Question 1: A primary care NP is developing a clinical practice guideline for management of a patient population in a midsized suburban hospital. The NP should:

a. use an existing guideline from a leading research hospital.

b. follow the guideline provided by a third-party payer to help ensure reimbursement.

c. review expert opinion and experimental, anecdotal, correlational study data.

d. write the guideline to adhere to long-standing practice protocols already in use

Question 2: A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for a patient with chronic stable angina. The NP should teach the patient to:

a. change the patch four times daily. b. use the patch as needed for angina pain. c. use two patches daily and change them every 12 hours. d. apply one patch daily in the morning and remove in 12 hours.

Question 3: A patient is diagnosed with asthma. The primary care nurse practitioner (NP) prescribes an inhaled corticosteroid and an inhaled bronchodilator medication and provides education about how to use inhalers. At a follow-up visit 2 weeks later, the patient’s pulmonary function tests are worse. The NP should:

a. provide a detailed written asthma action plan for the patient. b. ask the patient to describe how the medications have been used. c. review the symptoms of an acute asthma exacerbation with the patient. d. teach the patient to use the albuterol more often and order an oral steroid.

Question 4: A patient who will undergo surgery in implant a biosynthetic heart valve asks the primary care NP whether any medications will be necessary postoperatively. The NP should tell the patient that it will be necessary to take:

a. daily low-dose aspirin for 1 year. b. heparin injections as needed based on activated partial thromboplastin time levels. c. lifelong warfarin combined with enoxaparin as needed. d. warfarin for 3 months postoperatively plus long-term aspirin.

Question 5: A patient has a BMI of 35, a fasting plasma glucose of 120 mg/dL, elevated triglycerides, and a history of myocardial infarction. The primary care NP plans to initiate dietary and lifestyle counseling and should consider prescribing:

a. ephedra. b. orlistat (Xenical). c. phentermine (Adipex-P). d. phentermine and topiramate (Onexa).

Question 6: A patient who has severe arthritis and who takes nonsteroidal antiinflammatory drugs (NSAIDs) daily develops a duodenal ulcer. The patient has tried a cyclooxygenase-2 selective NSAID in the past and states that it is not as effective as the current NSAID. The primary care nurse practitioner (NP) should:

a. prescribe cimetidine (Tagamet). b. prescribe omeprazole (Prilosec). c. teach the patient about a bland diet. d. change the NSAID to a corticosteroid.

Question 7: A patient comes to the clinic reporting dizziness and fatigue associated with nausea and vomiting. The primary care NP suspects anemia and orders a complete blood count. The patient’s hemoglobin is elevated. The NP correctly concludes that the patient is not anemic. The NP has made an error in:

a. context formulation. b. inappropriate knowledge base. c. cost-versus-benefit analysis. d. hypothesis triggering and information processing.

Question 8: A patient who has diabetes is taking metformin 1000 mg daily. At a clinic visit, the patient reports having abdominal pain and nausea. The primary care NP notes a heart rate of 92 beats per minute. The NP should:

a. obtain LFTs. b. decrease the dose of metformin. c. change metformin to glyburide. d. order electrolytes, ketones, and serum glucose.

Question 9: An 80-year-old patient asks a primary care NP about OTC antacids for occasional heartburn. The NP notes that the patient has a normal complete blood count and normal electrolytes and a slight elevation in creatinine levels. The NP should recommend:

a. calcium carbonate (Tums). b. aluminum hydroxide (Amphojel). c. sodium bicarbonate (Alka-Seltzer). d. magnesium hydroxide (Milk of Magnesia).

Question 10: A patient who has angina is taking nitroglycerin and long-acting nifedipine. The primary care NP notes a persistent blood pressure of 90/60 mm Hg at several follow-up visits. The patient reports lightheadedness associated with standing up. The NP should consult with the patient’s cardiologist about changing the medication to:

a. amlodipine (Norvasc). b. isradipine (DynaCirc). c. verapamil HCl (Calan). d. short-acting nifedipine (Procardia).

