Practice Questions

Question 1

A 62-year-old man presents to the emergency
department (ED) with the chief concern of chest
pain that woke him from sleep and radiates to
his jaw. An electrocardiogram (ECG) reveals
ST-segment depression in leads II, III, and aVF.
His blood pressure is 112/62 mm Hg and heart rate
is 60 beats/minute. Cardiac enzymes have been
obtained, and the first troponin result was slightly
positive. Preparations are under way to take the
patient to the cardiac catheterization laboratory
for evaluation. Which medication regimen is most
appropriate for this patient at this time?
A. Aspirin 325 mg, clopidogrel 600-mg loading dose (LD), and unfractionated heparin
(UFH) infusion 80-unit/kg bolus, followed
by 18 units/kg/hour and metoprolol 5 mg
intravenously.
B. Aspirin 81 mg; prasugrel 60-mg LD; UFH
infusion 60-unit/kg bolus, followed by 12
units/kg/hour; and intravenous enalaprilat.
C. Aspirin 325 mg, ticagrelor 180-mg LD, and
UFH infusion 60-unit/kg bolus, followed by
12 units/kg/hour.
D. Aspirin 81 mg, prasugrel 60-mg LD, nitroglycerin infusion at 10 mcg/minute, and
bivalirudin 0.75-mg/kg bolus and 1.75-mg/kg/
hour infusion.

Answer 1

C

Acute Care Cardiology

Question 2

An 81-year-old African American man (weight 90
kg) presents to the ED with chest pressure (10/10
on a pain scale). His ECG reveals ST-segment depression in the inferior leads. His medical history is significant for hypertension and chronic
kidney disease. Pertinent laboratory results are troponin 5.8 ng/L, serum creatinine (SCr) 3.7 mg/dL,
and estimated creatinine clearance (eCrCl) 20 mL/
minute. The patient has been given aspirin 325
mg single dose; a nitroglycerin drip, initiated at 5
mcg/minute, will be titrated to chest pain relief and
blood pressure. The patient consents for cardiac
catheterization after adequate hydration. Which
anticoagulation strategy is most appropriate to initiate in this patient?
A. Intravenous heparin 4000-unit intravenous
bolus, followed by a 1000-unit/hour continuous infusion.
B. Enoxaparin 90 mg subcutaneously every 12
hours.
C. Fondaparinux 2.5 mg subcutaneously daily.
D. Bivalirudin 67.5-mg bolus, followed by a 157-
mg/hour infusion.

Answer 2

Acute Care Cardiology

A

Question 3

A 56-year-old man presents to the hospital with
the chief concern of chest pain that was unrelieved
at home with sublingual nitroglycerin. His ECG
reveals ST-segment depression and T-wave inversion. Cardiac markers show an elevated troponin I.
The cardiologist has requested that the patient go
to the cardiac catheterization laboratory for further
evaluation. The patient has a history of coronary
artery disease (CAD) and had a myocardial infarction (MI) about 6 months ago. During his previous
hospitalization, he was confirmed to have developed
heparin-induced thrombocytopenia (HIT) after his
platelet count (Plt) dropped to 40,000/mm3
and he
had a positive ELISA (enzyme-linked immunosorbent assay) upon serologic testing after his previous
catheterization. Given this patient’s diagnosis and
history, which treatment regimen would be most
appropriate during his cardiac catheterization?
A. Tirofiban.
B. Bivalirudin.
C. Enoxaparin.
D. Tenecteplase.

Answer 3

Acute Care Cardiology

B

Question 4

A 62-year-old man presents to the ED after several hours of chest discomfort. His ECG reveals
a 1- to 2-mm ST-segment elevation with positive troponins. He has also had increasing shortness of
breath and lower-extremity swelling over the past
2–3 weeks. His medical history is significant for
tobacco use for 40 years, chronic obstructive pulmonary disease, diabetes, and hypertension. His
blood pressure is 102/76 mm Hg and heart rate is
111 beats/minute. He has rales in both lungs and
2–3+ pitting edema in his extremities. His echocardiogram reveals an ejection fraction of 25%.
After primary percutaneous coronary intervention
(PCI), he is transferred to the cardiac intensive
care unit. Which best describes the acute use of
β-blocker therapy in this patient?
A. Give 12.5 mg of oral carvedilol within the first
24 hours.
B. Give 5 mg of intravenous metoprolol at the
bedside.
C. Give 200 mg of oral metoprolol succinate at
discharge.
D. Give no β-blocker at this time.

Answer 4

Acute Care Cardiology

D

Question 5

. A 60-year-old man (weight 75 kg) presents to
the ED with crushing substernal chest pain and
ST-segment elevations on ECG. He has a medical
history of diabetes and a 40 pack-year history of
smoking. He is taken immediately to the catheterization laboratory for primary PCI, and a drugeluting stent is placed in his left anterior descending artery. In addition to aspirin, which regimen
would best maintain this patient’s stent patency?
A. Clopidogrel 300-mg LD, followed by 75 mg
daily for 12 months.
B. Prasugrel 60-mg LD, followed by 10 mg daily
for 12 months.
C. Ticagrelor 180-mg LD, followed by 90 mg
twice daily for 6 months.
D. Clopidogrel 600-mg LD, followed by 75 mg
daily for 6 months.

Answer 5

Acute Care Cardiology

B

Question 6

A 60-year-old woman with New York Heart
Association (NYHA) class IV heart failure (HF)
(heart failure with reduced ejection fraction
[HFrEF]) is admitted for increased shortness of
breath and dyspnea at rest. Her extremities appear
well perfused, but she has 3+ pitting edema in her
lower extremities. Her vital signs include blood
pressure 125/70 mm Hg, heart rate 92 beats/minute, and oxygen saturation (Sao2
) 89% on 100%
facemask. After initiating an intravenous diuretic,
which intravenous agent is best to rapidly treat this
patient’s pulmonary symptoms?
A. Dobutamine.
B. Milrinone.
C. Nitroglycerin.
D. Metoprolol.

Answer 6

Acute Care Cardiology

C

Question 7

A 75-year-old woman admitted for pneumonia
has a history of several non–ST-segment elevation
myocardial infarctions (NSTEMIs). She had an
episode of sustained ventricular tachycardia (VT)
during this hospitalization. Her corrected QT (QTc)
interval was 380 milliseconds on the telemetry.
Her left ventricular ejection fraction (LVEF) was
found to be 25%. Her serum potassium and magnesium were 4.6 mEq/L and 2.2 mg/dL, respectively.
Which intravenous agent is most appropriate for
this patient’s ventricular arrhythmias?
A. Procainamide.
B. Metoprolol.
C. Magnesium.
D. Amiodarone.

Answer 7

Acute Care Cardiology

D

Question 8

A 53-year-old woman is admitted to the hospital
after the worst headache she has ever had. Her
medical history includes exertional asthma, poorly
controlled hypertension, glaucoma, and hyperlipidemia. She is nonadherent to her medications
and has not taken her prescribed blood pressure
medications for 4 days. Vital signs include blood
pressure 220/100 mm Hg and heart rate 65 beats/
minute. She has retinal hemorrhaging on funduscopic examination. Which is most appropriate for
this patient’s hypertensive emergency?
A. Fenoldopam 0.1 mcg/kg/minute.
B. Nicardipine 5 mg/hour.
C. Labetalol 0.5 mg/minute.
D. Enalaprilat 0.625 mg intravenously every 6
hours.

Answer 8

Acute Care Cardiology

B

Question 9

A 52-year-old woman has a witnessed cardiac
arrest in a shopping mall and is resuscitated with
an automatic external defibrillator device. On electrophysiologic study, she has inducible VT. Which is most appropriate for reducing the secondary
incidence of sudden cardiac death (SCD)?
A. Propafenone.
B. Amiodarone.
C. Implantable cardioverter-defibrillator (ICD).
D. Metoprolol.

Answer 9

Acute Care Cardiology

C

Question 10

The Sudden Cardiac Death in Heart Failure trial
evaluated the efficacy of amiodarone or an ICD
versus placebo in preventing all-cause mortality
in ischemic and nonischemic patients with NYHA
class II and III HF. There was a 7.2% absolute risk
reduction and a 23% relative risk reduction in allcause mortality at 60 months with an ICD versus
placebo. Which best shows the number of patients
needed to treat with an ICD to prevent one death
versus placebo?
A. 1.
B. 4.
C. 14.
D. 43.

Answer 10

Acute Care Cardiology

C

Question 11

A 66-year-old woman (weight 70 kg) with a history of MI, hypertension, hyperlipidemia, and diabetes mellitus presents with sudden-onset diaphoresis, nausea, vomiting, and dyspnea, followed by a bandlike upper
chest pain (8/10) radiating to her left arm. She had felt well until 1 month ago, when she noticed her typical
angina was occurring with less exertion. Her ECG reveals ST-segment depression in leads II, III, and aVF and
hyperdynamic T waves and positive cardiac enzymes. Blood pressure is 150/90 mm Hg, and all laboratory
results are normal; SCr is 1.2 mg/dL. Home medications are aspirin 81 mg/day, simvastatin 40 mg every night,
metoprolol 50 mg twice daily, and metformin 1 g twice daily. Which regimen is best for this patient?
A. An early invasive approach with aspirin 325 mg, ticagrelor 180 mg one dose, and UFH 60-unit/kg bolus;
then 12 units/kg/hour titrated to 50–70 seconds.
B. An early invasive approach with aspirin 325 mg and enoxaparin 70 mg subcutaneously twice daily.
C. An ischemia-guided strategy with tirofiban 25 mcg/kg; then 0.15 mg/kg/minute plus enoxaparin 80 mg
subcutaneously twice daily, aspirin 325 mg, and clopidogrel 300 mg one dose; then 75 mg once daily.
D. An ischemia-guided strategy with aspirin 325 mg and ticagrelor 180 mg one dose; plus UFH 70-unit/kg
bolus; then 15 units/kg/hour.

Answer 11

Acute Care Cardiology

A

Question 12

A 45-year-old patient underwent an elective percutaneous transluminal coronary angioplasty and drug-eluting
stent placement in the right coronary artery. Which best represents the minimum time DAPT should be continued?
A. 1 month.
B. 3 months.
C. 6 months.
D. 12 months.

Answer 12

Acute Care Cardiology

C

Question 13

A 52-year-old man (weight 100 kg) with a history of hypertension and hypertriglyceridemia presents at a major
university teaching hospital with a cardiac catheterization laboratory. He has had 3 hours of crushing 10/10
substernal chest pain radiating to both arms that began while he was eating his lunch (seated), which is accompanied by nausea, diaphoresis, and shortness of breath. He has never before had chest pain of this character or
intensity. He usually can walk several miles without difficulty and smokes 1.5 packs/day of cigarettes. Home
medications are lisinopril 2.5 mg/day and aspirin 81 mg daily. Current vital signs include heart rate 68 beats/
minute and blood pressure 178/94 mm Hg. His ECG reveals a 3-mm ST-segment elevation in leads V2–V4, I,
and aVL. Serum chemistry values are within normal limits. The first set of cardiac markers shows positive
troponins, 0.8 mcg/L (normal defined as less than 0.1 mcg/L). Which regimen is best for this patient’s STEMI?
A. Reperfusion with primary PCI with stenting, clopidogrel 300 mg one dose, aspirin 325 mg one dose, and
tirofiban 25 mcg/kg followed by 0.15 mcg/kg/minute.
B. Reperfusion with a reteplase 10-unit bolus twice (30 minutes apart), clopidogrel 300 mg one dose, aspirin
325 mg one dose, and UFH 60 unit/kg followed by 12 unit/kg/hour.
C. Reperfusion with tenecteplase 25-mg intravenous push one dose, ticagrelor 180 mg one dose, aspirin 325
mg one dose, and bivalirudin 0.75 mg/kg followed by 1.75 mg/kg/hour.
D. Reperfusion with primary PCI with stenting, prasugrel 60 mg one dose, aspirin 325 mg one dose, and
bivalirudin 0.75 mg/kg followed by 1.75 mg/kg/hour.

Answer 13

Acute Care Cardiology

D

Question 14

A 76-year-old male smoker (weight 61 kg) has a history of hypertension, benign prostatic hypertrophy, and
lower back pain. Three weeks ago, he began to have substernal chest pain with exertion (together with dyspnea), which radiated to both arms and was associated with nausea and diaphoresis. These episodes have
increased in frequency to four or five times daily; they are relieved with rest. He has never had an ECG. Today,
he awoke with 7/10 chest pain and went to the ED of a rural community hospital 2 hours later. He was acutely
dyspneic and had ongoing pain. Home medications are aspirin 81 mg/day for 2 months, doxazosin 2 mg/day,
and ibuprofen 800 mg three times daily. Vital signs include heart rate 42 beats/minute (sinus bradycardia) and
blood pressure 104/48 mm Hg. Laboratory results include blood urea nitrogen (BUN) 45 mg/dL, SCr 2.5 mg/
dL, and troponin 1.5 ng/L (normal value less than 0.1 ng/L). His ECG reveals a 3-mm ST-segment elevation.
Aspirin, ticagrelor, and sublingual nitroglycerin were given in the ED. The nearest hospital with a catheterization laboratory facility is 2½ hours away. Which regimen is best?
A. Give alteplase 15 units intravenously plus enoxaparin 30-mg intravenous bolus.
B. Use an ischemia-guided treatment strategy with UFH 4000-unit intravenous bolus, followed by 800 units
intravenously per hour.
C. Give tenecteplase 35 mg intravenously plus UFH 4000-unit intravenous bolus followed by 800 units intravenously per hour.
D. Transfer the patient to a facility for primary PCI.

Answer 14

Acute Care Cardiology

C

Question 15

A 72-year-old man is admitted to the hospital for HF decompensation. The patient has progressively increased
dyspnea when walking (now 10 ft [3 m], previously 30 ft [6 m]) and orthopnea (now four pillows, previously two
pillows), increased bilateral lower-extremity swelling (3+), 13 kg of weight gain in the past 3 weeks, and dietary
nonadherence. He has a history of idiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III), paroxysmal AF, and hyperlipidemia. Pertinent laboratory values are as follows: BNP 2300 pg/mL (0–50 pg/mL), K+ 4.9
mEq/L, BUN 32 mg/dL, SCr 2.0 mg/dL (baseline 1.9 mg/dL), aspartate aminotransferase (AST) 40 IU/L, alanine
aminotransferase 42 IU/L, INR 1.3, aPTT 42 seconds, blood pressure 108/62 mm Hg, heart rate 82 beats/minute,
and Sao2 95%. Home medications include carvedilol 12.5 mg twice daily, lisinopril 40 mg/day, furosemide 80 mg
twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day.
5. Which regimen is best for treating his ADHF?
A. Carvedilol 25 mg twice daily.
B. Sodium nitroprusside 0.1 mcg/kg/min via continuous infusion.
C. Furosemide 120 mg intravenously twice daily.
D. Milrinone 0.5 mcg/kg/minute

Answer 15

Acute Care Cardiology

C

Question 16

A 72-year-old man is admitted to the hospital for HF decompensation. The patient has progressively increased
dyspnea when walking (now 10 ft [3 m], previously 30 ft [6 m]) and orthopnea (now four pillows, previously two
pillows), increased bilateral lower-extremity swelling (3+), 13 kg of weight gain in the past 3 weeks, and dietary
nonadherence. He has a history of idiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III), paroxysmal AF, and hyperlipidemia. Pertinent laboratory values are as follows: BNP 2300 pg/mL (0–50 pg/mL), K+ 4.9
mEq/L, BUN 32 mg/dL, SCr 2.0 mg/dL (baseline 1.9 mg/dL), aspartate aminotransferase (AST) 40 IU/L, alanine
aminotransferase 42 IU/L, INR 1.3, aPTT 42 seconds, blood pressure 108/62 mm Hg, heart rate 82 beats/minute,
and Sao2 95%. Home medications include carvedilol 12.5 mg twice daily, lisinopril 40 mg/day, furosemide 80 mg
twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day

After being initiated on intravenous loop diuretics with only minimal urinary output, the patient is transferred
to the coronary care unit for further management of diuretic-refractory decompensated HF. His Sao2
is now
87% on a 4-L nasal cannula, and an arterial blood gas is being obtained. His blood pressure is 110/75 mm
Hg and heart rate is 75 beats/minute. The patient’s SCr and K+
concentrations have begun to rise and are now
2.7 mg/dL and 5.4 mmol/L, respectively. In addition to a one-time dose of intravenous chlorothiazide, which
regimen is most appropriate for this patient?
A. Nitroglycerin 20 mcg/minute.
B. Sodium nitroprusside 0.3 mg/kg/minute.
C. Dobutamine 5 mcg/kg/minute.
D. Milrinone 0.5 mcg/kg/minute.

