assessment and Diagnosis

Which historical feature most raises concern for a cardiac cause of syncope?

  1. Syncope preceded by nausea and warmth
  2. Syncope after prolonged standing
  3. Syncope during exertion Correct answer.
  4. Syncope with coughing

Explanation

Exertional syncope suggests inadequate cardiac output during increased demand and raises concern for structural heart disease or arrhythmia. Situational and vasovagal syncope have more benign triggers.

Question 16Assessment and Diagnosis

A painful vesicular rash in a dermatomal distribution that does not cross the midline is most consistent with which diagnosis?

  1. Contact dermatitis
  2. Cellulitis
  3. Herpes zoster Correct answer.
  4. Impetigo

Explanation

Herpes zoster reactivation produces a painful vesicular eruption confined to one or adjacent dermatomes and respects the midline. Bacterial and eczematous conditions do not follow dermatomes in this way.

Question 17Assessment and Diagnosis

An older hospitalized patient develops acute fluctuating attention and altered level of consciousness over 24 hours. Which diagnosis is most likely?

  1. Dementia
  2. Schizophrenia
  3. Depression
  4. Delirium Correct answer.

Explanation

Delirium is characterized by acute onset, fluctuating attention, and altered awareness, commonly triggered by illness, medications, or hospitalization. Dementia is chronic and progressive without acute fluctuation.

Question 18Assessment and Diagnosis

A crescendo-decrescendo systolic murmur heard best at the right upper sternal border and radiating to the carotids is most consistent with which lesion?

  1. Aortic stenosis Correct answer.
  2. Mitral regurgitation
  3. Hypertrophic cardiomyopathy
  4. Ventricular septal defect

Explanation

Aortic stenosis produces a systolic ejection murmur at the right upper sternal border with radiation to the carotids. The murmur peaks later as stenosis worsens.

Question 19Assessment and Diagnosis

Which set of findings meets the qSOFA criteria for sepsis risk?

  1. Temperature 38.5°C, heart rate 110/min, WBC 14,000/mm3
  2. Respiratory rate 24/min, altered mentation, systolic blood pressure 96 mm Hg Correct answer.
  3. Heart rate 115/min, respiratory rate 20/min, oxygen saturation 94%
  4. Temperature 36.0°C, WBC 3,000/mm3, lactate 1.5 mmol/L

Explanation

qSOFA uses respiratory rate ≥22/min, altered mentation, and systolic blood pressure ≤100 mm Hg. Two or more criteria identify increased risk of poor outcomes in suspected infection.

Question 20Assessment and Diagnosis

Which imaging study is the preferred initial test for suspected nephrolithiasis in a nonpregnant adult with flank pain?

  1. Magnetic resonance urography
  2. Abdominal ultrasound
  3. Noncontrast computed tomography Correct answer.
  4. Plain abdominal radiograph

Explanation

Noncontrast CT of the abdomen and pelvis detects most stones, identifies obstruction, and excludes alternative causes of flank pain. Ultrasound is preferred in pregnancy or when radiation must be avoided.

Question 21Assessment and Diagnosis

A pain-free patient has biphasic T waves in leads V2 and V3. This ECG pattern most suggests which condition?

  1. Pulmonary embolism
  2. Critical proximal left anterior descending artery stenosis Correct answer.
  3. Acute pericarditis
  4. Hyperkalemia

Explanation

Wellens pattern, with biphasic or deeply inverted T waves in V2-V3 during a pain-free interval, indicates critical proximal LAD stenosis and impending anterior infarction. Urgent reperfusion assessment is required.

Question 22Assessment and Diagnosis

Which disorder is most likely in a patient with hypotension, hyperpigmentation, hyponatremia, and hyperkalemia?

  1. Primary adrenal insufficiency Correct answer.
  2. Syndrome of inappropriate antidiuretic hormone
  3. Primary hyperaldosteronism
  4. Pheochromocytoma

Explanation

Primary adrenal insufficiency causes cortisol and aldosterone deficiency, leading to hypotension, hyponatremia, hyperkalemia, and hyperpigmentation from elevated ACTH. Aldosterone excess produces the opposite electrolyte pattern.

Question 23Assessment and Diagnosis

A patient has schistocytes, thrombocytopenia, prolonged PT and PTT, low fibrinogen, and elevated D-dimer. Which diagnosis best fits?