Question 11: A patient comes to the clinic to discuss weight loss. The primary care NP notes a BMI of 32 and performs a health risk assessment that reveals no obesity-related risk factors. The NP should recommend:

a. orlistat (Xenical). b. surgical intervention. c. changes in diet and exercise. d. changes in diet and exercise along with short-term phentermine.

Question 12: A patient brings written information about a medication to a primary care NP about a new drug called Prism and wants to know if the NP will prescribe it. The NP notes that the information is from an internet site called “Prism.com.” The NP should tell this patient that:

a. this information is probably from a drug advertisement website. b. this is factual, evidence-based material with accurate information. c. the information is from a nonprofit group that will not profit from drug sales. d. internet information is unreliable because anyone can post information there.

Question 13: A primary care NP is preparing to order digoxin for an 80-year-old patient who has systolic heart failure. The NP obtains renal function tests, which are normal. The NP should:

a. prescribe a digoxin 0.125 mg tablet once daily. b. give an initial dose of 0.5 mg digoxin tablet and then 0.125 mg every 6 hours 4. c. administer a digoxin 0.6 mg capsule once and then 0.3 mg every 8 hours 3. d. administer a loading dose of intravenous digoxin in the clinic and then give 0.125 mg once daily.

Question 14: A patient who weighs 170 lb wishes to lose weight, with a target weight goal of 125 lb. To initiate a program that will result in a loss of 1 lb per week, the primary care NP should recommend a dietary intake of _____ kcal.

a. 1000  b. 1200  c. 1700  d. 2000

Question 15: A primary care nurse practitioner (NP) prescribes a drug to an 80-year-old African-American woman. When selecting a drug and determining the correct dose, the NP should understand that the knowledge of how age, race, and gender may affect drug excretion is based on an understanding of:

a. bioavailability. b. pharmacokinetics. c. pharmacodynamics. d. anatomy and physiology.

Question 16: A patient who takes a calcium channel blocker is in the clinic for an annual physical examination. The cardiovascular examination is normal. As part of routine monitoring for this patient, the primary care NP should evaluate:

a. serum calcium channel blocker level.

b. complete blood count and electrolytes.

c. liver function tests (LFTs) and renal function.

d. thyroid and insulin levels.

Question 17: A patient has been diagnosed with IBS and tells the primary care NP that symptoms of diarrhea and cramping are worsening. The patient asks about possible drug therapy to treat the symptoms. The NP should prescribe:

a. mesalamine (Asacol). b. dicyclomine (Bentyl). c. simethicone (Phazyme). d. metoclopramide (Reglan).

Question 18: A patient who is taking an oral anticoagulant is in the clinic in the late afternoon and reports having missed the morning dose of the medication because the prescription was not refilled. The primary care NP should counsel this patient to:

a. avoid foods that are high in vitamin K for several days. b. take a double dose of the medication the next morning. c. refill the prescription and take today's dose immediately. d. skip today's dose and resume a regular dosing schedule in the morning.

Question 19: A patient who takes spironolactone for heart failure has begun taking digoxin (Lanoxin) for atrial fibrillation. The primary care NP provides teaching for this patient and asks the patient to repeat back what has been learned. Which statement by the patient indicates understanding of the teaching?

a. "I should avoid high-sodium foods." b. "I should eat foods high in potassium." c. "I need to take a calcium supplement every day." d. "I should use a salt substitute while taking these medications."

Question 20: The primary care NP sees a new African-American patient who has blood pressure readings of 140/90 mm Hg, 130/85 mm Hg, and 142/80 mm Hg on three separate occasions. The NP learns that the patient has a family history of hypertension. The NP should:

a. initiate monotherapy with a thiazide diuretic. b. prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor. c. discuss dietary and lifestyle modifications with the patient. d. begin combination therapy with an ARB and a calcium-channel blocker.

