Question 1: A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues to have LDL cholesterol of 140 mg/dL after 3 months of therapy. The primary care NP increases the dose from 10 mg daily to 20 mg daily. The patient reports headache and dizziness a few weeks after the dose increase. The NP should:

a. recommend supplements of omega-3 along with the atorvastatin.

b. change the atorvastatin dose to 15 mg twice daily.

c. add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily.

d. change the patient’s medication to cholestyramine

Question 2: A patient who has hyperlipidemia has been taking atorvastatin (Lipitor) 60 mg daily for 6 months. The patient’s initial lipid profile showed LDL of 180 mg/dL, HDL of 45 mg/dL, and triglycerides of 160 mg/dL. The primary care NP orders a lipid profile today that shows LDL of 105 mg/dL, HDL of 50 mg/dL, and triglycerides of 120 mg/dL. The patient reports muscle pain and weakness. The NP should:

a.order liver function tests (LFTs).

b. order a creatine kinase-MM (CK-MM) level.

c. change atorvastatin to twice-daily dosing.

d. add gemfibrozil (Lopid) to the patient’s medication regimen

Question 3: A patient comes to the clinic with a 4-day history of 10 to 12 liquid stools each day. The patient reports seeing blood and mucus in the stools. The patient has had nausea but no vomiting. The primary care NP notes a temperature of 37.9° C, a heart rate of 96 beats per minute, and a blood pressure of 90/60 mm Hg. A physical examination reveals dry oral mucous membranes and capillary refill of 4 seconds. The NP’s priority should be to:

a. obtain stool cultures.

b. begin rehydration therapy.

c. consider prescribing metronidazole.

d. administer opioid antidiarrheal medications.

Question 4: A perimenopausal woman tells the primary care NP that she is having hot flashes and increasingly severe mood swings. The woman has had a hysterectomy. The NP should prescribe:

a. estrogen-only HT. b. estrogen-progesterone HT. c. low-dose oral contraceptive therapy. d. selective serotonin reuptake inhibitor therapy until menopause begins.

Question 5: 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 6: A parent calls a clinic for advice about giving an over-the-counter cough medicine to a 6-year-old child. The parent tells the NP that the medication label does not give instructions about how much to give a child. The NP should:

a. order a prescription antitussive medication for the child. b. ask the parent to identify all of the ingredients listed on the medication label. c. calculate the dose for the active ingredient in the over-the-counter preparation. d. tell the parent to approximate the dose at about one third to one half the adult dose.

Question 7: A patient who has disabling intermittent claudication is not a candidate for surgery. Which of the following medications should the primary care NP prescribe to treat this patient?

a. Cilostazol (Pletal) b. Warfarin (Coumadin) c. Pentoxifylline (Trental) d. Low-dose, short-term aspirin

Question 8: The primary care NP prescribes an extended-cycle monophasic pill regimen for a young woman who reports having multiple partners. Which statement by the patient indicates she understands the regimen?

a. "I have to take a pill only every 3 months." b. "I should expect to have only four periods each year." c. "I will need to use condoms for only 7 more days." d. "This type of pill has fewer side effects than other types."

Question 9: The primary care NP prescribes an inhaled corticosteroid for a patient who has asthma. The third-party payer for this patient denies coverage for the brand that comes in the specific strength the NP prescribes. The NP should:

a. provide pharmaceutical company samples of the medication for the patient. b. inform the patient that the drug must be paid for out of pocket because it is not covered. c. order the closest formulary-approved approximation of the drug and monitor effectiveness. d. write a letter of medical necessity to the insurer to explain the need for this particular medication.

Question 10: A primary care NP prescribes levothyroxine for a patient to treat thyroid deficiency. When teaching this patient about the medication, the NP should:

a. counsel the patient to take the medication with food. b. tell the patient that changing brands of the medication should be avoided. c. instruct the patient to stop taking the medication if signs of thyrotoxicosis occur. d. tell the patient that the drug may be stopped when thyroid function tests stabilize.