Answer 16

Acute Care Cardiology

A

Question 17

72-year-old man is admitted to the hospital for HF decompensation. The patient has progressively increased
dyspnea when walking (now 10 ft [3 m], previously 30 ft [6 m]) and orthopnea (now four pillows, previously two
pillows), increased bilateral lower-extremity swelling (3+), 13 kg of weight gain in the past 3 weeks, and dietary
nonadherence. He has a history of idiopathic dilated cardiomyopathy (LVEF 25%, NYHA class III), paroxysmal AF, and hyperlipidemia. Pertinent laboratory values are as follows: BNP 2300 pg/mL (0–50 pg/mL), K+ 4.9
mEq/L, BUN 32 mg/dL, SCr 2.0 mg/dL (baseline 1.9 mg/dL), aspartate aminotransferase (AST) 40 IU/L, alanine
aminotransferase 42 IU/L, INR 1.3, aPTT 42 seconds, blood pressure 108/62 mm Hg, heart rate 82 beats/minute,
and Sao2 95%. Home medications include carvedilol 12.5 mg twice daily, lisinopril 40 mg/day, furosemide 80 mg
twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day.

The patient initially responds with 2 L of urinary output overnight, and his weight decreases by 1 kg the next
day. However, by day 5, his urinary output has diminished again, and his SCr has risen to 4.3 mg/dL. He was
drowsy and confused this morning during rounds. His extremities are cool and cyanotic, blood pressure is
89/58 mm Hg, and heart rate is 98 beats/minute. It is believed that he is no longer responding to his current
regimen. A Swan-Ganz catheter is placed to determine further management. Hemodynamic values are cardiac
index 1.5 L/minute/m2
, SVR 2650 dynes/second/cm5
, and Pulmonary capillary wedge pressure 30 mm Hg.
Which regimen is most appropriate for his current symptoms?
A. Milrinone 0.2 mcg/kg/minute.
B. Dobutamine 10 mcg/kg/minute.
C. Sodium nitroprusside 0.1 mcg/kg/minute.
D. Phenylephrine 20 mcg/minute.

Answer 17

Acute Care Cardiology

A

Question 18

A 68-year-old man is admitted after an episode of syncope, with a presyncopal syndrome of seeing black spots and
dizziness before passing out. Telemetry monitor showed sustained VT for 45 seconds. His medical history includes
HF NYHA class III, LVEF 30%, two MIs, hypertension for 20 years, LV hypertrophy, diabetes, and diabetic
nephropathy. His medications include lisinopril 5 mg/day, furosemide 20 mg twice daily, metoprolol 25 mg twice
daily, digoxin 0.125 mg/day, glipizide 5 mg/day, atorvastatin 40 mg, and aspirin 81 mg/day. His blood pressure is
120/75 mm Hg, with heart rate 80 beats/minute, BUN 30 mg/dL, and SCr 2.2 mg/dL.
8. Which is the best therapy to initiate for conversion of his sustained VT?
A. Amiodarone 150 mg intravenously for 10 minutes, then 1 mg/minute for 6 hours, then 0.5 mg/minute.
B. Sotalol 80 mg twice daily titrated to QTc of about 450 milliseconds.
C. Dofetilide 500 mcg twice daily titrated to QTc of about 450 milliseconds.
D. Procainamide 20 mg/minute, with a maximum of 17 mg/kg.

Answer 18

Acute Care Cardiology

A

Question 19

A 68-year-old man is admitted after an episode of syncope, with a presyncopal syndrome of seeing black spots and
dizziness before passing out. Telemetry monitor showed sustained VT for 45 seconds. His medical history includes
HF NYHA class III, LVEF 30%, two MIs, hypertension for 20 years, LV hypertrophy, diabetes, and diabetic
nephropathy. His medications include lisinopril 5 mg/day, furosemide 20 mg twice daily, metoprolol 25 mg twice
daily, digoxin 0.125 mg/day, glipizide 5 mg/day, atorvastatin 40 mg, and aspirin 81 mg/day. His blood pressure is
120/75 mm Hg, with heart rate 80 beats/minute, BUN 30 mg/dL, and SCr 2.2 mg/dL.

The patient presents to the ED 3 months after amiodarone maintenance initiation (he refused ICD placement)
after a syncopal episode, during which he lost consciousness for 30 seconds, according to witnesses. He also
has rapid heart rate episodes during which he feels dizzy and lightheaded. He feels very warm all the time (he
wears shorts, even though it is winter), cannot sleep, and has lost 3 kg in weight. He received a diagnosis of
hyperthyroidism caused by amiodarone therapy. On telemetry, he has runs of nonsustained VT. Which best
predicts the duration of amiodarone-associated hyperthyroidism in this patient?
A. 12 hours.
B. 1 month.
C. 6 months.
D. 18 months.

Answer 19

Acute Care Cardiology

C

Question 20

A 64-year-old woman presents to the ED with the chief concern of palpitations. Her medical history includes
hypertension controlled with a diuretic and an inferior-wall MI 6 months ago. She is pale and diaphoretic but
can respond to commands. The patient’s laboratory values are within normal limits. Her vital signs include
blood pressure 95/70 mm Hg and heart rate 145 beats/minute; telemetry shows sustained VT. Despite chronic
use of β-blocker therapy, the patient has developed sustained VT that is successfully terminated with lidocaine. Subsequent electrophysiologic testing reveals inducible VT, and sotalol 80 mg orally twice daily is prescribed. Two hours after the second dose, the patient’s QTc is 520 milliseconds. Which regimen change would
be most appropriate for this patient?
A. Continue sotalol at 80 mg orally twice daily.
B. Increase sotalol to 120 mg orally twice daily.
C. Discontinue sotalol and initiate dofetilide 125 mcg orally twice daily.
D. Discontinue sotalol and initiate amiodarone 400 mg orally three times daily.

Answer 20

Acute Care Cardiology

D

Question 21

A 68-year-old man with a history of stage 5 chronic kidney disease receiving hemodialysis, hypertension,
CAD post-MI, HFrEF, and gastroesophageal reflux disease presents with acute-onset shortness of breath and
chest pain. After his recent dialysis, he was nonadherent to medical therapy for 2 days and noticed he had
gained 2 kg in 24 hours. His baseline orthopnea worsened to sleeping sitting up in a chair for the 2 nights
before admission. He admits smoking cocaine within the past 24 hours and developed acute-onset chest tightness with diaphoresis and nausea, and his pain was 7/10. He went to the ED, where his blood pressure was
250/120 mm Hg. He had crackles halfway up his lungs on examination, and chest radiography detected bilateral fluffy infiltrates with prominent vessel cephalization. His ECG revealed sinus tachycardia, heart rate 122
beats/minute, and ST-segment depressions in leads 2, 3, and aVF. He was admitted for a hypertensive emergency. Laboratory results are as follows: BUN 48 mg/dL, SCr 11.4 mg/dL, BNP 2350 pg/mL, troponin T 1.5
ng/L (less than 0.1 mcg/L), creatine kinase 227 units/L, and creatine kinase-MB 22 units/L. Which medication
is best for this patient’s hypertensive emergency?
A. Intravenous nitroglycerin 5 mcg/minute titrated to a 25% reduction in MAP.
B. Labetalol 2 mcg/minute titrated to a 50% reduction in MAP.
C. Sodium nitroprusside 0.25 mcg/kg/minute titrated to a 25% reduction in MAP.
D. Clonidine 0.1 mg orally every 2 hours as needed for a 50% reduction in MAP.

Answer 21

Acute Care Cardiology

A

Question 22

A 56-year-old white woman with a long history of hypertension because of nonadherence and recently diagnosed HF (ejection fraction 35%) presents to the local ED with blood pressure 210/120 mm Hg and heart rate
105 beats/minute. She states that she felt a little lightheaded but that she now feels okay. She ran out of her
blood pressure medications (including hydrochlorothiazide, carvedilol, and lisinopril) 3 days ago. Her current
laboratory values are within normal limits. Which medication is best for this patient?
A. Sodium nitroprusside 0.25 mcg/kg/minute titrated to a 25% reduction in MAP.
B. Labetalol 80 mg intravenously; repeat until blood pressure is less than 120/80 mm Hg.
C. Resumption of home medications; refer for follow-up within 2 days.
D. Resumption of home medications; initiate amlodipine 10 mg daily; refer for follow-up in 1 week.

Answer 22

Acute Care Cardiology

C

Question 23

R.S., a 58-year-old woman with a history of hypertension (HTN), chronic coronary disease (CCD),
myocardial infarction (MI) 4 months ago, and dyslipidemia, presents to the clinic for a follow-up.
She has no worsening signs or symptoms of dyspnea or edema compared with her baseline. An
echocardiogram reveals a left ventricular ejection
fraction (LVEF) of 35%. She is in New York Heart
Association (NYHA) class III. Her medications
include aspirin 81 mg/day, metoprolol succinate
150 mg/day, and atorvastatin 40 mg/day at night.
Her vital signs include blood pressure (BP) 138/80
mm Hg and heart rate (HR) 58 beats/minute. Her
lungs are clear, and laboratory results are within
normal limits. Given her history and physical
examination, what is the most appropriate modification to R.S.’s current drug therapy?
A. Continue current therapy.
B. Initiate digoxin 0.125 mg/day.
C. Initiate vericiguat 2.5 mg/day.
D. Initiate sacubitril 24 mg/valsartan 26 mg twice
daily

Answer 23

Chronic Care Cardiology

D

Question 24

J.O. is a 64-year-old woman with NYHA class II
nonischemic dilated cardiomyopathy (LVEF of
30%). She presents to the heart failure (HF) clinic
for a follow-up. She is euvolemic. Her medications
include enalapril 10 mg twice daily, furosemide
40 mg twice daily, and potassium chloride 20 mEq
twice daily. Her vital signs include BP 130/88 mm
Hg and HR 78 beats/minute. Her laboratory results
are within normal limits. What is the best way to
manage J.O.’s HF?
A. Continue current regimen.
B. Increase enalapril to 20 mg twice daily.
C. Initiate carvedilol 3.125 mg twice daily.
D. Initiate digoxin 0.125 mg/day

Answer 24

Chronic Care Cardiology

C

Question 25

J.M. is a 65-year-old woman with a history of HTN who presents to her primary care physician with shortness of breath and markedly decreased exercise tolerance. An echocardiogram reveals an LVEF of 65%, with diastolic dysfunction. J.M. currently takes losartan 150 mg/day for HTN. Her vital signs include BP 134/84 mm Hg and HR 68 beats/minute. Her lung fields are clear to auscultation, and there is no evidence of systemic congestion. Her laboratory results include SCr 1.1 mg/ dL and K 5.1 mEq/L. Which is the best change to make to J.M.’s pharmacologic regimen today? A. Add metoprolol succinate 50 mg/day. B. Initiate furosemide 40 mg/day. C. Add spironolactone 25 mg/day. D. Add empagliflozin 10 mg/day.

Answer 25

Chronic Care Cardiology D

Question 26

B.W. is a 78-year-old man with a history of HTN, peripheral arterial disease (PAD), gastroesophageal reflux disease, and asymptomatic atrial fibrillation (AF) for the past month. His therapy includes aspirin 325 mg/day, lansoprazole 30 mg every night, atenolol 50 mg/day, lisinopril 10 mg/day, and atorvastatin 20 mg/day. His vital signs include BP 132/72 mm Hg and HR 68 beats/minute. Which is the best therapy for B.W. at this time? A. Add diltiazem and rivaroxaban. B. Add digoxin and increase lisinopril to 20 mg/ day. C. Discontinue atorvastatin and add warfarin. D. Add apixaban and decrease aspirin to 81 mg/day.

Answer 26

Chronic Care Cardiology D

Question 27

Z.G. is a 61-year-old man with AF, HTN, and dyslipidemia. His medications include digoxin 0.125 mg/day, warfarin 5 mg/day, amlodipine 10 mg/day, and pravastatin 20 mg every night. He comes to the clinic with no complaints except for palpitations and shortness of breath when doing yard work. His vital signs include BP 138/80 mm Hg and HR 100 beats/minute. His international normalized ratio (INR) is 2.4, and his digoxin concentration is 1.1 ng/mL. All other laboratory results are within normal limits. Which is the best option to help with Z.G.’s symptoms? A. Add metoprolol succinate 50 mg/day. B. Increase digoxin to 0.25 mg/day. C. Add verapamil 240 mg/day. D. Continue current regimen and advise the patient to avoid activitiesthat cause signs orsymptoms.

Answer 27

Chronic Care Cardiology A

Question 28

R.P. is an 69-year-old Hispanic man with a history of HTN and gout. His medications include allopurinol 300 mg/day, amlodipine 10 mg/day, and aspirin 81 mg/day. His vital signs include BP 145/85 mm Hg and HR 82 beats/minute. His laboratory values are normal and his 10-year atherosclerotic cardiovascular disease (ASCVD) risk is 22.4%. Which is the best therapy for R.P.? A. Add hydrochlorothiazide 25 mg/day to achieve a systolic blood pressure (SBP) goal of less than 130 mm Hg. B. Add lisinopril 40 mg/day and titrate to achieve an SBP goal of less than 140. C. Add losartan 25 mg/day to achieve an SBP less than 130 mm Hg. D. Make no changes to his current medications because his SBP is at goal.

Answer 28

Chronic Care Cardiology C

Question 29

J.T. is a 58-year-old man who presents to his primary care provider for the first time in 10 years. He has smoked 2 packs/day for the past 30 years and takes no medication. A fasting lipid panel shows total cholesterol (TC) 222 mg/dL, lowdensity lipoprotein cholesterol (LDL-C) 105 mg/dL, triglycerides (TG) 330 mg/dL, and high-density lipoprotein cholesterol (HDL-C) 51 mg/dL. His vital signs include BP 140/75 mm Hg and HR 80 beats/minute. His pooled cohort equation reveals a 10-year ASCVD risk of 14.6%. Which would be the best pharmacologic therapy to initiate in J.T.? A. Initiate simvastatin 20 mg/day and gemfibrozil 600 mg twice daily. B. Initiate rosuvastatin 2.5 mg/day. C. Initiate pravastatin 20 mg/day and fenofibrate 160 mg/day. D. Initiate atorvastatin 20 mg/day

Answer 29

Chronic Care Cardiology D

Question 30

J.S. is a 43-year-old man with HTN who presents for an annual physical examination. His family history is significant for his father having HTN. His only medication is lisinopril 10 mg/day. His BP is 145/90 mm Hg. A fasting lipid profile shows TC 238 mg/dL, TG 95 mg/dL, LDL-C 176 mg/dL, and HDL-C 43 mg/dL. His calculated 10-year ASCVD risk according to the pooled cohort equation is 3.9%. Which best describes the next step for management in J.S.? A. Initiate high-intensity statin therapy. B. Initiate fenofibrate 130 mg/day. C. Initiate moderate-intensity statin therapy. D. Do not initiate statin therapy and reevaluate risk in 4–6 years

Answer 30

Chronic Care Cardiology D

Question 31

J.C. is a 62-year-old man (height 177.8 cm, weight 135 kg [1 month ago 143 kg]) with a history of diabetes, chronic kidney disease (CKD), bipolar disorder, CCD, and hypertriglyceridemia that, in the past, has resulted in pancreatitis. His family history is significant for his father having CCD and hypertriglyceridemia. He is not a smoker, but admits drinking a 6-pack of beer daily. Pertinent laboratory findings include a hemoglobin A1C of 11.6% and a serum creatinine (SCr) of 2.6 mg/dL. He currently takes atorvastatin 40 mg every evening, aspirin 81 mg/day, metformin 1000 mg twice daily, olanzapine 10 mg/day, metoprolol tartrate 50 mg twice daily, and coenzyme Q10 200 mg/day. His fasting lipid profile is TC 402 mg/dL, LDL-C unable to calculate, HDL-C 48 mg/dL, and TG 1500 mg/ dL. His other laboratory values are within normal limits. Which best describes potential secondary causes of elevated TG concentrations that should be considered in J.C.? A. Obesity, poorly controlled diabetes, olanzapine, metoprolol, coenzyme Q10. B. Alcohol consumption, poorly controlled diabetes, weight loss, metoprolol. C. Obesity, metformin, hyperthyroidism, alcohol consumption. D. Alcohol consumption, obesity, poorly controlled diabetes, olanzapine, metoprolol.

Answer 31

Chronic Care Cardiology D

Question 32

A.M. is a 32-year-old woman with type 1 diabetes and HTN. Her current medication regimen is as follows: ramipril 10 mg/day, chlorthalidone 25 mg/day, amlodipine 10 mg/day, ethinyl estradiol 20 mcg/norethindrone 1 mg daily (for the past 2 years), and insulin as directed. Her vital signs today include BP 145/83 mm Hg, repeated BP 145/81 mm Hg; HR 82 beats/minute; height 167.64 cm; weight 70 kg. A.M. presents to the clinic for HTN management. She has no new concerns but expresses that she would prefer not to take any more drugs, if possible. Which option is the best clinical plan for A.M.? A. No change in therapy is currently warranted. B. Advise weight loss and recheck her BP in 3 months. C. Change chlorthalidone to hydrochlorothiazide. D. Discuss changing her contraceptive method.