Question 21: An African-American patient is taking captopril (Capoten) 25 mg twice daily. When performing a physical examination, the primary care nurse practitioner (NP) learns that the patient continues to have blood pressure readings of 135/90 mm Hg. The NP should:

a. increase the captopril dose to 50 mg twice daily. b. add a thiazide diuretic to this patient's regimen. c. change the drug to losartan (Cozaar) 50 mg once daily. d. recommend a low-sodium diet in addition to the medication.

Question 22: A patient who has a history of chronic constipation uses a bulk laxative to prevent episodes of acute constipation. The patient reports having an increased frequency of episodes. The primary care NP should recommend:

a. adding docusate sodium (Colace).

b. polyethylene glycol (MiraLAX) and bisacodyl (Dulcolax).

c. lactulose (Chronulac) and polyethylene glycol (MiraLAX).

d. adding nonpharmacologic measures such as biofeedback

Question 23: A woman with IBS has been taking antispasmodic medications and reports some relief, but she tells the primary care NP that the disease is interfering with her ability to work because of increased pain. The NP should consider prescribing:

a. alosetron (Lotronex). b. misoprostol (Cytotec). c. simethicone (Phazyme). d. tricyclic antidepressants (TCAs).

Question 24: A 55-year-old woman has not had menstrual periods for 5 years and tells the primary care nurse practitioner (NP) that she is having increasingly frequent vasomotor symptoms. She has no family history or risk factors for coronary heart disease (CHD) or breast cancer but is concerned about these side effects of hormone therapy (HT). The NP should:

a. tell her that starting HT now may reduce her risk of breast cancer. b. advise a short course of HT now that may decrease her risk for CHD. c. tell her that HT will not help control her symptoms during postmenopause. d. recommend herbal supplements for her symptoms to avoid HT side effects.

Question 25: A patient who has atrial fibrillation (AF) has been taking warfarin (Coumadin). The primary care nurse practitioner (NP) plans to change the patient’s medication to dabigatran (Pradaxa). To do this safely, the NP should:

a. initiate dabigatran when the patient's international normalized ratio (INR) is less than 2. b. start dabigatran 7 to 14 days after discontinuing warfarin. c. begin giving dabigatran 1 week before discontinuing warfarin. d. order frequent monitoring of the patient's INR after dabigatran therapy begins.

Question 26: A 45-year-old patient who has a positive family history but no personal history of coronary artery disease is seen by the primary care NP for a physical examination. The patient has a body mass index of 27 and a blood pressure of 130/78 mm Hg. Laboratory tests reveal low-density lipoprotein, 110 mg/dL; high-density lipoprotein, 70 mg/dL; and triglycerides, 120 mg/dL. The patient does not smoke but has a sedentary lifestyle. The NP should recommend:

a. 30 minutes of aerobic exercise daily. b. taking 81 to 325 mg of aspirin daily. c. beginning therapy with a statin medication. d. starting a thiazide diuretic to treat hypertension.

Question 27: A sexually active patient tells the primary care NP that she has been unable to get her new COCP pill pack until today and has missed 3 days of pills. The NP should tell her to:

a. use backup contraception and take 2 pills each day for the next 2 days. b. begin a new pack of pills today and use backup contraception for 7 days. c. begin a new pack of pills today, take a Plan B pill, and use backup contraception for 7 days. d. Take a pregnancy test, begin a new pack of pills today, and use backup contraception for 7 days.

Question 28: A patient who has insulin-dependent type 2 diabetes reports having difficulty keeping blood glucose within normal limits and has had multiple episodes of both hypoglycemia and hyperglycemia. As adjunct therapy to manage this problem, the primary care NP should prescribe:

a. pramlintide (Symlin). b. repaglinide (Prandin). c. glyburide (Micronase). d. metformin (Glucophage).