  1. Immune thrombocytopenic purpura
  2. Disseminated intravascular coagulation Correct answer.
  3. Thrombotic thrombocytopenic purpura
  4. Hemolytic uremic syndrome

Explanation

Disseminated intravascular coagulation consumes platelets and coagulation factors, producing thrombocytopenia, prolonged clotting times, low fibrinogen, and elevated D-dimer with microangiopathic hemolysis. TTP and HUS usually have normal coagulation studies.

Question 24Assessment and Diagnosis

A patient with chronic alcohol use presents with confusion, horizontal ophthalmoplegia, and ataxia. Which diagnosis is most likely?

  1. Wernicke encephalopathy Correct answer.
  2. Hepatic encephalopathy
  3. Korsakoff syndrome
  4. Alcohol withdrawal delirium

Explanation

Wernicke encephalopathy is caused by thiamine deficiency and classically presents with encephalopathy, oculomotor dysfunction, and ataxia. Prompt thiamine treatment is required to prevent progression.

Question 25Assessment and Diagnosis

A hypotensive patient with distended neck veins has pulsus paradoxus greater than 10 mm Hg. Which condition is most likely?

  1. Cardiac tamponade Correct answer.
  2. Constrictive pericarditis
  3. Hypertrophic cardiomyopathy
  4. Aortic stenosis

Explanation

Cardiac tamponade impairs diastolic filling and exaggerates the normal inspiratory fall in systolic pressure, producing pulsus paradoxus. Hypotension and elevated jugular venous pressure support the diagnosis.

Question 26Assessment and Diagnosis

Which ECG change is most characteristic of moderate-to-severe hyperkalemia?

  1. Peaked, narrow-based T waves Correct answer.
  2. Diffuse ST-segment elevation with PR depression
  3. Prolonged QT interval with prominent U waves
  4. Sawtooth flutter waves at 300 beats per minute

Explanation

Rising extracellular potassium shortens repolarization and produces tall, narrow, peaked T waves, followed later by PR prolongation, loss of P waves, and QRS widening. These changes progress as the potassium level rises, so peaked T waves should prompt urgent confirmation with a serum potassium level.

Question 27Assessment and Diagnosis

Which laboratory result meets the diagnostic threshold for diabetes mellitus in an asymptomatic adult?

  1. Hemoglobin A1c of 6.8% Correct answer.
  2. Two-hour glucose of 130 mg/dL during an oral glucose tolerance test
  3. Fasting plasma glucose of 118 mg/dL
  4. Random plasma glucose of 160 mg/dL

Explanation

Diagnostic thresholds are fasting glucose of 126 mg/dL or higher, two-hour OGTT glucose of 200 mg/dL or higher, A1c of 6.5% or higher, or a random glucose of 200 mg/dL or higher with symptoms. In an asymptomatic patient, an abnormal result generally requires confirmation on a second sample.

Question 28Assessment and Diagnosis

Which cluster of findings suggests rising intracranial pressure?

  1. Hypotension, tachycardia, and tachypnea
  2. Hypertension, bradycardia, and irregular respirations Correct answer.
  3. Hypotension with bradycardia and hypothermia
  4. Hypertension with a narrow pulse pressure and tachycardia

Explanation

The Cushing reflex of systolic hypertension with a widened pulse pressure, bradycardia, and irregular respirations signals critically elevated intracranial pressure and impending herniation. It is a late finding and requires immediate intervention rather than observation.

Question 29Assessment and Diagnosis

An adult with a stable eGFR of 32 mL/min/1.73 m² and no albuminuria is classified as which CKD stage?

  1. Stage 3b Correct answer.
  2. Stage 3a
  3. Stage 2
  4. Stage 4

Explanation

CKD stage is assigned by glomerular filtration rate once abnormalities persist beyond three months: G1 is 90 or higher, G2 is 60 to 89, G3a is 45 to 59, G3b is 30 to 44, G4 is 15 to 29, and G5 is below 15. A stable eGFR of 32 falls in the 30-to-44 band, which is stage 3b.

Question 30Assessment and Diagnosis

A lumbar puncture shows 1,400 white cells/µL with 88% neutrophils, glucose 28 mg/dL, and protein 210 mg/dL. Which diagnosis is most likely?

  1. Bacterial meningitis Correct answer.
  2. Viral meningitis
  3. Cryptococcal meningitis
  4. Normal pressure hydrocephalus

Explanation

A neutrophilic pleocytosis with a markedly low cerebrospinal fluid glucose and high protein is the classic bacterial pattern. Viral meningitis usually produces a lymphocytic pleocytosis with normal glucose, while fungal disease tends to be lymphocytic with low glucose.

Question 31Assessment and Diagnosis

A patient with unilateral calf swelling and tenderness has a Wells score of 3 for deep vein thrombosis. Which is the most appropriate next step?