Answer 32

Chronic Care Cardiology D

Question 33

A.M. is a 32-year-old woman with type 1 diabetes and HTN. Her current medication regimen is as follows: ramipril 10 mg/day, chlorthalidone 25 mg/day, amlodipine 10 mg/day, ethinyl estradiol 20 mcg/norethindrone 1 mg daily (for the past 2 years), and insulin as directed. Her vital signs today include BP 145/83 mm Hg, repeated BP 145/81 mm Hg; HR 82 beats/minute; height 167.64 cm; weight 70 kg. A.M. presents to the clinic for HTN management. She has no new concerns but expresses that she would prefer not to take any more drugs, if possible. A.M. and her husband have decided they are ready to have children. What is the best medication option for A.M.? A. No change in therapy is warranted. B. Discontinue ramipril and replace with labetalol. C. Increase chlorthalidone to 50 mg/day. D. Discontinue all antihypertensive therapy

Answer 33

Chronic Care Cardiology B

Question 34

A 66-year-old African American man (height 177.8 cm, weight 91 kg) with AF and CCD (non– ST-segment elevation MI and stent placement 3 years ago) presents with palpitations. Rate control therapy, including trials of β-blockers and nondihydropyridine calcium channel blockers, has been unsuccessful in controlling his symptoms. He currently takes metoprolol succinate 50 mg/ day, aspirin 81 mg/day, atorvastatin 80 mg/day, lisinopril 5 mg/day, and warfarin 4 mg/day. His laboratory results show INR 2.2, potassium (K) 4.8 mEq/L, SCr 1.2 mg/dL. His BP is 110/70 mm Hg, and his HR is 95 beats/minute. Which is the best antiarrhythmic therapy for him? A. Disopyramide. B. Flecainide. C. Propafenone. D. Sotalol.

Answer 34

Chronic Care Cardiology D

Question 35

L.S. is a 48-year-old woman with alcohol-induced cardiomyopathy. Her most recent LVEF is 20%; her daily activities are limited by dyspnea and fatigue (NYHA class III). Her medications include lisinopril 40 mg daily, furosemide 40 mg twice daily, carvedilol 12.5 mg twice daily, spironolactone 25 mg/day, and digoxin 0.125 mg/day. She has been stable on these doses for the past month. Her most recent laboratory results include sodium (Na) 140 mEq/L, potassium (K) 4.0 mEq/L, chloride 105 mEq/L, bicarbonate 26 mEq/L, blood urea nitrogen 12 mg/dL, SCr 0.8 mg/dL, glucose 98 mg/dL, calcium 9.0 mg/dL, phosphorus 2.8 mg/ dL, magnesium 2.0 mEq/L, and digoxin 0.7 ng/mL. She weighs 69 kg, and her vital signs include BP 112/70 mm Hg and HR 72 beats/minute. In the clinic today, she has concerns for increased shortness of breath and fatigue. On physical examination, you note 2+ bilateral lower extremity pitting edema and hear crackles on inspiration. What is the best approach for maximizing the management of her HF? A. Increase carvedilol to 25 mg twice daily. B. Increase lisinopril to 80 mg/day. C. Add empagliflozin 10 mg/day. D. Increase digoxin to 0.25 mg/day.

Answer 35

Chronic Care Cardiology C

Question 36

J.T. is a 62-year-old man (height 182.88 cm, weight 85 kg) with a history of CCD (MI 3 years ago), HTN, depression, CKD (baseline SCr 2.8 mg/dL), PAD, osteoarthritis, hypothyroidism, and HF (LVEF of 25%). His medications include aspirin 81 mg/day, atorvastatin 40 mg every night, enalapril 5 mg twice daily, metoprolol succinate 50 mg/day, furosemide 80 mg twice daily, cilostazol 100 mg twice daily, acetaminophen 650 mg four times daily, sertraline 100 mg/day, and levothyroxine 0.1 mg/day. His vital signs include BP 128/74 mm Hg and HR 72 beats/minute. Pertinent laboratory results include K 4.1 mEq/L, SCr 2.8 mg/dL, and a thyroid-stimulating hormone of 2.6 mIU/L. His HF is stable and considered NYHA class II. What is the best approach for maximizing the management of his HF? A. Discontinue metoprolol and begin carvedilol 12.5 mg twice daily. B. Change enalapril to sacubitril/valsartan 24/26 mg orally twice daily. C. Add spironolactone 25 mg/day. D. Add digoxin 0.125 mg/day.

Answer 36

Chronic Care Cardiology B

Question 37

J.T. is a 62-year-old man (height 182.88 cm, weight 85 kg) with a history of CCD (MI 3 years ago), HTN, depression, CKD (baseline SCr 2.8 mg/dL), PAD, osteoarthritis, hypothyroidism, and HF (LVEF of 25%). His medications include aspirin 81 mg/day, atorvastatin 40 mg every night, enalapril 5 mg twice daily, metoprolol succinate 50 mg/day, furosemide 80 mg twice daily, cilostazol 100 mg twice daily, acetaminophen 650 mg four times daily, sertraline 100 mg/day, and levothyroxine 0.1 mg/day. His vital signs include BP 128/74 mm Hg and HR 72 beats/minute. Pertinent laboratory results include K 4.1 mEq/L, SCr 2.8 mg/dL, and a thyroid-stimulating hormone of 2.6 mIU/L. His HF is stable and considered NYHA class II. Which drug that J.T. (from Patient Case 2) is currently taking would be best to discontinue because of his HFrEF? A. Acetaminophen. B. Sertraline. C. Cilostazol. D. Levothyroxine.

Answer 37

Chronic Care Cardiology C

Question 38

P.M. is a 52-year-old man (height 177.8 cm, weight 116 kg) with a history of HTN and a transient ischemic attack 2 years ago. He visits his primary care doctor with the chief concern of several weeks of a “fluttering” feeling in his chest on occasion. He thinks the fluttering is nothing; however, his wife insists he have it checked. His current medications include metoprolol tartrate 50 mg twice daily and aspirin 81 mg/day. He is adherent to this regimen and has health insurance, but he does not like to make the 3-hour trip to his primary care provider. His laboratory data from his past visit were all within normal limits. His vitalsignstoday include BP 130/78 mm Hg and HR 76 beats/minute. All laboratory values are within normal limits. An electrocardiogram (ECG) reveals an irregularly irregular rhythm, with no P waves, and a HR of 74 beats/minute. A diagnosis of AF is made. What is the best approach for managing his AF at this time? A. Begin digoxin 0.25 mg/day. B. Begin diltiazem CD 240 mg/day. C. Begin warfarin 5 mg/day and titrate to a goal INR of 2.5. D. Begin dabigatran 150 mg twice daily.

Answer 38

Chronic Care Cardiology D

Question 39

H.D. is a 67-year-old man with a history of HTN and AF for 4 years. His medications include ramipril 5 mg twice daily, sotalol 120 mg twice daily, digoxin 0.125 mg/day, and warfarin 5 mg/day. He visits his primary care physician after being discharged from the emergency department with increased fatigue on exertion palpitations, and lower extremity edema. His vital signs today include BP 115/70 mm Hg and HR 88 beats/minute, and all laboratory results are within normal limits; however, his lower extremity edema has worsened. His INR is 2.8. His ECG shows AF. An echocardiogram reveals an LVEF of 35%–40%. H.D.’s physician would like to continue a rhythm control approach. What is the best treatment option for managing his AF? A. Discontinue sotalol and begin metoprolol succinate 12.5 mg/day. B. Discontinue sotalol and begin dronedarone 400 mg twice daily. C. Discontinue sotalol and begin amiodarone 400 mg twice daily, tapering to goal dose of 200 mg/day for the next 6 weeks. D. Continue sotalol and add metoprolol tartrate 25 mg twice daily

Answer 39

Chronic Care Cardiology C

Question 40

. W.D. is a 55-year-old woman who was recently admitted to the hospital with acute myocardial infarction which was treated with a stent. She has a medical history of HTN and GERD. She is visiting your clinic today for management of her cardiovascular medications. Her vitals today include BP 152/86 mm Hg and HR 82 beats/minute. Her labs are all WNL, including Na 140 mEq/L, K 4.3 mEq/L, and SCr 1.0 mg/dL. Her current medication regimen includes clopidogrel 75 mg daily, aspirin 81 mg daily, and atorvastatin 40 mg daily. What is the most appropriate approach to manage her HTN? A. Add carvedilol monotherapy B. Add lisinopril and metoprolol C. Add amlodipine and metoprolol D. Add lisinopril monotherapy

Answer 40

Chronic Care Cardiology D

Question 41

T.J. is a 58-year-old African American woman presenting for routine follow-up of her chronic obstructive pulmonary disease. She has no other medical history. Her blood pressure today (average of 2 readings) is 138/88 mm Hg. Her HR is 77 beats/minute. Her BP at her last visit was 136/86 mm Hg. Her current medications include tiotropium dry powder inhaler daily and an albuterol metered dose inhaler as needed. Her labs include Na 140 mEq/L, K 4.0 mEq/L, Cl 102 mEq/L, bicarbonate 28 mEq/L, serum urea nitrogen 14 mg/dL, and SCr 0.8 mg/dL. Her 10-year ASCVD risk is 12%. What is the best approach for managing her HTN? A. Begin diet and lifestyle modifications only B. Begin lifestyle modifications and add amlodipine 5 mg daily C. Begin lifestyle modifications and add lisinopril 2.5 mg daily D. Begin lifestyle modifications and add lisinopril 2.5 mg daily plus hydrochlorothiazide 12.5 mg daily

Answer 41

Chronic Care Cardiology B

Question 42

M.M. is a 63-year-old woman who just finished 6 months of diet and exercise for dyslipidemia. She has a history of hypertension, diabetes, and asthma. She smokes one pack of cigarettes and drinks three beers per day. Her mother had HTN and suffered an MI at age 42 years. Her father had HTN and diabetes. Her medications are albuterol metered dose inhaler, lisinopril, metformin, linagliptin, and calcium carbonate antacids. Her vital signs include BP 134/84 mm Hg and HR 75 beats/minute. Her laboratory results are as follows: HDL-C 38 mg/dL, LDL-C 134 mg/dL, TG 186 mg/dL, TC 209 mg/dL, and hemoglobin A1C 8.6%. Her pooled cohort equation estimates a 10-year ASCVD risk of 27.8%. What is the most appropriate next step for M.M.? A. Initiate a low-intensity statin B. Initiate a moderate-intensity statin C. Initiate a high-intensity statin D. Initiate a high-intensity statin plus ezetimibe

Answer 42

Chronic Care Cardiology C

Question 43

According to the ACC/AHA blood cholesterol guidelines, which is best described as a high-intensity statin dose? A. Pravastatin 20 mg/day. B. Lovastatin 20 mg/day. C. Atorvastatin 40 mg/day. D. Rosuvastatin 10 mg/day.

Answer 43

Chronic Care Cardiology C

Question 44

Which best describes a potential secondary cause of high TG concentrations? A. Amiodarone. B. Biliary obstruction. C. Sirolimus. D. Saturated fats

Answer 44

Chronic Care Cardiology C

Question 45

A 66-year-old man with a medical history of HTN and ACS with a drug-eluting coronary stent placement 14 months ago presents to the primary care clinic. Current medications include aspirin 81 mg/day, prasugrel 10 mg/day, nitroglycerin 0.4-mg sublingual tablets as needed for chest pain, metoprolol succinate 75 mg/day, ramipril 10 mg/day, and atorvastatin 20 mg/day. He asks you how long he will need to take prasugrel. What is the best answer? A. Call your physician because you may be able to stop prasugrel now. B. Your prasugrel should have been discontinued 6 months after ACS; discontinue it now. C. You will need to take prasugrel indefinitely. D. You will need to take prasugrel for at least 18 months after your MI and stent placement.

Answer 45

Chronic Care Cardiology A

Question 46

J.M. is a 72-year-old female (weight 57 kg) who presents to the hospital with nonvalvular atrial fibrillation (AF). After her heart rate is controlled with metoprolol, she is asymptomatic. She also has hypertension, dyslipidemia, and depression. Her medications include metoprolol tartrate 100 mg orally twice daily, enalapril 10 mg orally twice daily, and citalopram 20 mg orally daily. Her heart rate is 78 beats/minute and blood pressure is 134/86 mm Hg. Her SCr is 0.8 mg/dL and CrCl is 60 mL/minute; she has normal hepatic function. Which best depicts J.M.’s CHA2DS2-VASc score and HAS-BLED score? A. CHA2DS2-VASc score 1; HAS-BLED score 1. B. CHA2DS2-VASc score 3; HAS-BLED score 1. C. CHA2DS2-VASc score 5; HAS-BLED score 4. D. CHA2DS2-VASc score 3; HAS-BLED score 2.

Answer 46

Anticoagulation B

Question 47

J.M. is a 72-year-old female (weight 57 kg) who presents to the hospital with nonvalvular atrial fibrillation (AF). After her heart rate is controlled with metoprolol, she is asymptomatic. She also has hypertension, dyslipidemia, and depression. Her medications include metoprolol tartrate 100 mg orally twice daily, enalapril 10 mg orally twice daily, and citalopram 20 mg orally daily. Her heart rate is 78 beats/minute and blood pressure is 134/86 mm Hg. Her SCr is 0.8 mg/dL and CrCl is 60 mL/minute; she has normal hepatic function. Which is the most appropriate stroke prevention strategy for J.M.? A. Aspirin 325 mg orally once daily. B. Rivaroxaban 20 mg orally once daily. C. Apixaban 2.5 mg orally twice daily. D. Edoxaban 30 mg orally once daily.

Answer 47

Anticoagulation B

Question 48

J.M. is a 72-year-old female (weight 57 kg) who presents to the hospital with nonvalvular atrial fibrillation (AF). After her heart rate is controlled with metoprolol, she is asymptomatic. She also has hypertension, dyslipidemia, and depression. Her medications include metoprolol tartrate 100 mg orally twice daily, enalapril 10 mg orally twice daily, and citalopram 20 mg orally daily. Her heart rate is 78 beats/minute and blood pressure is 134/86 mm Hg. Her SCr is 0.8 mg/dL and CrCl is 60 mL/minute; she has normal hepatic function. J.M. was initiated on dabigatran and 3 months later is involved in a motor vehicle accident resulting in an intracranial hemorrhage. Which is the most appropriate reversal strategy for J.M.? A. Protamine. B. Fresh frozen plasma (FFP). C. Coagulation factor Xa [recombinant], inactivated. D. Idarucizumab.

Answer 48

Anticoagulation D

Question 49

B.T. is 68-year-old male (height 183 cm, weight 96 kg) who recently underwent surgical aortic valve replacement with a bioprosthetic valve and is recovering well. He also has hypertension, dyslipidemia, systolic heart failure, and a history of sustained ventricular tachycardia. His medications include carvedilol 25 mg orally twice daily, lisinopril 10 mg orally daily, furosemide 40 mg orally daily, amiodarone 400 mg orally daily, and atorvastatin 80 mg orally daily. His CrCl is 40 mL/ minute, hepatic function is normal, and other laboratory data are within normal limits. Which is the most appropriate antithrombotic regimen for B.T.? A. Aspirin 81 mg orally daily. B. Warfarin 7.5 mg orally daily to an INR of 2.5–3.5. C. Apixaban 5 mg orally twice daily. D. Dabigatran 150 mg twice daily

Answer 49

Anticoagulation A

Question 50

B.T. is 68-year-old male (height 183 cm, weight 96 kg) who recently underwent surgical aortic valve replacement with a bioprosthetic valve and is recovering well. He also has hypertension, dyslipidemia, systolic heart failure, and a history of sustained ventricular tachycardia. His medications include carvedilol 25 mg orally twice daily, lisinopril 10 mg orally daily, furosemide 40 mg orally daily, amiodarone 400 mg orally daily, and atorvastatin 80 mg orally daily. His CrCl is 40 mL/ minute, hepatic function is normal, and other laboratory data are within normal limits. Which best depicts how long B.T. should receive therapy? A. At least 1 month. B. At least 3 months. C. At least 1 year. D. Indefinitely.

Answer 50

Anticoagulation D

Question 51

M.R. is a 51-year-old female (height 165 cm, weight 98 kg, BMI 36 kg/m2 ) who presents to the ED with pain, swelling, and redness in her right leg up into her thigh. She also has some shortness of breath and pain in the middle of her chest. She reports that she had a hysterectomy about 2 weeks ago and has not been moving much at home in the past 2 weeks. On physical examination, her right leg is warmer than her left and tender to the touch. Her cardiac examination appears normal, with vital signs consisting of a heart rate of 80 beats/minute, blood pressure 146/96 mm Hg, respiratory rate 20 breaths/minute, and Sao2 92% on room air. Her initial laboratory information includes a positive D-dimer, a negative troponin, and a CrCl of 65 mL/minute. Duplex ultrasound detects a right femoral-popliteal deep vein thrombosis (DVT), and CT reveals a pulmonary embolism (PE). Her other conditions include hypertension, type 2 diabetes, and dyslipidemia. She has also smoked 1 pack/day of cigarettes for the past 30 years. Her medications include lisinopril 10 mg orally daily, chlorthalidone 25 mg orally daily, metformin 1000 mg orally twice daily, pravastatin 40 mg orally daily, and hydrocodone 5 mg/acetaminophen 325 mg orally every 6 hours as needed for pain. Which best depicts M.R.’s number of venous thromboembolism (VTE) risk factors? A. 3. B. 4. C. 5. D. 6.