Question 11: A patient who has had four to five liquid stools per day for 4 days is seen by the primary care NP. The patient asks about medications to stop the diarrhea. The NP tells the patient that antidiarrheal medications are:

a. not curative and may prolong the illness. b. useful in cases of acute infection with elevated temperature. c. most beneficial when symptoms persist longer than 2 weeks. d. useful when other symptoms, such as hematochezia, develop.

Question 12: The primary care NP sees a patient covered by Medicaid, writes a prescription for a medication, and is informed by the pharmacist that the medication is “off-formulary.” The NP should:

a. inform the patient that an out-of-pocket expense will be necessary. b. write the prescription for a generic drug if it meets the patient's needs. c. call the patient's insurance provider to advocate for this particular drug. d. contact the pharmaceutical company to see if medication samples are available.

Question 13: A patient who has type 2 diabetes mellitus takes metformin (Glucophage). The patient tells the primary care NP that he will have surgery in a few weeks. The NP should recommend:

a. taking the metformin dose as usual the morning of surgery. b. using insulin during the perioperative and postoperative periods. c. that the patient stop taking metformin several days before surgery. d. adding a sulfonylurea medication until recovery from surgery is complete.

Question 14: A thin 52-year-old woman who has recently had a hysterectomy tells the primary care NP she is having frequent hot flashes and vaginal dryness. A recent bone density study shows early osteopenia. The woman’s mother had CHD. She has no family history of breast cancer. The NP should prescribe:

a. estrogen-only HT now. b. estrogen-only HT in 5 years. c. estrogen-progesterone HT now. d. estrogen-progesterone HT in 5 years.

Question 15: A patient who has diabetic gastroparesis sees a gastroenterology specialist who orders metoclopramide (Reglan). Within 24 hours, the patient describes having extrapyramidal symptoms (EPS) to the primary care NP. The NP will contact the gastroenterologist and should expect to prescribe:

a. benztropine (Cogentin). b. cimetidine. c. an SSRI antidepressant. d. a TCA.

Question 16: The primary care NP is preparing to prescribe isosorbide dinitrate sustained release (Dilatrate SR) for a patient who has chronic, stable angina. The NP should recommend initial dosing of:

a. 60 mg four times daily at 6-hour intervals. b. 40 mg twice daily 30 minutes before meals. c. 60 mg on awakening and 40 mg 7 hours later. d. 80 mg three times daily at 8:00 AM, 1:00 PM, and 6:00 PM.

Question 17: A patient who has hypothyroidism has been taking levothyroxine 50 mcg daily for 2 weeks. The patient reports continued fatigue. The primary care NP should:

a. order a T4 level today. b. increase the dose to 100 mcg. c. check the TSH level in 1 week. d. reassure the patient that this will improve in several weeks.

Question 18: The primary care NP has referred a child who has significant gastrointestinal reflux disease to a specialist for consideration for a fundoplication and gastrostomy tube placement. The child’s weight is 80% of what is recommended for age, and a recent swallow study revealed significant risk for aspiration. The child’s parents do not want the procedure. The NP should:

a. compromise with the parents and order a nasogastric tube for feedings. b. initiate a discussion with the parents about the potential outcomes of each possible action. c. refer the family to a case manager who can help guide the parents to the best decision. d. understand that the child's parents have a right to make choices that override those of the medical team.

Question 19: A female patient who is underweight tells the primary care NP that she has been using bisacodyl (Dulcolax) daily for several years. The NP should:

a. prescribe docusate sodium (Colace) and decrease bisacodyl gradually. b. suggest she use polyethylene glycol (MiraLAX) on a daily basis instead. c. tell her that long-term use of suppositories is safer than long-term laxative use. d. counsel the patient to discontinue the laxative and increase fluid and fiber intake.