Question 29: The primary care NP sees a new patient for a routine physical examination. When auscultating the heart, the NP notes a heart rate of 78 beats per minute with occasional extra beats followed by a pause. History reveals no past cardiovascular disease, but the patient reports occasional syncope and shortness of breath. The NP should:

a. order an ECG and refer to a cardiologist. b. schedule a cardiac stress test and a graded exercise test. c. order a complete blood count (CBC) and electrolytes and consider a trial of procainamide. d. prescribe a B-blocker and anticoagulant and order 24-hour Holter monitoring.

Question 30: A patient who has migraine headaches has begun taking timolol and 2 months after beginning this therapy reports no change in frequency of migraines. The patient’s current dose is 30 mg once daily. The primary care NP should:

a. change the medication to propranolol. b. increase the dose to 40 mg once daily. c. obtain serum drug levels to see if the dose is therapeutic. d. tell the patient to continue taking the timolol and return in 1 month.

Question 31: A patient who has breast cancer has been taking toremifene for 2 weeks. She tells her primary care NP that she thinks her tumor has grown larger. The NP should:

a. schedule her for a breast ultrasound. b. reassure her that this is common and will subside. c. tell her she may need an increased dose of this medication. d. contact her oncologist to discuss adding another medication.

Question 32: A CNM:

a. may treat only women. b. has prescriptive authority in all 50 states. c. may administer only drugs used during labor and delivery. d. may practice only in birthing centers and home birth settings.

Question 33: The primary care NP is preparing to prescribe a diuretic for a patient who has heart failure. The patient reports having had an allergic reaction to sulfamethoxazole-trimethoprim (Bactrim) previously. The NP should prescribe:

a. ethacrynic acid. b. furosemide (Lasix). c. acetazolamide (Diamox). d. hydrochlorothiazide (HydroDIURIL).

Question 34: In every state, prescriptive authority for NPs includes the ability to write prescriptions:

a. for controlled substances. b. for specified classifications of medications. c. without physician-mandated involvement. d. with full, independent prescriptive authority.       

Question 35: The primary care NP is seeing a patient for a hospital follow-up after the patient has had a first myocardial infarction. The patient has a list of the prescribed medications and tells the NP that “no one explained anything about them.” The NP’s initial response should be to:

a. ask the patient to describe the medication regimen. b. ask the patient to make a list of questions about the medications. c. determine what the patient understands about coronary artery disease. d. give the patient information about drug effects and any adverse reactions.

Question 36: A patient with primary hypercholesterolemia is taking an HMG-CoA reductase inhibitor. All of the patient’s baseline LFTs were normal. At a 6-month follow-up visit, the patient reports occasional headache. A lipid profile reveals a decrease of 20% in the patient’s LDL cholesterol. The NP should:

a. order LFTs. b. order CK-MM tests. c. consider decreasing the dose of the medication. d. reassure the patient that this side effect is common.

Question 37: A patient receives an inhaled corticosteroid to treat asthma. The patient asks the primary care NP why the drug is given by this route instead of orally. The NP should explain that the inhaled form:

a. is absorbed less quickly. b. has reduced bioavailability. c. has fewer systemic side effects. d. provides dosing that is easier to regulate.

Question 38: The primary care nurse practitioner (NP) sees a patient for a physical examination and orders laboratory tests that reveal low-density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30 mg/dL, and triglycerides of 350 mg/dL. The patient has no previous history of coronary heart disease. The NP should consider prescribing:

a. ezetimibe (Zetia). b. gemfibrozil (Lopid). c. simvastatin (Zocor). d. nicotinic acid (Niaspan).

Question 39: A woman who is taking a progestin-only pill has just stopped nursing her 9-month-old infant and tells the primary care NP that she would like to space her children about 2 years apart. The NP should:

a. discontinue the progestin-only pill. b. prescribe a COCP and a folic acid supplement. c. prescribe a progestin-only pill for another 6 months. d. suggest that she use a barrier method of contraception.