Answer 51

Anticoagulation C

Question 52

M.R. is a 51-year-old female (height 165 cm, weight 98 kg, BMI 36 kg/m2 ) who presents to the ED with pain, swelling, and redness in her right leg up into her thigh. She also has some shortness of breath and pain in the middle of her chest. She reports that she had a hysterectomy about 2 weeks ago and has not been moving much at home in the past 2 weeks. On physical examination, her right leg is warmer than her left and tender to the touch. Her cardiac examination appears normal, with vital signs consisting of a heart rate of 80 beats/minute, blood pressure 146/96 mm Hg, respiratory rate 20 breaths/minute, and Sao2 92% on room air. Her initial laboratory information includes a positive D-dimer, a negative troponin, and a CrCl of 65 mL/minute. Duplex ultrasound detects a right femoral-popliteal deep vein thrombosis (DVT), and CT reveals a pulmonary embolism (PE). Her other conditions include hypertension, type 2 diabetes, and dyslipidemia. She has also smoked 1 pack/day of cigarettes for the past 30 years. Her medications include lisinopril 10 mg orally daily, chlorthalidone 25 mg orally daily, metformin 1000 mg orally twice daily, pravastatin 40 mg orally daily, and hydrocodone 5 mg/acetaminophen 325 mg orally every 6 hours as needed for pain. Which is the most appropriate treatment strategy for M.R.? A. Enoxaparin 100 mg subcutaneously every 12 hours and dabigatran 150 mg orally twice daily; after 5 days, enoxaparin can be discontinued. B. Rivaroxaban 15 mg orally twice daily for 7 days, followed by 20 mg orally once daily. C. Enoxaparin 100 mg subcutaneously every 12 hours for 5 days; then initiate edoxaban 60 mg orally once daily. D. Unfractionated heparin (UFH) 4000-unit bolus, followed by 1000 units/hour and warfarin 7.5 mg orally daily to an INR of 2.0–3.0, discontinuing UFH when a therapeutic INR is reached.

Answer 52

Anticoagulation C

Question 53

A male patient (height 186 cm, weight 125 kg) is admitted for the treatment of a DVT with a PE. He is administered a 10,000-unit bolus of UFH and initiated on an infusion of 2000 units/hour. Twelve hours into the infusion, he begins to vomit blood. Which is the most appropriate protamine dose for this patient? A. 100 mg. B. 50 mg. C. 22.5 mg. D. 11.25 mg

Answer 53

Anticoagulation B

Question 54

A female patient (height 163 cm, weight 65 kg) has undergone a hip fracture surgery. She has normal renal and hepatic function. Which is the most appropriate regimen for preventing VTE in this patient? A. Dabigatran 110 mg orally once 2 hours after surgery, followed by 220 mg orally once daily. B. Enoxaparin 30 mg subcutaneously once daily. C. Fondaparinux 2.5 mg subcutaneously once daily. D. Edoxaban 60 mg orally once daily.

Answer 54

Anticoagulation C

Question 55

B.D. is a 73-year-old male (height 175 cm, weight 80 kg) with newly diagnosed nonvalvular AF. He also has a history of hypertension, dyslipidemia, stable ischemic heart disease, and systolic heart failure. His medications include aspirin 81 mg orally daily, enalapril 10 mg orally daily, atorvastatin 80 mg orally daily, metoprolol succinate 200 mg orally daily, furosemide 40 mg orally daily, spironolactone 25 mg orally daily, and amlodipine 10 mg orally daily. His heart rate is 72 beats/minute and blood pressure is 122/72 mm Hg. His laboratory values include K 4.9 mEq/L, stable SCr 1.9 mg/dL, and blood glucose 101 mg/dL. Which best depicts B.D.’s CHA2 DS2 -VASc score? A. 2. B. 3. C. 4. D. 5.

Answer 55

Anticoagulation B

Question 56

B.D. is a 73-year-old male (height 175 cm, weight 80 kg) with newly diagnosed nonvalvular AF. He also has a history of hypertension, dyslipidemia, stable ischemic heart disease, and systolic heart failure. His medications include aspirin 81 mg orally daily, enalapril 10 mg orally daily, atorvastatin 80 mg orally daily, metoprolol succinate 200 mg orally daily, furosemide 40 mg orally daily, spironolactone 25 mg orally daily, and amlodipine 10 mg orally daily. His heart rate is 72 beats/minute and blood pressure is 122/72 mm Hg. His laboratory values include K 4.9 mEq/L, stable SCr 1.9 mg/dL, and blood glucose 101 mg/dL. Which is most accurate regarding DOAC therapy for reducing the risk of stroke in patients with nonvalvular AF such as B.D.? A. All the DOACs significantly reduced ischemic stroke in the phase III trials compared with warfarin. B. All the DOACs significantly reduced hemorrhagic stroke in the phase III trials compared with warfarin. C. Apixaban is more effective than rivaroxaban because apixaban was superior to warfarin in the ARISTOTLE trial and rivaroxaban was only noninferior to warfarin in the ROCKET-AF trial. D. Dabigatran was studied in patients with highest risk across the phase III trials and should not be used in patients with a CHADS2 score less than 3.

Answer 56

Anticoagulation B

Question 57

B.D. is a 73-year-old male (height 175 cm, weight 80 kg) with newly diagnosed nonvalvular AF. He also has a history of hypertension, dyslipidemia, stable ischemic heart disease, and systolic heart failure. His medications include aspirin 81 mg orally daily, enalapril 10 mg orally daily, atorvastatin 80 mg orally daily, metoprolol succinate 200 mg orally daily, furosemide 40 mg orally daily, spironolactone 25 mg orally daily, and amlodipine 10 mg orally daily. His heart rate is 72 beats/minute and blood pressure is 122/72 mm Hg. His laboratory values include K 4.9 mEq/L, stable SCr 1.9 mg/dL, and blood glucose 101 mg/dL. Which is the most appropriate regimen for reducing B.D.’s risk of stroke? A. Dabigatran 75 mg orally twice daily. B. Rivaroxaban 20 mg orally once daily. C. Apixaban 5 mg orally twice daily. D. Edoxaban 60 mg orally once daily

Answer 57

Anticoagulation C

Question 58

B.D. is a 73-year-old male (height 175 cm, weight 80 kg) with newly diagnosed nonvalvular AF. He also has a history of hypertension, dyslipidemia, stable ischemic heart disease, and systolic heart failure. His medications include aspirin 81 mg orally daily, enalapril 10 mg orally daily, atorvastatin 80 mg orally daily, metoprolol succinate 200 mg orally daily, furosemide 40 mg orally daily, spironolactone 25 mg orally daily, and amlodipine 10 mg orally daily. His heart rate is 72 beats/minute and blood pressure is 122/72 mm Hg. His laboratory values include K 4.9 mEq/L, stable SCr 1.9 mg/dL, and blood glucose 101 mg/dL. Six months later, B.D. elects to undergo PCI for the management of his chronic coronary artery disease. He has had no medication changes, and his vital signs and laboratory information remain consistent. Which is the best available evidence-based approach to B.D.’s antithrombotic therapy? A. Rivaroxaban 10 mg orally daily plus clopidogrel 75 mg orally daily. B. Apixaban 2.5 mg orally twice daily plus clopidogrel 75 mg orally daily. C. Adjusted-dose warfarin to an INR of 2.0–3.0 plus aspirin 81 mg orally daily plus clopidogrel 75 mg orally daily. D. Edoxaban 15 mg orally once daily plus aspirin 81 mg orally daily plus clopidogrel 75 mg orally daily

Answer 58

Anticoagulation A

Question 59

S.D. is a 62-year-old female (height 165 cm, weight 80 kg) with a history of significant primary mitral regurgitation. Her echocardiogram reveals significant leaflet flaring that is not amendable to mitral valve repair. She also has a history of hypertension, dyslipidemia, and gout. Her medications include lisinopril 10 mg orally daily, hydrochlorothiazide 25 mg orally daily, simvastatin 40 mg orally daily, and allopurinol 300 mg orally daily. Her heart rate is 68 beats/minute and blood pressure is 128/74 mm Hg. Her CrCl is 68 mL/minute. She is scheduled to undergo valve replacement surgery and will receive a mechanical mitral valve. You are discussing the oral anticoagulant postoperative plan with S.D.’s team Which is the optimal regimen for preventing thrombosis? A. Adjusted-dose warfarin to an INR goal of 2.5–3.5 plus aspirin 81 mg orally daily. B. Adjusted-dose warfarin to an INR goal of 2.0–3.0 plus aspirin 81 mg orally daily. C. Adjusted-dose warfarin to an INR goal of 2.0–3.0. D. Adjusted-dose warfarin to an INR goal of 2.5–3.5.

Answer 59

Anticoagulation D

Question 60

S.D. is a 62-year-old female (height 165 cm, weight 80 kg) with a history of significant primary mitral regurgitation. Her echocardiogram reveals significant leaflet flaring that is not amendable to mitral valve repair. She also has a history of hypertension, dyslipidemia, and gout. Her medications include lisinopril 10 mg orally daily, hydrochlorothiazide 25 mg orally daily, simvastatin 40 mg orally daily, and allopurinol 300 mg orally daily. Her heart rate is 68 beats/minute and blood pressure is 128/74 mm Hg. Her CrCl is 68 mL/minute. She is scheduled to undergo valve replacement surgery and will receive a mechanical mitral valve. You are discussing the oral anticoagulant postoperative plan with S.D.’s team Which best describes thrombotic risk in patients with valve replacement surgery? A. Bioprosthetic valves carry a higher risk of thrombosis than mechanical valves. B. The highest risk of thrombosis with bioprosthetic valve placement is during the first year after surgery. C. All patients with mechanical heart valves require bridging therapy during invasive procedures. D. Valve replacement in the mitral position carries a higher risk of thrombosis than in the aortic position

Answer 60

Anticoagulation D

Question 61

B.G. is a 62-year-old male (height 175 cm, weight 110 kg) hospitalized for a heart failure exacerbation. He has symptoms when doing only limited exertion and has been out of bed only to use the bathroom for the past 3 days. His medical history also includes stable ischemic heart disease, hypertension, type 2 diabetes, and a PE 2 years ago. He smokes 2 packs of cigarettes/day and drinks 1 glass of wine with dinner most evenings. His medications include bisoprolol 5 mg orally daily, lisinopril 10 mg orally daily, aspirin 81 mg orally daily, ranolazine 1000 mg orally twice daily, furosemide 40 mg orally daily, spironolactone 25 mg orally daily, and metformin 1000 mg orally twice daily. His blood pressure today is 110/70 mm Hg and heart rate is 58 beats/ minute. His laboratory values are normal except for a BNP of 1498 ng/mL. Which is the most appropriate VTE prevention strategy for B.G.? A. Administer fondaparinux 5 mg subcutaneously daily. B. Administer apixaban 2.5 mg orally twice daily. C. Administer enoxaparin 40 mg subcutaneously daily. D. His risk does not warrant prophylactic therapy.

Answer 61

Anticoagulation C

Question 62

A 48-year-old male (height 178 cm, weight 90 kg) presents to the ED with pain and swelling in his left leg. On examination, his leg is warm to the touch and tender and has 3+ pitting edema below the knee. His D-dimer is positive, and his duplex ultrasonography identifies a femoral-popliteal DVT. He understands that he will need to receive anticoagulant therapy but wants to avoid any injections, if possible. He has good insurance coverage. His other medical conditions are hypertension, HIV, and dyslipidemia. His medications include benazepril 20 mg orally daily, ritonavir 100 mg orally daily, darunavir 800 mg orally daily, emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg orally daily, and atorvastatin 10 mg orally daily. His vital signs are stable, and his CrCl is 78 mL/minute. Which is the most appropriate anticoagulant regimen to initiate for this patient? A. Rivaroxaban 15 mg orally twice daily for 21 days, followed by 20 mg orally daily. B. Edoxaban 60 mg orally daily. C. Warfarin 2.5 mg orally daily. D. Apixaban 5 mg orally twice daily for 7 days, followed by 2.5 mg orally twice daily.

Answer 62

Anticoagulation D

Question 63

. A 49-year-old male (height 175 cm, weight 100 kg) was diagnosed with an idiopathic DVT 3 weeks ago. He currently takes warfarin 8 mg orally daily. He missed his INR readings last week when he went on a short vacation. Today, his INR is 10.4. He is not currently bleeding and has no risk factors for bleeding. In addition to holding his warfarin dose, which is the best initial strategy for managing this patient’s high INR? A. Hold warfarin only. B. Hold warfarin and administer 4PCC 50 units/kg intravenously. C. Hold warfarin and administer vitamin K 5 mg orally. D. Hold warfarin and administer vitamin K 10 mg intravenously.

Answer 63

Anticoagulation C

Question 64

A 58-year-old male is receiving enoxaparin 40 mg subcutaneously daily for VTE prophylaxis. While trying to shave himself at 6 p.m., he cuts his neck, and the medical team cannot stop the bleeding. His last enoxaparin dose was administered at 8 a.m. Which would be the most appropriate protamine dose (in milligrams) for this patient? A. 10. B. 20. C. 40. D. 50

Answer 64

Anticoagulation B

Question 65

A 58-year-old woman remains intubated in the intensive care unit (ICU) after a recent abdominal operation. In the operating room, she receives more than 10 L of fluid and blood products, but has received aggressive diuresis with furosemide postoperatively. In the past 3 days, she has generated 12 L of urine output, and her blood urea nitrogen (BUN) and serum creatinine (SCr) have steadily increased to 40 and 1.5 mg/dL, respectively. Her urine chloride (Cl) concentration was 9 mEq/L (24 hours after her last dose of furosemide). This morning, her arterial blood gas (ABG) reveals pH 7.50, Paco2 46 mm Hg, and bicarbonate (HCO3 − ) 34 mEq/L. Her vital signs include blood pressure 85/40 mm Hg and heart rate 110 beats/minute. Which action is best to improve her acid-base status? A. 0.9% sodium chloride bolus. B. 5% dextrose (D5 W) bolus. C. Hydrochloric acid infusion. D. Acetazolamide intravenously

Answer 65

Critical Care A

Question 66

A 21-year-old man (weight 80 kg) admitted 1 day ago after a gunshot wound to the abdomen is receiving mechanical ventilation and is thrashing around in bed and pulling at his endotracheal tube. His score is +3 on the Richmond AgitationSedation Scale (RASS). The patient is negative for delirium according to the Confusion Assessment Method for the ICU (CAM-ICU). His pulmonary status precludes extubation, and the attending physician estimates that he will remain intubated for at least 48 more hours. The medical team has decided that his RASS goal should be between 0 and -1. He is receiving a fentanyl infusion (150 mcg/hour), which has been adequately controlling his pain (Critical-Care Pain Observation Tool [CPOT] less than 3 for 24 hours). Vital signs include blood pressure 110/70 mm Hg and heart rate 110 beats/minute. His baseline QTc interval is 460 milliseconds. Which is the best intervention for achieving this patient’s RASS goal? A. Initiate a dexmedetomidine 1-mcg/kg loading dose over 10 minutes, followed by 0.7 mcg/kg/ hour. B. Initiate a lorazepam 3-mg intravenous load, followed by a lorazepam 3-mg/hour infusion. C. Initiate propofol at 5 mcg/kg/minute and titrate by 5 mcg/kg/minute every 5 minutes as needed. D. Initiate haloperidol 1 mg intravenously, and double the dose every 1 hour as needed.

Answer 66

Critical Care C

Question 67

A 62-year-old woman is admitted to the medical ICU for respiratory dysfunction necessitating mechanical ventilation. She has no significant medical history. Her chest radiograph reveals bilateral lower lobe infiltrates, her white blood cell count (WBC) is 21 × 103 cells/mm3 , lactate is 1.7 mmol/L, temperature is 103.3°F (39.6°C), blood pressure is 82/45 mm Hg (normal for her is 115/70 mm Hg), heart rate is 110 beats/minute, and respiratory rate is 22 breaths/minute. After she is given a diagnosis of community-acquired pneumonia, she is empirically initiated on ceftriaxone 2 g/day and azithromycin 500 mg/day intravenously. After fluid resuscitation with 6 L of lactated Ringer solution, her blood pressure is unchanged. Dopamine is initiated and titrated to 9 mcg/kg/minute, with a resulting blood pressure of 96/58 mm Hg, and her heart rate is 138 beats/minute. She has made less than 100 mL of urine during the past 6 hours, and her SCr has increased from 0.9 mg/dL to 1.3 mg/ dL. Her serum albumin concentration is 2.7 g/dL. Which therapy is best for this patient at this time? A. Administer 5% albumin 500 mL intravenously over 1 hour and reassess mean arterial pressure (MAP). B. Initiate hydrocortisone 50 mg intravenously every 6 hours. C. Change dopamine to norepinephrine 0.01 mcg/kg/minute to maintain a MAP greater than 65 mm Hg. D. Reduce the dopamine infusion to 1 mcg/kg/ minute to maintain a urine output of at least 1 mL/kg/hour.