Question 20: A patient takes a cardiac medication that has a very narrow therapeutic range. The primary care NP learns that the particular brand the patient is taking is no longer covered by the patient’s medical plan. The NP knows that the bioavailability of the drug varies from brand to brand. The NP should:

a. contact the insurance provider to explain why this particular formulation is necessary. b. change the patient's medication to a different drug class that doesn't have these bioavailability variations. c. accept the situation and monitor the patient closely for drug effects with each prescription refill. d. ask the pharmaceutical company that makes the drug for samples so that the patient does not incur out-of-pocket expense.

Question 21: A patient is in the clinic for a follow-up examination after a myocardial infarction (MI). The patient has a history of left ventricular systolic dysfunction. The primary care NP should expect this patient to be taking:

a. nadolol (Corgard).

b. carvedilol (Coreg).

c. timolol (Blocadren).

d. propranolol (Inderal).

Question 22: A male patient tells the primary care NP he is experiencing decreased libido, lack of energy, and poor concentration. The NP performs an examination and notes increased body fat and gynecomastia. A serum testosterone level is 225 ng/dL. The NP’s next action should be to:

a. order LH and FSH levels. b. order a serum prolactin level. c. prescribe testosterone replacement. d. obtain a morning serum testosterone level.

Question 23: 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 24: A 50-year-old woman who is postmenopausal is taking an aromatase inhibitor as part of a breast cancer treatment regimen. She calls her primary care NP to report that she has had hot flashes and increased vaginal discharge but no bleeding. The NP should:

a. schedule her for a gynecologic examination. b. recommend that she use a barrier method of contraception. c. tell her to stop taking the medication and call her oncologist. d. reassure her that these are normal side effects of the medication.

Question 25: A 40-year-old patient is in the clinic for a routine physical examination. The patient has a body mass index (BMI) of 26. The patient is active and walks a dog daily. A lipid profile reveals low-density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30 mg/dL, and triglycerides of 250 mg/dL. The primary care nurse practitioner (NP) should:

a. order a fasting plasma glucose level. b. consider prescribing metformin (Glucophage). c. suggest dietary changes and increased exercise. d. obtain serum insulin and hemoglobin A1c levels.

Question 26: 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 27: A man with a BMI of 38 and a waist size of 48 inches is seen in the clinic for an annual well check-up. The primary care NP orders laboratory tests and notes a fasting plasma glucose of 110 mg/dL, triglyceride level of 220 mg/dL, and high-density lipoprotein level of 40 mg/dL. The man’s blood pressure is 160/110 mm Hg. The man has a history of cardiovascular disease and tells the NP he has tried to lose weight numerous times. The NP should consider:

a. orlistat (Xenical). b. phentermine (Adipex-P). c. an oral antidiabetic agent. d. a strict low-fat, low-sodium diet.

Question 28: A primary care NP orders thyroid function tests. The patient’s TSH is 1.2 microunits/mL, and T4 is 1.7 ng/mL. The NP should:

a. assess the patient for symptoms of hyperthyroidism. b. ask the patient about the use of medications such as lithium. c. tell the patient that the results most likely indicate hypothyroidism. d. ask an endocrinologist to evaluate for possible Hashimoto's thyroiditis.

Question 29: A postmenopausal woman develops NSAID-induced ulcer. The primary care NP should prescribe:

a. ranitidine (Zantac). b. omeprazole (Prilosec). c. esomeprazole (Nexium). d. pantoprazole (Protonix).