  1. Order a contrast-enhanced CT of the abdomen and pelvis
  2. Start empiric anticoagulation and repeat the score in 24 hours
  3. Obtain a D-dimer and treat only if it is elevated
  4. Perform compression ultrasonography of the affected leg Correct answer.

Explanation

A Wells score above 2 places the patient in the likely-probability group, in which imaging is indicated and a D-dimer adds little because a negative result does not safely exclude thrombosis. Compression ultrasonography of the proximal veins is the initial imaging study of choice.

Question 32Assessment and Diagnosis

Which ECG finding is most consistent with acute pericarditis?

  1. Diffuse ST elevation with PR-segment depression Correct answer.
  2. Narrow QRS tachycardia without visible P waves
  3. Reciprocal ST depression in contiguous leads
  4. New left bundle branch block with Q waves

Explanation

Pericardial inflammation produces widespread concave ST elevation and PR depression across many leads, reflecting involvement of the epicardium rather than a single coronary territory. ST elevation limited to a vascular territory with reciprocal changes points instead to myocardial infarction.

Question 33Assessment and Diagnosis

A patient with sudden tearing chest pain radiating to the back has a 25 mm Hg blood pressure difference between the arms. Which study best confirms the diagnosis?

  1. Troponin and serial ECGs
  2. CT angiography of the chest and aorta Correct answer.
  3. Chest radiograph with a portable technique
  4. Transthoracic echocardiography

Explanation

Interarm blood pressure differential with abrupt tearing pain suggests aortic dissection, and CT angiography of the chest and aorta is the preferred confirmatory study in a stable patient. Transesophageal echocardiography or MRI are alternatives when CT is unavailable or contraindicated.

Question 34Assessment and Diagnosis

A euvolemic patient has serum sodium 122 mEq/L, serum osmolality 268 mOsm/kg, urine osmolality 520 mOsm/kg, and urine sodium 70 mEq/L while taking no diuretics. Which diagnosis fits best?

  1. Diuretic-induced hyponatremia with high urine sodium
  2. Primary polydipsia with maximally dilute urine
  3. Syndrome of inappropriate ADH secretion Correct answer.
  4. Hyperglycemic hyponatremia from uncontrolled diabetes

Explanation

Hypo-osmolar, euvolemic hyponatremia with inappropriately concentrated urine and high urine sodium in a patient off diuretics is the signature of inappropriate ADH secretion. The workup first excludes hyperglycemia, renal salt wasting, and thyroid or adrenal deficiency.

Question 35Assessment and Diagnosis

Which laboratory finding best distinguishes iron deficiency anemia from anemia of chronic disease?

  1. Serum ferritin of 8 ng/mL Correct answer.
  2. Reticulocyte count of 1.8%
  3. Mean corpuscular volume of 76 fL
  4. Hemoglobin of 9.5 g/dL

Explanation

Ferritin reflects body iron stores and is markedly depressed in iron deficiency, whereas it is normal or elevated as an acute-phase reactant in anemia of chronic disease. A low ferritin in a patient with anemia is highly specific for iron deficiency.

Question 36Assessment and Diagnosis

Which test is preferred to detect latent tuberculosis infection in an adult who received the BCG vaccine as a child?

  1. Sputum acid-fast bacillus smear
  2. Interferon-gamma release assay Correct answer.
  3. Tuberculin skin test with a 10 mm cutoff
  4. Chest radiograph with lateral decubitus views

Explanation

BCG vaccination can cause false-positive tuberculin skin tests, so an interferon-gamma release assay is preferred because it uses antigens absent from BCG and most nontuberculous mycobacteria. Neither test distinguishes latent from active disease, which requires clinical and radiographic evaluation.

Question 37Assessment and Diagnosis

In a pregnant patient at 34 weeks with new hypertension, which finding supports the diagnosis of preeclampsia?

  1. Platelet count of 210,000/µL
  2. Urine protein-to-creatinine ratio of 0.45 Correct answer.
  3. Urine protein-to-creatinine ratio of 0.1
  4. Blood pressure that normalizes with rest

Explanation

A spot urine protein-to-creatinine ratio of 0.3 or greater meets the proteinuria criterion for preeclampsia when a 24-hour collection is not practical. Preeclampsia is defined by new hypertension after 20 weeks plus proteinuria or other end-organ features such as thrombocytopenia or renal insufficiency.

Question 38Assessment and Diagnosis

Twelve hours after sudden onset of the worst headache of her life, a patient has a noncontrast head CT that is normal. Which next step is most appropriate?