Answer 67

Critical Care C

Question 68

A 92-year-old woman (weight 51 kg) is admitted to the ICU with urosepsis and septic shock. She lives in a long-term care facility and has a medical history significant for coronary artery disease and hypertension. Her blood pressure is 72/44 mm Hg, central venous pressure (CVP) is 5 mm Hg, heart rate 120 beats/minute, and oxygen saturation (Sao2 ) is 99%; her laboratory values are normal, except for a BUN of 74 mg/dL and Cr of 2.7 mg/dL (baseline of 1.5 mg/dL). Her urine output is about 20 mL/hour. Appropriate empiric antibiotics were initiated. Which therapy is most appropriate to initiate next? A. Norepinephrine 0.05 mcg/kg/minute. B. Lactated Ringer solution 1500-mL bolus. C. Dopamine 5 mcg/kg/minute. D. Albumin 5% 500-mL bolus

Answer 68

Critical Care B

Question 69

46-year-old man had a witnessed cardiac arrest in an airport terminal. After about 5 minutes, emergency medical services arrived, and defibrillator pads were applied. The cardiac monitor showed ventricular tachycardia (VT), and the patient had no discernible pulse. He was defibrillated with 200 J without return of spontaneous circulation (ROSC). He received an additional two shocks of 200 J with no improvement. Between shocks, the patient received compressions. An intravenous line was obtained, and an epinephrine 1-mg intravenous push was given; chest compressions and artificial respirations were initiated. Within 1 minute, the patient was reassessed. The cardiac monitor still showed VT, and he remained pulseless; therefore, another shock of 200 J, followed by an amiodarone 300-mg intravenous push, was administered. After this, the patient was converted to a normal sinus rhythm with a heart rate of 100 beats/minute. The patient was then transported to the hospital, intubated and unresponsive. Which recommendation is most likely to improve this patient’s outcomes? A. Administer sodium bicarbonate 50 mEq intravenously. B. Administer vasopressin 40 unitsintravenously. C. Administer a continuous infusion of heparin. D. Initiate a targeted temperature management protocol.

Answer 69

Critical Care D

Question 70

A 72-year-old man is admitted to the medical ICU for post-cardiac arrest care with targeted temperature management. His body temperature was maintained at 91.4°F (33°C) for 24 hours, and the health care team decides it is time to rewarm slowly at 0.5°C every hour. Which is most important to consider during the rewarming phase? A. Frequent laboratory monitoring is necessary to guide potassium supplementation because of the risk of hypokalemia. B. A vecuronium continuous infusion should be administered to prevent shivering. C. Phenytoin should be administered for seizure prophylaxis. D. Frequent blood glucose monitoring is necessary, given the risk of hypoglycemia.

Answer 70

Critical Care D

Question 71

A 65-year-old man with a history of hypothyroidism, heart failure, and myocardial infarction is admitted to the ICU with severe community-acquired pneumonia. Six hours after admission, he develops acute respiratory failure, hypotension, and acute kidney injury from presumed sepsis. He is placed on mechanical ventilation, and a nasogastric tube is placed, with no plans for extubation. Which is most appropriate for this patient’s stress ulcer prophylaxis (SUP)? A. Administer sucralfate 1 g four times daily by nasogastric tube. B. Administer magnesium hydroxide 30 mL four times daily by nasogastric tube. C. Administer famotidine 20 mg intravenously daily. D. No prophylaxis is indicated for this patient because he has no risk factors for SUP.

Answer 71

Critical Care C

Question 72

A 45-year-old man is admitted to the ICU with H1N1 influenza causing respiratory failure. He is intubated and sedated with fentanyl 200 mcg/hour and propofol 25 mcg/kg/minute. He has received 4 L of lactated Ringer solution and 1 L of albumin and is currently receiving norepinephrine 0.15 mcg/kg/minute and vasopressin 0.03 unit/minute for hemodynamic support. His current vital signs are blood pressure 85/58 mm Hg, heart rate 99 beats/minute, and respiratory rate 18 breaths/minute. Which is the best plan for this patient’s steroid therapy? A. Initiate hydrocortisone 50 mg every 6 hours intravenously. B. Perform a cosyntropin stimulation test and initiate hydrocortisone 50 mg every 6 hours intravenously if the patient does not have an increase greater than 9 mcg/dL from baseline. C. Check a random cortisol and initiate hydrocortisone 50 mg every 6 hours intravenously if the result is less than 10 mcg/dL. D. Steroids are not indicated at this time.

Answer 72

Critical Care A

Question 73

A 19-year-old man (height 71 inches [180 cm], weight 68 kg) is admitted to the ICU after ingesting an unknown quantity of acetaminophen. After initial resuscitation and treatment with acetylcysteine, the patient remains unresponsive and intubated. The intensivist would like to start enteral nutrition (EN) as soon as possible. Which is the best way to calculate the patient’s caloric and protein needs? A. Estimate caloric needs at 25 kcal/kg and protein at 1.2 g/kg. B. Perform indirect calorimetry to estimate caloric and protein needs. C. Estimate caloric needs at 14 kcal/kg and protein at 2 g/kg. D. Calculate caloric needs based on the Mifflin equation, and order a prealbumin concentration to assess protein needs.

Answer 73

Critical Care A

Question 74

A 57-year-old woman is admitted to the ICU with injuries sustained after a fall from 12 feet. She has traumatic brain injury and has been intubated for airway protection. What is the best intervention to prevent ventilator-associated pneumonia in this patient? A. Initiate pantoprazole 40 mg intravenously daily. B. Perform selective digestive decontamination with enteral polymyxin B sulfate, neomycin sulfate, and vancomycin hydrochloride. C. Maintain head of bed elevation at 20 degrees at all times. D. Start chlorhexidine 0.12% oral swabs twice daily.

Answer 74

Critical Care D

Question 75

You are the critical care pharmacist for a 300-bed hospital. The critical care committee wants to institute an evidence-based glucose control protocol for the ICU. What is the best goal to implement for patients who present with septic shock? A. Check blood glucose every 6 hours and treat with sliding scale protocol when greater than 180 mg/dL. B. Initiate insulin infusion with a target of 110–140 mg/dL for two blood glucose values greater than 140 mg/dL. C. Initiate insulin infusion with a target of 140–200 mg/dL for two blood glucose values greater than 180 mg/dL. D. Initiate insulin infusion with a target blood glucose of 80–110 mg/dL for two blood glucose values greater than 150 mg/dL.

Answer 75

Critical Care C

Question 76

Which is the most appropriate therapy to reduce the risk of delayed ischemia and improve neurologic outcomes after an aneurysmal subarachnoid hemorrhage (SAH)? A. Clevidipine continuous infusion titrated to maintain a systolic blood pressure (SBP) less than 160 mm Hg. B. Nimodipine 60 mg orally every 4 hours for 21 days. C. Norepinephrine continuous infusion titrated to maintain an SBP greater than 160 mm Hg. D. Amlodipine 10 mg orally every 24 hours for 21 days.

Answer 76

Critical Care B

Question 77

A 62-year-old woman has been hospitalized in the ICU for several weeks. Her hospital stay has been complicated by aspiration pneumonia and sepsis, necessitating prolonged courses of antibiotics. For the past few days, she has been having high temperatures, and her stool output has increased dramatically. Her most recent stool samples have tested positive for Clostridioides difficile toxin, and her laboratory tests show serum sodium 138 mEq/L, K 3.5 mEq/L, Cl 115 mEq/L, HCO3 − 15 mEq/L, albumin 4.4 g/dL, pH 7.32, and Paco2 30 mm Hg. Which is most consistent with this patient’s primary acid-base disturbance? A. AG metabolic acidosis. B. Non-AG metabolic acidosis. C. Chloride-responsive metabolic alkalosis. D. Acute respiratory acidosis.

Answer 77

Critical Care B

Question 78

A 32-year-old man with no pertinent medical history is admitted to the hospital after being “found down” in his home with an empty bottle of alprazolam by his side. On arrival at the emergency department, he was neurologically unresponsive, with the following ABG values: pH 7.21, Paco2 58 mm Hg, Pao2 90 mm Hg, HCO3 − 24 mEq/L, and Sao2 86% on 2 L/minute of oxygen by nasal cannula. Which action is most appropriate? A. Administer acetazolamide 500 mg intravenous push. B. Administer 100% oxygen by face mask. C. Give sodium bicarbonate 100 mEq intravenous push. D. Provide urgent intubation.

Answer 78

Critical Care D

Question 79

A 55-year-old woman is admitted to the hospital after several days of worsening shortness of breath. Recently, she was discharged from the hospital after a similar episode and was doing fine until 3 days before admission, when she developed a productive cough, necessitating an increase in her home oxygen and more frequent use of her metered dose inhalers. On admission to the medical ICU, she was anxious and markedly distressed, with rapid, shallow breaths. She was hypertensive (160/80 mm Hg), tachycardic (140 beats/minute), and tachypneic (respiratory rate 28 breaths/minute). Her ABG showed pH 7.30, Paco2 59 mm Hg, Pao2 50 mm Hg, HCO3 − 28 mEq/L, and Sao2 83% on 6 L/minute of oxygen by face mask, and she was immediately intubated. Her most recent laboratory tests show serum sodium 142 mEq/L, K 3.8 mEq/L, Cl 109 mEq/L, HCO3 − 28 mEq/L, and albumin 4.1 g/dL. Which primary acid-base disturbance is most consistent with this patient’s presentation and laboratory data? A. AG metabolic acidosis. B. Non-AG metabolic acidosis C. Respiratory acidosis. D. Respiratory alkalosis.

Answer 79

Critical Care C

Question 80

A 65-year-old woman is admitted to cardiac surgery ICU after an aortic valve replacement. On hospital day 4, she is hypotensive (blood pressure 80/50 mm Hg), tachycardic (heart rate 125 beats/minute), tachypneic (respiratory rate 30 breaths/minute), hypoxemic (Pao2 40 mm Hg), febrile (temperature 103.1°F [39.5°C]), and confused. The patient is given adequate boluses of lactated Ringer solution and is then intubated and initiated on piperacillin/tazobactam and vancomycin for possible nosocomial pneumonia. After fluid boluses fail to improve her hemodynamic and clinical status, a pulmonary artery catheter is placed, which reveals a PCWP of 18 mm Hg, CI of 3.3 L/minute/m2 and SVR of 515 dynes/second/cm5 . Her chest radiograph reveals a left lower lobe consolidation, and she still needs 100% fraction of inspired oxygen (FiO2). Which action is best? A. Administer angiotensin II infusion titrated to achieve a MAP of at least 65 mm Hg. B. Administer a dobutamine infusion titrated to achieve a MAP of at least 65 mm Hg. C. Administer a norepinephrine infusion titrated to achieve a MAP of at least 65 mm Hg. D. Administer a dopamine infusion titrated to achieve a MAP of at least 65 mm Hg

Answer 80

Critical Care C

Question 81

A patient (weight 75 kg) is to be initiated on a continuous infusion of norepinephrine for blood pressure support because of septic shock. The nurse has a 250-mL bag of normal saline containing 4 mg of norepinephrine. Which rate is most appropriate to infuse the norepinephrine drip at a dose of 0.05 mcg/kg/minute? A. 7 mL/hour. B. 14 mL/hour. C. 31.5 mL/hour. D. 79 mL/hour

Answer 81

Critical Care B

Question 82

A 42-year-old man was found unresponsive at his group home covered in vomit. He was intubated by the paramedics. On arrival at the emergency department, his blood pressure is 72/30 mm Hg and heart rate is 95 beats/minute. During the next few hours, he receives 5 L of lactated Ringer solution, 500 mL of 5% albumin, and norepinephrine infusing at 0.5 mcg/kg/minute. With these interventions, his blood pressure is 87/56 mm Hg and heart rate is 148 beats/minute. Pertinent laboratory values include WBC 20 × 103 cells/mm3 , lactic acid 1.5 mmol/L, aspartate aminotransferase 78 units/L, SCr 2.2 (baseline 1) mg/dL, platelet count 118,000 cells/ mm3 , international normalized ratio (INR) 1.4, and urine output about 45 mL/hour since arrival. Which is the most appropriate intervention at this time? A. Add hydrocortisone 50 mg intravenously every 6 hours. B. Change norepinephrine infusion to phenylephrine infusion. C. Change norepinephrine infusion to dopamine infusion. D. Administer 1 L of lactated Ringer solution.

Answer 82

Critical Care B

Question 83

A 61-year-old woman collapses in front of her family members, who call 9-1-1 and begin CPR. The paramedics arrive and find the victim unresponsive, with an electrocardiogram revealing ventricular fibrillation, and administer two additional rounds of CPR and two defibrillations, which are successful. In the emergency department, the patient’s MAP is 68 mm Hg after fluids and norepinephrine, but the patient remains unresponsive. She is initiated on a TTM protocol. After 24 hours of TTM (body temperature 37°C), the patient is in the ICU, and the rewarming process has recently begun. The pharmacist arrives in the ICU about 30 minutes into the rewarming process. The patient has been receiving a continuous infusion of insulin throughout the period of TTM at an average rate of 4 units/hour, with blood glucose testing every 3 hours. The patient has been sedated with a continuous infusion of propofol and fentanyl and is receiving cisatracurium for neuromuscular blockade. The patient’s vital signs are stable, and her laboratory values are normal. Which pharmacist recommendation is most appropriate at this time? A. Increase blood glucose testing to now and every 1–2 hours during rewarming. B. Adjust cisatracurium infusion to achieve a TOF of 0/4 impulses. C. Discontinue propofol infusion to facilitate extubation. D. Increase insulin infusion to prevent hyperkalemia

Answer 83

Critical Care A

Question 84

An older woman is admitted to the ICU for acute decompensated heart failure and acute kidney injury with an ejection fraction of less than 30%. She is administered a continuous infusion of bumetanide; however, the benefit is limited because of her acute-on-chronic kidney disease. She is intubated on ICU day 2 because of worsening pulmonary edema and hypoxia. After intubation, her RASS score is 0, her CAM-ICU is negative, and her CPOT score is 4. Her blood pressure is 120/70 mm Hg and heart rate is 88 beats/minute. Which is the best recommendation for achieving her analgesia, sedation, and delirium goals? A. Initiate morphine at 5 mg/hour and titrate as needed. B. Administer haloperidol 5 mg intravenously as needed. C. Administer fentanyl 25 mcg intravenously every hour as needed. D. Initiate lorazepam 2 mg/hour and titrate as needed.

Answer 84

Critical Care C

Question 85

A 42-year-old woman with ARDS and a significant history of alcohol and tobacco abuse is transferred to the medical ICU from an outside hospital. She presented to the outside hospital after 1 week of productive cough, fever, chills, and increased shortness of breath. On admission to the medical ICU, she is hypotensive (80/60 mm Hg), tachycardic (130 beats/minute), and febrile (body temperature 102.2°F [39.0°C]). Her ABG shows pH 7.1, Paco2 56 mm Hg, Pao2 49 mm Hg, HCO3 − 16 mEq/L, and Sao2 76% on 100% FiO2 . The only other significant laboratory results are SCr 2.1 mg/dL and WBC 16 × 103 cells/mm3 . She is achieving her sedation goals with continuous infusions of propofol 20 mcg/kg/minute and fentanyl 200 mcg/hour. After several nonpharmacologic attempts to improve her oxygenation fail, she is paralyzed, and her ventilator settings are adjusted accordingly. Which statement about neuromuscular blockade in this patient is most appropriate? A. Opioids should be discontinued to avoid prolonged neuromuscular weakness. B. Vecuronium is the agent of choice. C. Sedatives should be titrated to maintain a RASS goal of 0 to –2 during neuromuscular blockade. D. Neuromuscular blockers should be titrated to the minimal dose necessary to achieve ventilator synchrony.

Answer 85

Critical Care D

Question 86

A 42-year-old woman with ARDS and a significant history of alcohol and tobacco abuse is transferred to the medical ICU from an outside hospital. She presented to the outside hospital after 1 week of productive cough, fever, chills, and increased shortness of breath. On admission to the medical ICU, she is hypotensive (80/60 mm Hg), tachycardic (130 beats/minute), and febrile (body temperature 102.2°F [39.0°C]). Her ABG shows pH 7.1, Paco2 56 mm Hg, Pao2 49 mm Hg, HCO3 − 16 mEq/L, and Sao2 76% on 100% FiO2 . The only other significant laboratory results are SCr 2.1 mg/dL and WBC 16 × 103 cells/mm3 . She is achieving her sedation goals with continuous infusions of propofol 20 mcg/kg/minute and fentanyl 200 mcg/hour. The patient was initiated on neuromuscular blockade as instructed and synchronous with the ventilator, but about 8 hours later, she began to move around violently in her bed. At this time, she was tachycardic (heart rate 120 beats/minute) and appeared agitated; her Sao2 dropped to 80%. Which action is best? A. Double the rate of the neuromuscular blocker every 5 minutes as needed until the patient stops moving. B. Increase the propofol infusion rate as needed to achieve sedation goals. C. Initiate a dexmedetomidine infusion. D. Check the TOF.