Question 40: A primary care NP sees a 3-year-old patient who has been vomiting for several days. The child has had fewer episodes of vomiting the past day and is now able to take sips of fluids without vomiting. The child has dry oral mucous membranes, 2-second capillary refill, and pale but warm skin. The child’s blood pressure is 88/46 mm Hg, the heart rate is 110 beats per minute, and the temperature is 37.2° C. The NP should:

a. prescribe promethazine. b. prescribe a scopolamine patch. c. begin oral rehydration therapy. d. send the child to the hospital for IV fluids.

Question 41: A patient has been using an herbal supplement for 2 years that the primary care NP knows may have toxic side effects. The NP should:

a. tell the patient to stop taking the supplement immediately. b. inform the patient of the risks of toxic side effects with this supplement. c. refer the patient to a CAM provider who can manage this patient's therapy. d. prescribe another herbal drug that has fewer adverse effects than the one the patient is taking.

Question 42: An 80-year-old patient who has persistent AF takes warfarin (Coumadin) for anticoagulation therapy. The patient has an INR of 3.5. The primary care NP should consider:

a. lowering the dose of warfarin. b. rechecking the INR in 1 week. c. omitting a dose and resuming at a lower dose. d. omitting a dose and administering 1 mg of vitamin K.

Question 43: A patient is in the clinic complaining of nausea and vomiting that has lasted 2 to 3 days. The patient has dry oral mucous membranes, a blood pressure of 90/56 mm Hg, a pulse of 96 beats per minute, and a temperature of 38.8° C. The primary care NP notes a capillary refill of greater than 3 seconds. The NP should:

a. obtain a complete blood count and serum electrolytes. b. prescribe a rectal antiemetic medication. c. admit to the hospital for intravenous (IV) rehydration. d. encourage the patient to take small, frequent sips of Gatorade.

Question 44: A patient asks a primary care NP whether over-the-counter drugs are safer than prescription drugs. The NP should explain that over-the-counter drugs are:

a. generally safe when label information is understood and followed. b. safer because over-the-counter doses are lower than prescription doses of the same drug. c. less safe because they are not well regulated by the Food and Drug Administration (FDA). d. not extensively tested, so claims made by manufacturers cannot be substantiated.

Question 45: A patient has been taking levothyroxine 100 mcg daily for several months. The patient comes to the clinic with complaints of insomnia and irritability. The primary care NP notes a heart rate of 92 beats per minute. The NP should:

a. change to liothyronine 75 mcg/day. b. discontinue levothyroxine indefinitely. c. order propylthiouracil to counter the increased thyroid levels. d. order TSH and T4 levels and decrease the dose to 75 mcg/day.

Question 46: A patient who has asthma and who is known to the primary care NP calls the NP after hours and asks for a refill of an albuterol metered-dose inhaler. The patient has not been seen in the clinic for more than a year. The NP should:

a. call the pharmacy to order the medication with several refills. b. send an electronic prescription to the pharmacy for one time only. c. send the patient to the emergency department for evaluation of symptoms. d. refill the drug and tell the patient that an office visit is necessary for further refills.

Question 47: A patient wants to know why a cheaper version of a drug cannot be used when the primary care NP writes a prescription for a specific brand name of the drug and writes, “Dispense as Written.” The NP should explain that a different brand of this drug:

a. may cause different adverse effects. b. does not necessarily have the same therapeutic effect. c. is likely to be less safe than the brand specified in the prescription. d. may vary in the amount of drug that reaches the site of action in the body.

Question 48: A patient who has congestive heart failure and arthritis has been taking chlorthalidone (Zaroxolyn) 25 mg daily for 6 months. The primary care NP notes a persistent blood pressure of 145/90 mm Hg. The NP should:

a. ask the patient which medications are used for pain. b. add furosemide (Lasix) to the patient's drug regimen. c. increase the dose of chlorthalidone to 100 mg daily. d. recommend that the patient use salt substitutes to season foods.

Question 49: The primary care NP sees a patient who has a history of hypertension and alcoholism. The patient is not taking any medications. The NP auscultates crackles in both lungs and palpates the liver 2 cm below the costal margin. Laboratory tests show an elevated creatinine level. The NP will refer this patient to a cardiologist and should prescribe:

a. albuterol metered-dose inhaler. b. furosemide (Lasix). c. spironolactone (Aldactone). d. chlorthalidone (Zaroxolyn).