Question 30: A patient who is newly diagnosed with type 2 diabetes mellitus has not responded to changes in diet or exercise. The patient is mildly obese and has a fasting blood glucose of 130 mg/dL. The patient has normal renal function tests. The primary care NP plans to prescribe a combination product. Which of the following is indicated for this patient?

a. Metformin/glyburide (Glucovance) b. Insulin and metformin (Glucophage) c. Saxagliptin/metformin (Kombiglyze) d. Metformin/pioglitazone (ACTOplus met)

Question 31: 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. Metformin/glyburide (Glucovance) b. Insulin and metformin (Glucophage) c. Saxagliptin/metformin (Kombiglyze) d. Metformin/pioglitazone (ACTOplus met)

Question 32: 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 33: 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 34: 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 35: A patient who is taking nifedipine develops mild edema of both feet. The primary care NP should contact the patient’s cardiologist to discuss:

a. changing to amlodipine. b. ordering renal function tests. c. increasing the dose of nifedipine. d. evaluation of left ventricular function.

Question 36: 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 37: A patient who takes an ACE inhibitor and a thiazide diuretic for hypertension will begin taking spironolactone. The primary care NP should counsel this patient to:

a. avoid foods that are high in potassium. b. use a salt substitute when seasoning foods. c. discuss changing the ACE inhibitor to an ARB with the cardiologist. d. avoid taking antacids containing magnesium while taking these drugs.

Question 38: A patient has been taking furosemide 80 mg once daily for 4 weeks and returns for a follow-up visit. The primary care NP notes a blood pressure of 100/60 mm Hg. The patient’s lungs are clear, and there is no peripheral edema. The patient’s serum potassium is 3.4 mEq/L. The NP should:

a. continue furosemide at the current dose. b. decrease furosemide to 60 mg once daily. c. increase furosemide to 80 mg twice daily. d. change furosemide dose the 40 mg twice daily.

Question 39: The primary care NP is reviewing evidence-based recommendations about the off-label use of a particular drug. Which recommendation should influence the NP’s decision about prescribing the medication?

a. Data from randomized, experimental studies b. Patient reports about effectiveness of the drug for this purpose c. Pharmaceutical company reports using anecdotal evidence d. Endorsement of this use by a leading practitioner in the field

Question 40: 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 41: A primary care NP sees a 5-year-old child who is morbidly obese. The child has an elevated hemoglobin A1c and increased lipid levels. Both of the child’s parents are overweight but not obese, and they tell the NP that they see nothing wrong with their child. They both state that it is difficult to refuse their child’s requests for soda or ice cream. The NP should:

a. suggest that they give the child diet soda and low-fat frozen yogurt. b. understand and respect the parents' beliefs about their child's self-image. c. initiate a dialogue with the parents about the implications of the child's laboratory values. d. suggest family counseling to explore ways to improve parenting skills and limits.

Question 42: A 55-year-old patient with no prior history of hypertension has a blood pressure greater than 140/90 on three separate occasions. The patient does not smoke, has a body mass index of 24, and exercises regularly. The patient has no known risk factors for cardiovascular disease. The primary care NP should:

a. prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor. b. perform a careful cardiovascular physical assessment. c. counsel the patient about dietary and lifestyle changes. d. order a urinalysis and creatinine clearance and begin therapy with a b-blocker.

Question 43: A patient who has diabetes mellitus and congestive heart failure takes insulin and warfarin. The patient will begin taking exogenous testosterone to treat secondary hypogonadism. The primary care NP should recommend:

a. increasing the dose of warfarin. b. more frequent blood glucose monitoring. c. a higher than usual dose of testosterone. d. increasing insulin doses to prevent hypoglycemia.

Question 44: A primary care NP sees a patient who reports having decreased frequency of stools over the past few months. In the clinic today, the patient has severe abdominal cramping and an abdominal radiograph shows an increased stool load in the sigmoid colon and rectum. The NP should:

a. give magnesium hydroxide (Milk of Magnesia). b. start daily methylcellulose (Citrucel) and increased fluids. c. order a sodium phosphate enema and psyllium (Metamucil). d. recommend polyethylene glycol (MiraLAX) and 2000 mL of fluid daily.