Answer 86

Critical Care B

Question 87

A 42-year-old woman with ARDS and a significant history of alcohol and tobacco abuse is transferred to the medical ICU from an outside hospital. She presented to the outside hospital after 1 week of productive cough, fever, chills, and increased shortness of breath. On admission to the medical ICU, she is hypotensive (80/60 mm Hg), tachycardic (130 beats/minute), and febrile (body temperature 102.2°F [39.0°C]). Her ABG shows pH 7.1, Paco2 56 mm Hg, Pao2 49 mm Hg, HCO3 − 16 mEq/L, and Sao2 76% on 100% FiO2 . The only other significant laboratory results are SCr 2.1 mg/dL and WBC 16 × 103 cells/mm3 . She is achieving her sedation goals with continuous infusions of propofol 20 mcg/kg/minute and fentanyl 200 mcg/hour. After that event, the patient did poorly the rest of the night. The patient was initiated on a norepinephrine infusion at 0.02 mcg/kg/minute to maintain an adequate blood pressure. Other medications initiated overnight included piperacillin/tazobactam, vancomycin, and gentamicin. By morning, her SCr has increased to 2.8 mg/dL, and the night shift nurse reports that the patient has had 0/4 twitches on TOF for the past 8 hours. Pertinent electrolyte values include K+ 4.9 mEq/L, calcium 9 mg/dL, and magnesium 2 mg/dL. What is most likely to potentiate the effects of the neuromuscular blocker? A. Piperacillin/tazobactam. B. Gentamicin. C. Norepinephrine. D. Potassium concentration.

Answer 87

Critical Care B

Question 88

A 73-year-old woman (weight 84 kg) is admitted to the ICU after a pneumonectomy and has been intubated for 4 days. Her blood pressure is 104/65 mm Hg, heart rate is 88 beats/minute, and Sao2 values are 98% on 40% FiO2 and positive end-expiratory pressure 5 cm H2 O; her Glasgow Coma Scale score is 11. Her other laboratory values are normal. Her medications include simvastatin 20 mg every night, aspirin 81 mg/ day, metoprolol 25 mg twice daily, heparin 5000 units subcutaneously every 8 hours, and 0.9% sodium chloride intravenously at 75 mL/hour The surgeon would like to initiate SUP. Which is the best recommendation for this patient? A. Administer famotidine 20 mg per tube every 12 hours. B. Administer magnesium hydroxide 30 mL per tube four times daily. C. Administer sucralfate 1 g per tube four times daily. D. SUP is not indicated.

Answer 88

Critical Care A

Question 89

A 73-year-old woman (weight 84 kg) is admitted to the ICU after a pneumonectomy and has been intubated for 4 days. Her blood pressure is 104/65 mm Hg, heart rate is 88 beats/minute, and Sao2 values are 98% on 40% FiO2 and positive end-expiratory pressure 5 cm H2 O; her Glasgow Coma Scale score is 11. Her other laboratory values are normal. Her medications include simvastatin 20 mg every night, aspirin 81 mg/ day, metoprolol 25 mg twice daily, heparin 5000 units subcutaneously every 8 hours, and 0.9% sodium chloride intravenously at 75 mL/hour One week later, the patient is extubated but still in the ICU. Her Glasgow Coma Scale score is 15, blood pressure is 112/70 mm Hg, and heart rate is 75 beats/minute, but her appetite is poor. Which statement is most appropriate regarding SUP for this patient? A. SUP should continue until the patient is discharged from the ICU. B. SUP should be discontinued now. C. Continue SUP until patient is eating. D. SUP should be discontinued at hospital discharge.

Answer 89

Critical Care B

Question 90

A 75-year-old woman (height 65 inches [165 cm], weight 68 kg) who is intubated needs mechanical ventilation for an acute exacerbation of chronic obstructive pulmonary disease. She has a medical history of heart failure and hypertension. Her laboratory values are normal except for a creatinine level of 1.9 mg/dL Which is the most appropriate recommendation to prevent VTE in this patient? A. Initiate intermittent pneumatic compression. B. Administer fondaparinux 2.5 mg subcutaneously once daily. C. Administer enoxaparin 30 mg subcutaneously twice daily. D. Administer heparin 5000 units subcutaneously three times daily

Answer 90

Critical Care D

Question 91

A 75-year-old woman (height 65 inches [165 cm], weight 68 kg) who is intubated needs mechanical ventilation for an acute exacerbation of chronic obstructive pulmonary disease. She has a medical history of heart failure and hypertension. Her laboratory values are normal except for a creatinine level of 1.9 mg/dL Three days later, the patient continues to need mechanical ventilation. Enteral nutrition has been initiated through her nasogastric feeding tube and has gradually been increased to her goal of 45 mL/hour. Over the past day, her gastric residuals are consistently 300–350 mL. Which statement is most appropriate to optimize this patient’s nutrition support? A. Change to PN. B. Add metoclopramide 5 mg intravenously every 6 hours. C. Change feeds to a more concentrated formula. D. Decrease tube feeds to 10 mL/hour.

Answer 91

Critical Care B

Question 92

A 74-year-old woman (weight 72 kg) arrives in the emergency department with a 3-day history of cough, body temperature of 102°F (38.9°C), and lethargy. She has the following vital signs and laboratory values: blood pressure 72/40 mm Hg, heart rate 115 beats/minute, urine output 10 mL/ hour, white blood cell count (WBC) 18 × 103 cells/ mm3 , hemoglobin 12.5 g/dL, and blood urea nitrogen (BUN)/serum creatinine (SCr) ratio of 28:1.7 mg/dL (baseline SCr 1.2 mg/dL), and blood glucose 82 mg/dL. After a 500-mL fluid bolus of 0.9% sodium chloride, her blood pressure is 80/46 mm Hg and her heart rate is 113 beats/minute. Her chest radiograph is consistent with pneumonia. Her medical history includes coronary artery disease and arthritis. Which is the most appropriate treatment at this time? A. Furosemide 40 mg intravenously. B. 5% albumin 500 mL infused over 4 hours plus norepinephrine titrated to maintain a systolic blood pressure of 90 mm Hg or higher. C. 1000-mL fluid bolus with 5% dextrose (D5 W) and 0.9% sodium chloride. D. 1000-mL fluid bolus with 0.9% sodium chloride.

Answer 92

Fluids, Electrolytes, Nutrition D

Question 93

An order has been received for 2% sodium chloride. Assume no commercially available product is available. Using 0.9% sodium chloride and 23.4% sodium chloride, first determine how much of each is necessary to prepare 1 L of 2% sodium chloride. Second, calculate the osmolarity of 2% sodium chloride. Finally, determine whether the resultant solution should be administered through a central or peripheral intravenous infusion (molecular weight [MW] of sodium chloride is 58.5, osmotic coefficient is 0.93). A. Mix 951 mL of 0.9% sodium chloride plus 49 mL of 23.4% sodium chloride; osmolarity = 635 mOsm/L; peripheral intravenous infusion. B. Mix 951 mL of 0.9% sodium chloride plus 49 mL of 23.4% sodium chloride; osmolarity = 954 mOsm/L; central intravenous infusion. C. Mix 850 mL of 0.9% sodium chloride plus 150 mL of 23.4% sodium chloride; osmolarity = 954 mOsm/L; central intravenous infusion. D. Mix 850 mL of 0.9% sodium chloride plus 150 mL of 23.4% sodium chloride; osmolarity =513mOsm/L; peripheralintravenousinfusion.

Answer 93

Fluids, Electrolytes, Nutrition A

Question 94

A 68-year-old man is admitted to the hospital for worsening shortness of breath during the past 2 weeks caused by heart failure. His serum sodium concentration on admission was 123 mEq/L. Other abnormal laboratory values include brain natriuretic peptide of 850 pg/mL and SCr of 1.7 mg/ dL. Chest radiography is consistent with pulmonary edema. The patient weighs 85 kg on admission, which is up 3 kg from his baseline weight. The patient is not experiencing nausea, headache, or mental status changes. The physician orders 3% sodium chloride to treat the hyponatremia. Which recommendation is best? A. 3% sodium chloride is an appropriate choice because the hyponatremia is probably acute. B. A 250-mL bolus of 3% sodium chloride is appropriate if used in combination with furosemide to prevent volume overload. C. 3% sodium chloride is appropriate if the serum sodium does not increase more than 10 mEq/L in 24 hours. D. The risks of 3% sodium chloride outweigh the potential benefit for this patient

Answer 94

Fluids, Electrolytes, Nutrition D

Question 95

A 55-year-old man with diabetes and kidney disease has hyperkalemia. His laboratory values include potassium (K+ ) 7.2 mEq/L, calcium (Ca2+) 9 mg/dL, albumin 3.5 g/dL, and blood glucose 302 mg/dL. His electrocardiogram (ECG) is abnormal, with peaked T waves. What is the best recommendation for initial treatment? A. Regular insulin 10 units intravenously plus 50 g of dextrose intravenously. B. 10% calcium gluconate 10 mL intravenously. C. Sodium polystyrene sulfonate (Kayexalate) 15 g orally. D. Sodium bicarbonate 50 mEq intravenously over 5 minutes.

Answer 95

Fluids, Electrolytes, Nutrition B

Question 96

A 68-year-old woman (weight 60 kg) is admitted to the hospital after a cardioembolic stroke. Her medical history is significant for atrial fibrillation, acute myocardial infarction, and diabetes. She has been unconscious for 48 hours. The medical team decides to start providing nutrition. All of her laboratory values, including glucose concentrations, are normal. Although she currently has no enteral access, she does have a peripheral intravenous catheter. Which nutritional regimen is best for this patient? A. Insert a central intravenous catheter and initiate parenteral nutrition (PN) containing 60 g of amino acids (AAs), 250 mL of 20% lipid emulsion, 300 g of dextrose, standard electrolytes, multivitamins, and trace elements in a volume of 2000 mL administered over 24 hours. B. Insert a central intravenous catheter and initiate PN containing 40 g of AAs, 250 mL of 20% lipid emulsion, 200 g of dextrose, standard electrolytes, multivitamins, and trace elements in a total volume of 2000 mL administered over 24 hours. C. Insert a nasogastric (NG) or nasoduodenal feeding tube and infuse an isotonic formula (1 kcal/mL) starting at 25 mL/hour and advance to a goal rate of 65 mL/hour. D. Insert a percutaneous endoscopic gastrostomy feeding tube and infuse an isotonic formula (1 kcal/mL) starting at 25 mL/hour and advance to a goal rate of 100 mL/hour.

Answer 96

Fluids, Electrolytes, Nutrition C

Question 97

A 70-year-old man is admitted to the hospital with peritonitis caused by severe inflammatory bowel disease. The patient has received adequate fluid resuscitation, and he is prescribed appropriate antibiotics. After several days of the patient being unable to tolerate oral or enteral nutrition, the physician consults the pharmacist to recommend a PN formula to be administered through a central line. The patient is hemodynamically stable, with normal electrolyte concentrations. Weight is 55 kg, BUN/SCr is 20/1.1 mg/dL, and WBC is 17 × 103 cells/mm3 . Assuming that appropriate electrolytes, multivitamins, and trace elements are included, which PN formula, when administered over 24 hours, will best provide this patient adequate calories, AAs, and lipids? A. AAs 10% 700 mL, dextrose 30% 325 mL, lipid 20% 500 mL. B. AAs 10% 450 mL, dextrose 70% 400 mL, lipid 20% 250 mL. C. AAs 10% 800 mL, dextrose 70% 350 mL, lipid 20% 250 mL D. AAs 15% 900 mL, dextrose 50% 500 mL, lipid 20% 250 mL.

Answer 97

Fluids, Electrolytes, Nutrition C

Question 98

A 59-year-old man has been admitted to the hospital after several days of vomiting and diarrhea. In the emergency department, he had several runs of nonsustained ventricular tachycardia. His plasma potassium on admission is 2.8 mEq/L. After 100 mEq of potassium chloride is infused over 24 hours, his repeated K+ is 3.2 mEq/L, and he continues to have runs of ventricular tachycardia. Other laboratory values include Na+ 143 mEq/L, magnesium 1.4 mg/dL, phosphorus 3 mg/dL, Ca2+ 9 mg/dL, and ionized Ca2+ 1.1 mmol/L. Which treatment would be best to give next? A. Administer potassium chloride 20 mEq intravenously over 1 hour each for 4 doses and recheck K+ . B. Administer magnesium sulfate as a 2 g slow intravenous infusion over 2 hours. C. Administer potassium phosphate 15 mmol intravenously over 4 hours. D. Administer calcium gluconate 2 g intravenously over 5 minutes.

Answer 98

Fluids, Electrolytes, Nutrition B

Question 99

Which nutritional strategy can best prevent gut mucosal atrophy and subsequent bacterial translocation? A. PN enriched with glutamine. B. PN enriched with branched-chain AAs. C. Enteral nutrition (EN). D. Zinc supplementation.

Answer 99

Fluids, Electrolytes, Nutrition C

Question 100

A female patient (weight 80 kg) in the intensive care unit has developed acute kidney injury caused by sepsis, and she requires intermittent hemodialysis daily to maintain her BUN/SCr ratio at 49:2.5 mg/ dL. Currently, she is receiving appropriate antibiotics and is hemodynamically stable. She has also been receiving PN providing 72 g of AAs per day. What is the best recommendation for this patient’s protein intake? A. Reduce AAs to 40 g/day. B. Reduce AAs to 64 g/day. C. Increase AAs to 96 g/day. D. Increase AAs to 160 g/day

Answer 100

Fluids, Electrolytes, Nutrition C

Question 101

A 65-year-old man (weight 80 kg) with a 3-day history of a body temperature of 102°F (38.9°C), lethargy, and productive cough is hospitalized for community-acquired pneumonia. His medical history includes uncontrolled hypertension and coronary artery disease. His vital signs include heart rate 104 beats/minute, blood pressure 112/68 mm Hg, and body temperature 101.4°F (38.6°C). His urine output is 10 mL/hour, K+ is 4 mEq/L, BUN is 46 mg/dL, SCr is 1.7 mg/dL, and WBC is 10.4 × 103 cells/mm3 . Other laboratory values are normal. Which is most appropriate at this time? A. Furosemide 40 mg intravenously. B. Albumin 25% 100 mL intravenously over 60 minutes. C. Lactated Ringer solution 1000 mL intravenously over 60 minutes. D. D5 W/0.45% sodium chloride plus potassium chloride 20 mEq/L to infuse at 110 mL/hour

Answer 101

Fluids, Electrolytes, Nutrition C

Question 102

A 65-year-old man (weight 80 kg) with a 3-day history of a body temperature of 102°F (38.9°C), lethargy, and productive cough is hospitalized for community-acquired pneumonia. His medical history includes uncontrolled hypertension and coronary artery disease. His vital signs include heart rate 104 beats/minute, blood pressure 112/68 mm Hg, and body temperature 101.4°F (38.6°C). His urine output is 10 mL/hour, K+ is 4 mEq/L, BUN is 46 mg/dL, SCr is 1.7 mg/dL, and WBC is 10.4 × 103 cells/mm3 . Other laboratory values are normal. After 2 days of appropriate antibiotic treatment, the patient has a WBC of 9 × 103 cells/mm3 , and he is afebrile. His blood pressure is 135/85 mm Hg, and his urine output is 45 mL/hour. His albumin is 3.2 g/dL, BUN is 14 mg/dL, K+ is 3.9 mEq/L, and SCr is 1.4 mg/dL. All other laboratory values are normal. His appetite is still poor, and he is not taking adequate fluids. He has peripheral intravenous access. Which option is most appropriate to initiate? A. Peripheral PN to infuse at 110 mL/hour. B. Albumin 5% 500 mL intravenously over 60 minutes. C. D5 W/0.45% sodium chloride plus potassium chloride 20 mEq/L to infuse at 110 mL/hour. D. Lactated Ringer solution to infuse at 75 mL/hour.

Answer 102

Fluids, Electrolytes, Nutrition C

Question 103

A 72-year-old woman (weight 60 kg) with a history of hypertension has developed hyponatremia after starting hydrochlorothiazide 3 weeks earlier. She experiences dizziness, fatigue, and nausea. Herserum sodium is 116 mEq/L. Her blood pressure is 86/50 mm Hg, and heart rate is 122 beats/minute. In addition to discontinuing hydrochlorothiazide, which initial treatment regimen is best? A. Administer 0.9% sodium chloride infused at 100 mL/hour. B. Administer 0.9% sodium chloride 500-mL bolus. C. Administer 3% sodium chloride infused at 60 mL/hour. D. Administer 23.4% sodium chloride 30-mL bolus as needed

Answer 103

Fluids, Electrolytes, Nutrition B

Question 104

A 72-year-old woman (weight 60 kg) with a history of hypertension has developed hyponatremia after starting hydrochlorothiazide 3 weeks earlier. She experiences dizziness, fatigue, and nausea. Herserum sodium is 116 mEq/L. Her blood pressure is 86/50 mm Hg, and heart rate is 122 beats/minute. Which is the best treatment goal for the first 24 hours in correcting the patient’s serum sodium from her initial value of 116 mEq/L? A. Increase Na+ concentration to 140 mEq/L. B. Increase Na+ concentration to 132 mEq/L. C. Increase Na+ concentration to 126 mEq/L. D. Maintain serum sodium of 116–120 mEq/L.