  1. MRI of the brain without contrast
  2. Start a triptan and reassess in the emergency department
  3. Lumbar puncture to assess for xanthochromia Correct answer.
  4. Reassurance and outpatient follow-up in one week

Explanation

CT sensitivity for subarachnoid hemorrhage is highest in the first hours and declines thereafter, so a normal scan 12 hours after a thunderclap headache does not exclude the diagnosis. Lumbar puncture for xanthochromia or red cell count is the next step to identify subarachnoid blood.

Question 39Assessment and Diagnosis

A 74-year-old reports two weeks of unilateral temporal headache, jaw claudication, and blurred vision; ESR is 88 mm/h. Which action should be taken first?

  1. Arrange temporal artery biopsy and await results before treatment
  2. Begin high-dose glucocorticoids immediately Correct answer.
  3. Obtain an MRI of the brain to exclude a mass lesion
  4. Start low-dose aspirin and schedule an outpatient biopsy

Explanation

Vision loss from giant cell arteritis is irreversible, so high-dose glucocorticoids must begin immediately when the presentation is typical, without waiting for confirmatory testing. Temporal artery biopsy remains useful but should be obtained within about two weeks, since steroids can reduce yield over time.

Question 40Assessment and Diagnosis

An obese patient (BMI 42) with stage 4 CKD presents with dyspnea; BNP is 70 pg/mL. Which interpretation is most accurate?

  1. A BNP below 100 pg/mL excludes heart failure only in patients over 75
  2. Heart failure is effectively excluded by this result
  3. BNP is less reliable here; obtain echocardiography Correct answer.
  4. The value is falsely elevated because of renal impairment

Explanation

Obesity lowers natriuretic peptide concentrations while renal impairment raises them, so a low BNP in a severely obese patient with CKD does not exclude heart failure. When the biomarker is uninterpretable, clinical assessment with echocardiography is the appropriate diagnostic step.

Question 41Clinical Management and Plan of Care

A 58-year-old man presents with 45 minutes of substernal chest pressure. The ECG shows ST-segment elevation in leads II, III, and aVF. In addition to arranging urgent reperfusion, which medication should be given as early as possible?

  1. Oral metoprolol 100 mg
  2. Chewed aspirin 325 mg Correct answer.
  3. Sublingual nifedipine 10 mg
  4. Intravenous furosemide 40 mg

Explanation

Chewed non-enteric aspirin 162 to 325 mg should be given within minutes of suspected acute coronary syndrome because it rapidly inhibits platelet thromboxane production and reduces mortality. It is a Class I recommendation and should precede or accompany reperfusion therapy.

Question 42Clinical Management and Plan of Care

A 62-year-old woman with heart failure and reduced ejection fraction (30%) remains symptomatic despite maximally tolerated lisinopril and metoprolol succinate. Which added agent has been shown to reduce both cardiovascular death and heart failure hospitalization?

  1. Digoxin
  2. Hydralazine with isosorbide dinitrate
  3. Sacubitril/valsartan Correct answer.
  4. Amlodipine

Explanation

In patients with heart failure and reduced ejection fraction, an angiotensin receptor-neprilysin inhibitor reduces cardiovascular death and heart failure hospitalization compared with an ACE inhibitor and should replace the ACE inhibitor after an appropriate washout. It is one of the four core guideline-directed therapy pillars.

Question 43Clinical Management and Plan of Care

A 67-year-old man with COPD presents with worsening dyspnea, increased sputum volume, and sputum that has turned purulent. He is hemodynamically stable and saturating 90% on his home oxygen. Which management plan is most appropriate?

  1. Inhaled short-acting bronchodilator alone
  2. Inhaled bronchodilator, systemic corticosteroid, and antibiotic Correct answer.
  3. Oral corticosteroid alone
  4. Observation with no change in therapy

Explanation

An exacerbation characterized by increased dyspnea plus increased sputum volume and purulence meets criteria for antibiotic therapy, and antibiotics are combined with short-acting bronchodilators and a short course of systemic corticosteroids. This triad improves recovery time and reduces treatment failure.

Question 44Clinical Management and Plan of Care

A 24-year-old man with type 1 diabetes presents with glucose 480 mg/dL, arterial pH 7.12, bicarbonate 10 mEq/L, positive serum ketones, and blood pressure 92/58 mmHg. Which intervention should be initiated first?