Question 45: A primary care NP writes a prescription for an off-label use for a drug. To help ensure compliance, the NP should:

a. include information about the off-label use on the E-script. b. provide the patient with written instructions about how to use the medication. c. tell the patient to let the pharmacist know that the drug is being used for an off-label use. d. follow up by phone in several days to see if the patient is using the drug appropriately.

Question 46: 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 47: A 2-year-old child has chronic “toddler’s” diarrhea, which has an unknown but benign etiology. The child’s parent asks the primary care NP if a medication can be used to treat the child’s symptoms. The NP should recommend giving:

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

Question 48: A primary care NP has prescribed phentermine for a patient who is obese. The patient loses 10 lb in the first month but reports that the drug does not seem to be suppressing appetite as much as before. The NP should:

a. discontinue the phentermine. b. increase the dose of phentermine. c. continue the phentermine at the same dose. d. change to a combination of phentermine and topiramate.

Question 49: A patient is newly diagnosed with type 2 diabetes mellitus. The primary care NP reviews this patient’s laboratory tests and notes normal renal function, increased triglycerides, and deceased HDL levels. The NP should prescribe:

a. nateglinide (Starlix). b. glyburide (Micronase). c. colesevelam (Welchol). d. metformin (Glucophage).

Question: A 50-year-old woman with a family history of CHD is experiencing occasional hot flashes and is having periods every 3 to 4 months. She asks the primary care NP about HT to relieve her symptoms. The NP should:

a. prescribe estrogen-only therapy. b. initiate oral contraceptive pills now. c. discuss using bioidentical HT. d. plan to use estrogen-progesterone therapy when menopause begins.

Question 51: A primary care NP prescribes a COCP for a woman who is taking them for the first time. After teaching, the woman should correctly state the need for using a backup form of contraception if she:

a. is having vomiting or diarrhea. b. delays taking a pill by 5 or 6 hours. c. takes nonsteroidal antiinflammatory drugs several days in a row. d. has recurrent headaches or insomnia.

Question 52: 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 53: A patient comes to the clinic with a 2-day history of cough and wheezing. The patient has no previous history of asthma. The patient reports having heartburn for several months, which has worsened considerably. The primary care NP makes a diagnosis of asthma and orders oral steroids and inhaled albuterol. The patient’s condition worsens, and a chest radiograph obtained 2 days later shows bilateral infiltrates. The NP has failed to:

a. confirm the diagnosis. b. determine the aggressiveness of therapy. c. prescribe an adequate dose of medications. d. allow the drugs an adequate amount of time to work.

Question 54: A 5-year-old child has chronic constipation. The primary care NP plans to prescribe a laxative for long-term management. In addition to pharmacologic therapy, the NP should also recommend _____ g of fiber per day.

a. 10  b. 15  c. 20  d. 25

Question 55: A patient in the clinic reports heartburn 30 minutes after meals, a feeling of fullness, frequent belching, and a constant sour taste. The patient has a normal weight and reports having a high-stress job. The primary care NP should recommend:

a. antacid therapy as needed. b. changes in diet to avoid acidic foods. c. daily treatment with a PPI. d. consultation with a gastroenterologist for endoscopy.

Question 56: 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 57: A 40-year-old woman tells the primary care nurse practitioner (NP) that she does not want more children and would like a contraceptive. She does not smoke and has no personal or family history of cardiovascular disease. She has frequent tension headaches. For this patient, the NP should prescribe:

a. condoms. b. tubal ligation. c. monophasic combined oral contraceptive pill (COCP). d. low-estrogen COCP.

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 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 60: A patient in the clinic develops sudden shortness of breath and tachycardia. The primary care NP notes thready pulses, poor peripheral perfusion, and a decreased level of consciousness. The NP activates the emergency medical system and should anticipate that this patient will receive:

a. intravenous alteplase. b. low-dose aspirin and warfarin. c. low-molecular-weight heparin (LMWH). d. unfractionated heparin (UFH) and warfarin.