Answer 104

Fluids, Electrolytes, Nutrition C

Question 105

A 72-year-old woman (weight 60 kg) with a history of hypertension has developed hyponatremia after starting hydrochlorothiazide 3 weeks earlier. She experiences dizziness, fatigue, and nausea. Herserum sodium is 116 mEq/L. Her blood pressure is 86/50 mm Hg, and heart rate is 122 beats/minute. One day later, the patient has somewhat improved. Her blood pressure is 122/80 mm Hg, and heart rate is 80 beats/minute. Her serum sodium is 120 mEq/L, and K+ is 3.2 mEq/L; she still feels tired. She is eating a regular diet. Her ECG is normal. Which is the best recommendation? A. D5 W/0.9% sodium chloride plus potassium chloride 40 mEq/L to infuse at 100 mL/hour. B. 0.9% sodium chloride infused at 100 mL/hour. C. 3% sodium chloride infused at 60 mL/hour. D. Potassium chloride 20 mEq by mouth every 6 hours for 4 doses.

Answer 105

Fluids, Electrolytes, Nutrition D

Question 106

A 74-year-old woman (weight 50 kg) has been receiving isotonic tube feedings at 60 mL/hour for the past 8 days through her gastrostomy feeding tube. She recently had an ischemic stroke; she is responsive but is not able to communicate. Her serum sodium was 142 mg/dL on the day the isotonic formula was initiated, and it has risen steadily to 149, 156, and 159 mg/dL on days 3, 4, and 8, respectively, after the start of the tube feedings. What is the best treatment for her hypernatremia? A. Administer sterile water intravenously at 80 mL/hour. B. Administer D5 W intravenously at 80 mL/hour. C. Administer D5 W/0.225% sodium chloride intravenously at 80 mL/hour. D. Administer water by enteral feeding tube 200 mL every 6 hours

Answer 106

Fluids, Electrolytes, Nutrition D

Question 107

A 61-year-old man comes to the emergency department with shortness of breath and bilateral lower leg edema. Pertinent vital signs and laboratory values include heart rate 30 beats/minute, blood pressure 102/57 mm Hg, K+ 7.9 mEq/L, Na+ 139 mEq/L, glucose 278 mg/dL, Ca2+ 8.8 mg/dL, digoxin 2.2 ng/mL, BUN 49 mg/dL, and SCr 2.4 mg/dL. His medical history includes heart failure, atrial fibrillation, coronary artery disease, peripheral arterial disease, and diabetes. The patient has peripheral intravenous access and an external pacemaker. Which treatment is most appropriate for lowering this patient’s potassium? A. Calcium gluconate 10 mL intravenously over 2 minutes. B. Insulin 10 units intravenously. C. Sodium bicarbonate 50 mEq intravenously over 10 minutes. D. Albuterol 10 mg nebulized over 10 minutes.

Answer 107

Fluids, Electrolytes, Nutrition B

Question 108

A 72-year-old woman (weight 65 kg) is switched from a standard enteral formula to a concentrated tube feeding designed for patients with kidney disease, because of hyperkalemia. The patient’s baseline and current SCr is 1.7 mg/dL, and her urine output is about 50 mL/hour. The tube feeding is infusing at a goal rate of 35 mL/hour through an NG feeding tube providing 2 kcal/mL, Na+ 41 mEq/L, and 717 mL/L of water. The patient’s serum sodium was 140 mEq/L when the tube feeding was initiated a few days ago, and her Na+ is now 145 mEq/L. What is the best approach for preventing hypernatremia in this patient? A. Change to an EN formula with a lower concentration of Na+ . B. Administer intravenous D5 W at 45 mL/hour. C. Administer 200 mL of water through a feeding tube every 4 hours. D. Reduce the tube feeding to 30 mL/hour.

Answer 108

Fluids, Electrolytes, Nutrition C

Question 109

A 43-year-old male trauma patient (height 75 inches, weight 100 kg) was recently extubated and is receiving PN. His PN formula contains 35 kcal/kg, protein 1.2 g/kg, and dextrose infusing at 4.4 mg/kg/minute, and 25% of total calories as lipid. He has gradually developed symptoms of hypercapnia and has developed a respiratory acidosis. The medical team is considering strategies to correct this to avoid reintubation. Which change to the PN formula could best correct this situation? A. Change PN to EN and maintain current caloric goals. B. Reduce dextrose amount in PN to 3 mg/kg/minute and increase lipid to maintain current caloric goal. C. Change electrolytes to the acetate salt in the PN to correct the acid-base imbalance. D. Reduce the calories to 25 kcal/kg to prevent overfeeding.

Answer 109

Fluids, Electrolytes, Nutrition D

Question 110

A patient (weight 70 kg) receives propofol at 45 mcg/kg/minute. Propofol is available at a concentration of 10 mg/mL and is mixed in a 10% lipid emulsion. Assuming the patient is receiving this infusion rate for 24 hours, which best approximates the total calories provided by the propofol infusion in a 24-hour period? A. 200 kcal. B. 250 kcal. C. 300 kcal. D. 500 kcal.

Answer 110

Fluids, Electrolytes, Nutrition D

Question 111

A patient (weight 65 kg) is receiving PN after abdominal surgery. The PN contains about 1600 kcal, including 100 g of protein, 500 kcal as lipid, and 200 g of dextrose. The following additives are also included in a 24-hour infusion of PN: sodium chloride 50 mEq, sodium acetate 100 mEq, potassium acetate 60 mEq, sodium phosphate 30 mmol, magnesium sulfate 12 mEq, calcium gluconate 10 mEq/day, multivitamins 10 mL, and trace elements 3 mL. The patient has an NG tube in place that is suctioning 400–500 mL/day, which is being replaced with an infusion of 0.9% sodium chloride. After 48 hours of PN, the patient has the following laboratory values: Na+ 140 mEq/L, K+ 3.8 mEq/L, Cl– 93 mEq/L, serum bicarbonate 35 mEq/L, pH 7.5, PCO2 47 mm Hg, and bicarbonate 36 mEq/L. Which adjustment to the PN formula is best at this time? A. Increase lipids to provide 750 kcal and reduce dextrose to 130 g. B. Increase sodium acetate to 150 mEq/day and discontinue sodium chloride. C. Increase sodium chloride to 150 mEq/day and discontinue sodium acetate. D. Add sodium bicarbonate 50 mEq to PN

Answer 111

Fluids, Electrolytes, Nutrition C

Question 112

A 75-year-old woman (weight 50 kg) is receiving PN after an extensive bowel resection. She is expected to require about 1 week of PN. She is receiving the following macronutrients in her formula: 70% dextrose 300 mL, 20% lipid 150 mL, and 10% AA 750 mL. . If these macronutrients are infused over 24 hours, which choice most closely approximates the total calories this patient is receiving daily? A. 20 kcal/kg. B. 26 kcal/kg. C. 30 kcal/kg. D. 35 kcal/kg

Answer 112

Fluids, Electrolytes, Nutrition B

Question 113

A 75-year-old woman (weight 50 kg) is receiving PN after an extensive bowel resection. She is expected to require about 1 week of PN. She is receiving the following macronutrients in her formula: 70% dextrose 300 mL, 20% lipid 150 mL, and 10% AA 750 mL. The patient has received the PN formula for 3 days. Her blood glucose concentrations have ranged from 220 to 280 mg/dL. She has orders for the following sliding scale of regular insulin: blood glucose 200–250 mg/dL, give 2 units; blood glucose 251–300 mg/dL, give 4 units; and blood glucose 301–350 mg/dL, give 6 units. She has been receiving 14–16 units of insulin daily through the sliding-scale orders. Her medical history is significant for hypertension, diabetes, chronic obstructive pulmonary disease, and colon cancer. Treatment was recently initiated with methylprednisolone 60 mg intravenously every 6 hours for a chronic obstructive pulmonary disease exacerbation. Today, the dose will be reduced to 40 mg intravenously every 8 hours. What is the best recommendation for better control of this patient’s blood glucose? A. Add insulin glargine 10–20 units/day to PN. B. Change 70% dextrose in PN to D5 W. C. Increase the sliding-scale insulin to 4 units for blood glucose 200–250 mg/dL, 8 units for blood glucose 251–300 mg/dL, and 12 units for blood glucose 301–350 mg/dL. D. Add neutral protamine Hagedorn insulin (NPH) 5 units subcutaneously every 12 hours.

Answer 113

Fluids, Electrolytes, Nutrition D

Question 114

A 36-year-old presents with a 16-year history of schizophrenia and alcohol use disorder. Medication was recently changed from haloperidol to aripiprazole because of gynecomastia and sexual dysfunction. Today, the patient is pacing in your office and seems anxious and agitated. The patient has not been sleeping well and feels uncomfortable in their skin. Which medication would be most appropriate to help relieve this patient’s symptoms? A. Benztropine. B. Dantrolene. C. Lorazepam. D. Propranolol.

Answer 114

Psychiatry & Mental Health D

Question 115

A 52-year-old (current BMI 35 kg/m2 ) with schizophrenia presents for a routine follow-up. Abnormal, uncontrollable repetitive chewing-type movements in their jaw exist. These movements are bothersome and interfere with eating ability. The patient stays home because of shame about being seen in public. Medication history includes perphenazine for the past 8 years with good control of symptoms. The patient is able to live independently and care for themselves. Therapeutic trials of aripiprazole, ziprasidone, and haloperidol have yielded subtherapeutic results. A 22.7-kg (50 lb) weight gain and development of type 2 diabetes occurred while taking olanzapine. The diabetes resolved off olanzapine. Which would be the best treatment? A. Add benztropine. B. Add lorazepam. C. Change to quetiapine. D. Add valbenazine.

Answer 115

Psychiatry & Mental Health D

Question 116

A 67-year-old is admitted for new-onset tonicclonic seizures. Medical history is negative for seizure disorders but positive for prediabetes and schizophrenia. The patient has long-term, stable schizophrenia controlled with clozapine 900 mg daily. Additional medications include diphenhydramine 50 mg at bedtime, metformin 1000 mg twice daily, and bupropion extended release (ER) 300 mg daily (for 2 months). Social history is negative for alcohol and illicit drug use but positive for a 25 pack-year tobacco history, which was stopped 2 weeks ago. Which medication is most likely responsible for the seizures? A. Bupropion. B. Clozapine. C. Diphenhydramine. D. Metformin.

Answer 116

Psychiatry & Mental Health B

Question 117

A 25-year-old presents to your practice with a depressed mood that has worsened during the past few weeks. The patient finds it difficult to get out of bed in the morning. When not sleeping, the patient is eating. Weight has increased by 4.5 kg (10 lb) in the past month. They are worried about their job and do not feel that they are “pulling [their] weight,” even though they recently received a glowing evaluation. They have passive thoughts of harming themselves but no definite plan. Medical history includes anxiety, gastroesophageal reflux disease, and hypothyroidism thyrotropin within normal limits). Current medications include levothyroxine 100 mcg daily, lansoprazole 30 mg every morning, and alprazolam 0.5 mg three times daily for anxiety. Which medication would best treat the current symptoms? A. Desipramine. B. Fluoxetine. C. Mirtazapine. D. Paroxetine.

Answer 117

Psychiatry & Mental Health B

Question 118

A 56-year-old presents with a medical history significant for recurrent major depression and type 2 diabetes with newly diagnosed neuropathy, obesity, and coronary artery disease. Current medications include citalopram 40 mg daily, carvedilol 25 mg twice daily, lisinopril 40 mg daily, and metformin 1000 mg twice daily. The patient is tearful during the appointment and continues to have symptoms of depression despite initial improvement with citalopram. The patient wants to change antidepressants. Which would be most beneficial? A. Bupropion. B. Duloxetine. C. Nortriptyline. D. Sertraline.

Answer 118

Psychiatry & Mental Health B

Question 119

A 45-year-old presents with agitation and diaphoresis and an oral temperature of 38.5°C (101.3°F). Their right eyelid began twitching about an hour ago, and it will not stop. Cold symptoms developed 2 days ago, and the patient began taking dextromethorphan and pseudoephedrine aroundthe-clock. Medical history includes depression, hypertension, and dyslipidemia. Current medications include cetirizine 10 mg at bedtime, paroxetine 40 mg at bedtime, diltiazem extended release (XR) 240 mg daily, and rosuvastatin 10 mg daily. Which combination of medications is most likely contributing to the current symptoms? A. Cetirizine and paroxetine. B. Dextromethorphan and pseudoephedrine. C. Diltiazem and pseudoephedrine. D. Paroxetine and dextromethorphan

Answer 119

Psychiatry & Mental Health D

Question 120

A 31-year-old presents with a 5-year history of type I bipolar disorder, which is treated with lithium 300 mg twice daily. The patient has been adherent to treatment. A lithium serum concentration, obtained yesterday before the morning lithium dose, is 1.0 mEq/L. There have been no manic symptoms for the past few years. Current admission is for a suicide attempt using acetaminophen. For the past few weeks, they have lost interest in their job and isolated themselves from other people. Which medication would best help the acute symptoms? A. Aripiprazole. B. Lamotrigine. C. Quetiapine. D. Venlafaxine

Answer 120

Psychiatry & Mental Health C

Question 121

A 28-year-old woman (height 61 inches, weight 74.8 kg, up from 68 kg 2 months ago) presents with a history of type I bipolar disorder. She has taken lithium 450 mg twice daily for the past 6 months. Her last lithium serum concentration (3 months ago) was 0.7 mEq/L. She presents today for an annual examination. Her laboratory test results include sodium 138 mEq/L, potassium 4.7 mEq/L, serum creatinine 0.9 mg/dL, glucose 124 mg/dL, and thyrotropin 24 mIU/mL. Additional medications include olanzapine 10 mg at bedtime (for 1 year), ethinyl estradiol/drospirenone daily, and a multivitamin. Which laboratory finding is most closely associated with her current medication regimen? A. Glucose. B. Serum creatinine. C. Sodium. D. Thyrotropin.

Answer 121

Psychiatry & Mental Health D

Question 122

A 43-year-old presents with right upper quadrant abdominal pain with rebound tenderness, nausea, and vomiting. Medical history is significant for rapid-cycling bipolar disorder, hypertension, obesity, and asthma. Current medications include divalproex sodium 500 mg twice daily, lamotrigine 150 mg twice daily, aripiprazole 30 mg daily, ramipril 10 mg daily, albuterol hydrofluoroalkane (HFA) 2 puffs every 6 hours, and fluticasone/salmeterol dry powder inhaler 250/50 mcg twice daily. A prednisone taper was initiated 3 days ago for an asthma exacerbation. Laboratory test results include sodium 141 mEq/L, potassium 3.3 mEq/L, chloride 95 mEq/L, carbon dioxide 26 mmol/L, serum creatinine 1.0 mg/dL, glucose 72 mg/dL, total cholesterol 165 mg/dL, triglycerides 188 mg/dL, aspartate aminotransferase (AST) 27 U/L, alanine aminotransferase (ALT) 21 U/L, amylase 456 U/L, lipase 387 U/L, and valproic acid trough concentration 56 mg/dL. Which medication is most likely to be impacted with her current medication regimen? A. Aripiprazole. B. Divalproex sodium. C. Lamotrigine. D. Prednisone.

Answer 122

Psychiatry & Mental Health B

Question 123

A 20-year-old presents to the emergency department after experiencing trembling, sweating, chest pain, and shortness of breath accompanied by intense fear. A myocardial infarction has been ruled out. The patient is diagnosed with panic disorder. In addition to a medication for acute symptoms, which medication would provide the best long-term control? A. Alprazolam. B. Buspirone. C. Hydroxyzine. D. Paroxetine.

Answer 123

Psychiatry & Mental Health D

Question 124

A 55-year-old woman presents with uncontrolled generalized anxiety disorder (GAD). Concomitant medical conditions include a history of breast cancer, dyslipidemia, osteoarthritis, vasomotor symptoms, and osteopenia. She takes tamoxifen, simvastatin, ibuprofen, lorazepam, and alendronate. Her physician would like her to have better control of her anxiety symptoms. He would also like to taper off lorazepam. Her GAD has not been controlled with escitalopram, sertraline, or duloxetine. Which agent would be best? A. Bupropion. B. Fluoxetine. C. Pregabalin. D. Venlafaxine.

Answer 124

Psychiatry & Mental Health C

Question 125

A 74-year-old has difficulty getting to sleep. Once asleep, rest is comfortable throughout the night. The patient has struggled with keeping a consistent bedtime for the past few months. There are no identifiable contributing factors. Concomitant medical conditions include hypertension, arthritis, and mild cognitive impairment. Diphenhydramine helped for only a few nights and “made me loopy.” They would like a medication with the least risk of hangover effect. Which medication is best? A. Eszopiclone. B. Ramelteon. C. Suvorexant. D. Zolpidem

Answer 125

Psychiatry & Mental Health B

Question 126

A 23-year-old has a history of heroin addiction and has successfully been maintained on methadone 40 mg daily for 1 year. The patient would like an option that does not require a visit to a daily opioid treatment program to get their methadone dose. The patient is taking no other medications or substances of abuse. Which treatment regimen is most appropriate? A. Initiate supervised buprenorphine/naloxone. B. Change to buprenorphine × 2 days; then take buprenorphine/naloxone. C. Change to naltrexone. D. Taper to methadone 30 mg; then change to buprenorphine.