  1. Intravenous sodium bicarbonate
  2. Intravenous potassium replacement before any fluids
  3. Intravenous 0.9% sodium chloride bolus Correct answer.
  4. Intravenous regular insulin bolus of 0.1 units/kg

Explanation

Volume resuscitation with isotonic crystalloid is the first step in diabetic ketoacidosis because these patients are profoundly volume depleted and insulin is less effective in the setting of hypoperfusion. Insulin infusion follows, and potassium is replaced once the serum level is known to be at least 3.3 mEq/L.

Question 45Clinical Management and Plan of Care

A 74-year-old woman with atrial fibrillation has hypertension and type 2 diabetes and no history of stroke, transient ischemic attack, or bleeding. Her CHA2DS2-VASc score is 3. Which antithrombotic strategy is indicated?

  1. Start aspirin 81 mg daily
  2. Start aspirin plus clopidogrel
  3. Start apixaban Correct answer.
  4. No antithrombotic therapy

Explanation

A CHA2DS2-VASc score of 2 or higher in a woman (or 1 or higher in a man) warrants oral anticoagulation, and a direct oral anticoagulant is preferred over warfarin in eligible patients with nonvalvular atrial fibrillation. Antiplatelet therapy is not an acceptable substitute for stroke prevention in atrial fibrillation.

Question 46Clinical Management and Plan of Care

A 58-year-old man with community-acquired pneumonia and well-controlled diabetes is being managed as an outpatient. He has no beta-lactam allergy and has not taken antibiotics in the past 3 months. Which regimen is recommended?

  1. Amoxicillin-clavulanate plus azithromycin Correct answer.
  2. Amoxicillin 500 mg three times daily
  3. Supportive care without antibiotics
  4. Vancomycin plus cefepime

Explanation

Outpatients with community-acquired pneumonia and a comorbidity such as diabetes should receive either a beta-lactam combined with a macrolide or doxycycline, or a respiratory fluoroquinolone as monotherapy. Combination therapy broadens coverage for atypical pathogens in this higher-risk group.

Question 47Clinical Management and Plan of Care

A 66-year-old woman presents with fever, hypotension, and a lactate of 3.4 mmol/L from a suspected urinary source. Which fluid resuscitation strategy should be initiated?

  1. 250 mL of hypertonic saline
  2. 500 mL of 5% albumin
  3. Crystalloid 30 mL/kg Correct answer.
  4. 10 mL/kg of 0.9% sodium chloride

Explanation

Sepsis with hypoperfusion, indicated here by hypotension and elevated lactate, warrants at least 30 mL/kg of intravenous crystalloid within the first 3 hours. Balanced crystalloid or 0.9% sodium chloride is appropriate; albumin and hypertonic saline are not first-line resuscitation fluids.

Question 48Clinical Management and Plan of Care

A 52-year-old Black adult has newly diagnosed stage 1 hypertension with no diabetes, chronic kidney disease, or heart failure. Which initial antihypertensive agent is preferred?

  1. Lisinopril 10 mg daily
  2. Chlorthalidone 12.5 mg daily Correct answer.
  3. Atenolol 50 mg daily
  4. Spironolactone 25 mg daily

Explanation

In Black adults without chronic kidney disease or diabetes, a thiazide-type diuretic or a calcium channel blocker is recommended as first-line therapy because of greater blood pressure lowering and cardiovascular benefit. ACE inhibitors are less effective as monotherapy in this population.

Question 49Clinical Management and Plan of Care

A 34-year-old woman with newly diagnosed overt hypothyroidism is started on a weight-based dose of levothyroxine. When should thyroid-stimulating hormone be rechecked?

  1. In 1 week
  2. In 6 to 8 weeks Correct answer.
  3. In 6 months
  4. In 72 hours

Explanation

The serum half-life of thyroxine is about 7 days, so a steady state is not reached for roughly 6 weeks. Thyroid-stimulating hormone should be reassessed 6 to 8 weeks after any dose change to allow accurate interpretation.

Question 50Clinical Management and Plan of Care

A 22-year-old woman with asthma has received three rounds of nebulized albuterol with ipratropium and intravenous methylprednisolone for a severe exacerbation. She remains dyspneic with a peak expiratory flow at 40% of predicted. Which adjunct should be added next?

  1. Oral montelukast 10 mg
  2. Intravenous magnesium sulfate 2 g Correct answer.
  3. Oral guaifenesin
  4. Nebulized hypertonic saline

Explanation

Intravenous magnesium sulfate is the recommended adjunct for severe asthma exacerbations that do not respond adequately to inhaled bronchodilators and systemic corticosteroids. It produces smooth muscle relaxation and improves airflow within about an hour.