Question 50: A patient with chronic back pain that is unrelieved by prescription analgesic medications asks a primary care nurse practitioner (NP) about acupuncture treatments. The NP should tell this patient:

a. biofield therapy has been shown to be more effective than acupuncture. b. creatine has been shown to be an effective herbal choice to treat back pain. c. there is no valid research documenting the efficacy of this treatment for pain. d. most studies that show benefits of alternative therapies are based on observation.

Question 51: A patient with congestive heart failure will begin therapy with a diuretic medication. The primary care NP orders laboratory tests, which reveal a glomerular filtration rate (GFR) of 25 mL/minute. The initial drug the NP should prescribe is:

a. metolazone. b. furosemide (Lasix). c. spironolactone (Aldactone). d. hydrochlorothiazide (HydroDIURIL).

Question 52: The primary care NP sees a patient several months after a myocardial infarction (MI). The patient has been taking furosemide to treat heart failure. The NP notes that the patient has edema of the hands, feet, and ankles. The NP should add which drug to this patient’s regimen?

a. Ethacrynic acid b. Chlorothiazide (Lozol) c. Triamterene (Dyrenium) d. Spironolactone (Aldactone)

Question 53: An important difference between physician assistants (PAs) and NPs is PAs:

a. always work under physician supervision. b. are not required to follow drug treatment protocols. c. may write for all drug categories with physician co-signatures. d. have both inpatient and outpatient independent prescriptive authority.

Question 54: A primary care NP is developing a handout to give to patients who will begin self-administering insulin. When developing this handout, the NP should:

a. provide detailed descriptions of each step in the process of injecting insulin. b. use correct medical terminology when describing insulin self-administration. c. provide as much factual information as possible about insulin administration. d. address one or two educational objectives that describe what the patient will learn.

Question 55: An 80-year-old patient has begun taking propranolol (Inderal) and reports feeling tired all of the time. The primary care NP should:

a. tell the patient to stop taking the medication immediately. b. recommend that the patient take the medication at bedtime. c. tell the patient that tolerance to this side effect will occur over time. d. contact the patient's cardiologist to discuss decreasing the dose of propranolol.

Question 56: An 80-year-old male patient will begin taking an B-antiadrenergic medication. The primary care NP should teach this patient to:

a. ask for assistance while bathing. b. restrict fluids to aid with diuresis. c. take the medication in the morning with food. d. be aware that priapism is a common side effect.

Question 57: A woman who uses a transdermal contraceptive calls the primary care NP to report that while dressing that morning she discovered that the patch had come off and she was unable to find the patch. The NP should tell her to apply a new patch and:

a. take one cycle of COCPs. b. take a home pregnancy test. c. use condoms for the next 7 days. d. contact the clinic if she misses a period.

Question 58: A woman who has been taking a COCP tells the primary care NP that, because of frequent changes in her work schedule, she has difficulty remembering to take her pills. The woman and the NP decide to change to a vaginal ring. The NP will instruct her to insert the ring:

a. within 7 days after her last active pill. b. and use a backup contraceptive for 7 days. c. and continue the COCP for one more cycle. d. on the same day she stops taking her COCP.

Question 59: A 12-year-old patient has acute diarrhea and an upper respiratory infection. Other family members have had similar symptoms, which have resolved. The primary care NP should recommend:

a. diphenoxylate (Lomotil). b. attapulgite (Kaopectate). c. an electrolyte solution (Pedialyte). d. bismuth subsalicylate (Pepto-Bismol).

Question 60: A patient is taking drug A and drug B. The primary care NP notes increased effects of drug B. The NP should suspect that in this case drug A is a cytochrome P450 (CYP450) enzyme:

a. inhibitor.

b. substrate.

c. inducer.

d. metabolizer