Answer 126

Psychiatry & Mental Health D

Question 127

A 55-year-old has a 30-year history of alcohol dependence. Daily intake is 1 pint of vodka. Several quit attempts have been unsuccessful. They recently reconciled with their estranged son and want to be sober so that they can be present in their son’s life. Medical history includes heroin use, depression, and posttraumatic stress disorder (PTSD). Concomitant medications include methadone maintenance (which they wish to continue) and sertraline (currently nonadherent). Liver function test results include AST 143 U/L, ALT 74 U/L, albumin 4.0 g/dL, alkaline phosphatase 75 U/L, total bilirubin 0.3 mg/dL, prothrombin time 15.1 seconds, international normalized ratio (INR) 0.9, platelet count 370,000/mm3 , and creatinine clearance 40 mL/minute/1.73 m2 . After alcohol detoxification, which maintenance treatment is most appropriate? A. Acamprosate 333 mg three times daily. B. Chlordiazepoxide 25 mg four times daily. C. Disulfiram 500 mg daily. D. Naltrexone 50 mg daily.

Answer 127

Psychiatry & Mental Health A

Question 128

A 44-year-old is preparing to be discharged from the hospital after a myocardial infarction. They have a 25 pack-year history of smoking cigarettes and currently smokes 1½ packs/day. Two unsuccessful quit attempts exist, including quitting “cold turkey” the first time about 5 years ago. Smoking resumed 6 months later after a job loss. Another attempt occurred 6 months ago using the 2-mg strength of nicotine gum. Seven pieces were chewed daily in an effort to save money. The patient has just been given a diagnosis of depression. Which regimen would be best? A. Bupropion sustained release (SR). B. Nicotine gum. C. Nicotine patch. D. Varenicline

Answer 128

Psychiatry & Mental Health A

Question 129

A 25-year-old (BMI 35 kg/m2 ) has recently diagnosed schizophrenia. The patient often hears voices telling them they are “stupid and worthless” and should “just jump off the roof of their apartment building.” The patient’s parents became very concerned about isolative behavior and brought the patient to the hospital. The patient was given haloperidol in the psychiatry unit and now presents with neck stiffness and in oculogyric crisis. Until now, they have not taken medications because they thought they could control their symptoms on their own with vitamins, though they have difficulty remembering to take these. The patient has an additional history of marijuana and alcohol use disorders. A blood alcohol concentration is 0, and a urine drug screen is negative. Which is most appropriate for this patient’s symptoms at this time? A. Benztropine. B. Dantrolene. C. Lorazepam. D. Propranolol.

Answer 129

Psychiatry & Mental Health A

Question 130

A 25-year-old (BMI 35 kg/m2 ) has recently diagnosed schizophrenia. The patient often hears voices telling them they are “stupid and worthless” and should “just jump off the roof of their apartment building.” The patient’s parents became very concerned about isolative behavior and brought the patient to the hospital. The patient was given haloperidol in the psychiatry unit and now presents with neck stiffness and in oculogyric crisis. Until now, they have not taken medications because they thought they could control their symptoms on their own with vitamins, though they have difficulty remembering to take these. The patient has an additional history of marijuana and alcohol use disorders. A blood alcohol concentration is 0, and a urine drug screen is negative. Aripiprazole is initiated. Which is the best rationale for this selection, given patient-specific factors? A. Aripiprazole has no risk of causing extrapyramidal symptoms (EPS). B. Aripiprazole is available in a long-acting injection (LAI) to increase adherence. C. Aripiprazole would eliminate this patient’s negative symptoms. D. Aripiprazole is effective against substance use disorders.

Answer 130

Psychiatry & Mental Health B

Question 131

A 25-year-old (BMI 35 kg/m2 ) has recently diagnosed schizophrenia. The patient often hears voices telling them they are “stupid and worthless” and should “just jump off the roof of their apartment building.” The patient’s parents became very concerned about isolative behavior and brought the patient to the hospital. The patient was given haloperidol in the psychiatry unit and now presents with neck stiffness and in oculogyric crisis. Until now, they have not taken medications because they thought they could control their symptoms on their own with vitamins, though they have difficulty remembering to take these. The patient has an additional history of marijuana and alcohol use disorders. A blood alcohol concentration is 0, and a urine drug screen is negative. Which is the best example of an adverse effect of aripiprazole that would be of concern when initiated in this patient? A. Sedation. B. Anticholinergic effects. C. Akathisia. D. Corrected QT (QTc) prolongation.

Answer 131

Psychiatry & Mental Health C

Question 132

A 25-year-old (BMI 35 kg/m2 ) has recently diagnosed schizophrenia. The patient often hears voices telling them they are “stupid and worthless” and should “just jump off the roof of their apartment building.” The patient’s parents became very concerned about isolative behavior and brought the patient to the hospital. The patient was given haloperidol in the psychiatry unit and now presents with neck stiffness and in oculogyric crisis. Until now, they have not taken medications because they thought they could control their symptoms on their own with vitamins, though they have difficulty remembering to take these. The patient has an additional history of marijuana and alcohol use disorders. A blood alcohol concentration is 0, and a urine drug screen is negative. One year later, they no longer respond to aripiprazole, and you decide to change their medication. They are only interested in oral medications. Given this patient’s history, which agent is most appropriate at this time? A. Clozapine. B. Fluphenazine. C. Olanzapine. D. Ziprasidone.

Answer 132

Psychiatry & Mental Health D

Question 133

A 45-year-old has a medical history significant for sleep apnea, hypertension, type 2 diabetes, chronic pain, and bulimia. The current clinic visit is for an assessment of depressive symptoms and a medication evaluation. Endorsed symptoms include sad mood, poor appetite (lost 6.8 kg [15 lb]), poor concentration, and feelings of hopelessness and worthlessness for the past 3 weeks. The patient has also stopped going to book club because of lack of motivation to get out of the house, and there are frequent nocturnal awakenings. The patient denies suicidal or homicidal ideation. The patient also denies any use of alcohol, tobacco, or illicit drugs. Current medications include hydrochlorothiazide, metformin, hydrocodone/acetaminophen, and aspirin. Current BMI is 20 kg/m2, and blood pressure today is 152/94 mm Hg. The patient reports adherence to current medications. Which selective serotonin reuptake inhibitor (SSRI) would most likely interact with the current medications? A. Citalopram. B. Fluvoxamine. C. Paroxetine. D. Sertraline

Answer 133

Psychiatry & Mental Health C

Question 134

A 45-year-old has a medical history significant for sleep apnea, hypertension, type 2 diabetes, chronic pain, and bulimia. The current clinic visit is for an assessment of depressive symptoms and a medication evaluation. Endorsed symptoms include sad mood, poor appetite (lost 6.8 kg [15 lb]), poor concentration, and feelings of hopelessness and worthlessness for the past 3 weeks. The patient has also stopped going to book club because of lack of motivation to get out of the house, and there are frequent nocturnal awakenings. The patient denies suicidal or homicidal ideation. The patient also denies any use of alcohol, tobacco, or illicit drugs. Current medications include hydrochlorothiazide, metformin, hydrocodone/acetaminophen, and aspirin. Current BMI is 20 kg/m2, and blood pressure today is 152/94 mm Hg. The patient reports adherence to current medications. Which antidepressant would be most appropriate for the depressive symptoms? A. Bupropion. B. Fluoxetine. C. Mirtazapine. D. Venlafaxine.

Answer 134

Psychiatry & Mental Health C

Question 135

A 45-year-old has a medical history significant for sleep apnea, hypertension, type 2 diabetes, chronic pain, and bulimia. The current clinic visit is for an assessment of depressive symptoms and a medication evaluation. Endorsed symptoms include sad mood, poor appetite (lost 6.8 kg [15 lb]), poor concentration, and feelings of hopelessness and worthlessness for the past 3 weeks. The patient has also stopped going to book club because of lack of motivation to get out of the house, and there are frequent nocturnal awakenings. The patient denies suicidal or homicidal ideation. The patient also denies any use of alcohol, tobacco, or illicit drugs. Current medications include hydrochlorothiazide, metformin, hydrocodone/acetaminophen, and aspirin. Current BMI is 20 kg/m2, and blood pressure today is 152/94 mm Hg. The patient reports adherence to current medications. It has been 4 weeks since the initial visit with you, and the patient has been treated with citalopram 20 mg/ day in the morning. Sad mood persists, but insomnia, concentration, and appetite have improved. Persistent symptoms include feelings of hopelessness and worthlessness, lack of motivation, and anhedonia. No adverse effects exist. At this point, which is the best recommendation to optimize therapy? A. Continue citalopram 20 mg/day. B. Increase citalopram to 40 mg/day. C. Add aripiprazole. D. Change to a different SSRI.

Answer 135

Psychiatry & Mental Health B

Question 136

A 45-year-old has a medical history significant for sleep apnea, hypertension, type 2 diabetes, chronic pain, and bulimia. The current clinic visit is for an assessment of depressive symptoms and a medication evaluation. Endorsed symptoms include sad mood, poor appetite (lost 6.8 kg [15 lb]), poor concentration, and feelings of hopelessness and worthlessness for the past 3 weeks. The patient has also stopped going to book club because of lack of motivation to get out of the house, and there are frequent nocturnal awakenings. The patient denies suicidal or homicidal ideation. The patient also denies any use of alcohol, tobacco, or illicit drugs. Current medications include hydrochlorothiazide, metformin, hydrocodone/acetaminophen, and aspirin. Current BMI is 20 kg/m2, and blood pressure today is 152/94 mm Hg. The patient reports adherence to current medications. Six months later, depression symptoms have resolved, but citalopram is causing anorgasmia, which is unacceptable to the patient. Which is the most appropriate recommendation at this time? A. Discontinue citalopram. B. Add bupropion to citalopram. C. Change to a different SSRI. D. Change to vortioxetine.

Answer 136

Psychiatry & Mental Health D

Question 137

A 26-year-old with a history of type I bipolar disorder presents to the inpatient unit. Their spouse found them withdrawing their life savings from the bank. The patient states that they are the perfect candidate for the presidency. The patient has not slept in the past 48 hours and is hyperverbal. The patient is placed on an involuntary mental health hold for control of manic symptoms. There is a history of nonadherence to medications and the patient currently takes none. The last hospitalization was 2 months ago, when the patient had significant depressive symptoms and suicidal ideation. The patient has three or four hospitalizations per year. Previous medication trials include olanzapine and lamotrigine. The patient has also been given a diagnosis of hepatitis C with AST 175 U/L and ALT 186 U/L. Which mood stabilizer is most appropriate for this patient at this time? A. Carbamazepine. B. Divalproex sodium. C. Lamotrigine. D. Lithium

Answer 137

Psychiatry & Mental Health D

Question 138

A 26-year-old with a history of type I bipolar disorder presents to the inpatient unit. Their spouse found them withdrawing their life savings from the bank. The patient states that they are the perfect candidate for the presidency. The patient has not slept in the past 48 hours and is hyperverbal. The patient is placed on an involuntary mental health hold for control of manic symptoms. There is a history of nonadherence to medications and the patient currently takes none. The last hospitalization was 2 months ago, when the patient had significant depressive symptoms and suicidal ideation. The patient has three or four hospitalizations per year. Previous medication trials include olanzapine and lamotrigine. The patient has also been given a diagnosis of hepatitis C with AST 175 U/L and ALT 186 U/L. Which treatment-emergent adverse effect would be of most concern and would require immediate evaluation if lithium were prescribed? A. Hypothyroidism. B. Coarse tremor. C. Severe acne. D. Weight gain.

Answer 138

Psychiatry & Mental Health B

Question 139

A 26-year-old with a history of type I bipolar disorder presents to the inpatient unit. Their spouse found them withdrawing their life savings from the bank. The patient states that they are the perfect candidate for the presidency. The patient has not slept in the past 48 hours and is hyperverbal. The patient is placed on an involuntary mental health hold for control of manic symptoms. There is a history of nonadherence to medications and the patient currently takes none. The last hospitalization was 2 months ago, when the patient had significant depressive symptoms and suicidal ideation. The patient has three or four hospitalizations per year. Previous medication trials include olanzapine and lamotrigine. The patient has also been given a diagnosis of hepatitis C with AST 175 U/L and ALT 186 U/L. Three months later, the patient’s condition has been stable on lithium 900 mg/day. Today, during a clinic visit, they are confused and slurring their words. The current lithium serum concentration is 1.9 mEq/L. Current medications include amlodipine for hypertension, atorvastatin for dyslipidemia, and zolpidem for sleep. They began running a week ago. They have been replacing fluids using an oral rehydrating solution (Gatorade) and taking ibuprofen around-the-clock for pain. Which most likely contributed to this patient’s current clinical situation? A. Amlodipine. B. Gatorade. C. Ibuprofen. D. Zolpidem

Answer 139

Psychiatry & Mental Health C

Question 140

A 36-year-old woman (BMI 20 kg/m2 ) with type I bipolar disorder presents to your clinic tearful, with a 2-week history of depressed mood, anhedonia, insomnia, feelings of worthlessness, and loss of appetite. She has passive thoughts of suicide, but no concrete plan. She currently takes lithium, with a trough serum concentration of 1.1 mEq/L. Which medication would be best to treat her current episode? A. Divalproex sodium. B. Lamotrigine. C. Quetiapine. D. Venlafaxine.

Answer 140

Psychiatry & Mental Health C

Question 141

A recent Iraq war veteran has responded to treatment with paroxetine for major depression for the past 3 weeks. Clinical presentation today includes experiencing nightmares, “feeling on edge all the time,” and having flashbacks of time in the war. After evaluation, the patient is diagnosed with posttraumatic stress disorder (PTSD). There is no history of substance dependence and no significant medical history. Which recommendation is most appropriate for this patient at this time? A. Continue paroxetine because it treats both PTSD and major depression. B. Discontinue paroxetine and initiate sertraline, which treats both PTSD and major depression. C. Continue paroxetine and add lorazepam for the anxiety symptoms. D. Discontinue paroxetine and initiate buspirone for the anxiety symptoms.

Answer 141

Psychiatry & Mental Health A

Question 142

A 48-year-old has newly diagnosed generalized anxiety disorder (GAD). The patient cannot sleep at night and reports frequent headaches treated with ibuprofen. Family history is positive for depression (mother) and anxiety (sister). Which medication would be best for long-term symptom resolution? A. Alprazolam. B. Buspirone. C. Paroxetine. D. Pregabalin.

Answer 142

Psychiatry & Mental Health C

Question 143

A 27-year-old with panic disorder is having difficulty functioning at work. The first panic attack occurred while getting a cup of coffee. It felt like a heart attack and was evaluated at the local emergency department, where physical causes were ruled out. There have been several subsequent episodes. Place and time of repeat episodes are unpredictable. Absenteeism from work is high, and job security is thus a concern. The medical history is otherwise unremarkable. Which medication would most quickly allow the patient to return to work? A. Alprazolam. B. Buspirone. C. Paroxetine. D. Venlafaxine

Answer 143

Psychiatry & Mental Health A

Question 144

A 21-year-old has newly diagnosed obsessive-compulsive disorder (OCD). They cannot hold a job because they are consumed by their obsessions and compulsions. They are convinced that their obsessions are reality. Which medication is most appropriate to initiate? A. Bupropion. B. Desipramine. C. Fluoxetine. D. Mirtazapine.

Answer 144

Psychiatry & Mental Health C

Question 145

A 38-year-old kindergarten teacher presents to the clinic today with noticeable dark circles under the eyes. They have difficulty with sleep, mainly with staying asleep. It takes about 20 minutes to fall asleep, but after about 5 hours, they wake up and cannot fall asleep again for several hours. This pattern has negatively affected job performance, and they feel tired all the time. They once took diphenhydramine for sleep but had to miss work because of extreme drowsiness in the morning. They wonder whether they could take any other medications. Other medical problems include hypothyroidism (levothyroxine 125 mcg at bedtime), hypertension (hydrochlorothiazide 25 mg in the morning), chronic back pain (ibuprofen 800 mg three times daily), and MDD (citalopram 20 mg in the morning). Which agent is most likely contributing to insomnia? A. Citalopram. B. Hydrochlorothiazide. C. Ibuprofen. D. Levothyroxine.

Answer 145

Psychiatry & Mental Health D

Question 146

A 38-year-old kindergarten teacher presents to the clinic today with noticeable dark circles under the eyes. They have difficulty with sleep, mainly with staying asleep. It takes about 20 minutes to fall asleep, but after about 5 hours, they wake up and cannot fall asleep again for several hours. This pattern has negatively affected job performance, and they feel tired all the time. They once took diphenhydramine for sleep but had to miss work because of extreme drowsiness in the morning. They wonder whether they could take any other medications. Other medical problems include hypothyroidism (levothyroxine 125 mcg at bedtime), hypertension (hydrochlorothiazide 25 mg in the morning), chronic back pain (ibuprofen 800 mg three times daily), and MDD (citalopram 20 mg in the morning). Which medication used for insomnia is most appropriate to recommend for this patient after adjusting the medication in question 17? A. Trazodone. B. Temazepam. C. Zaleplon. D. Zolpidem.

Answer 146

Psychiatry & Mental Health D

Question 147

A 38-year-old kindergarten teacher presents to the clinic today with noticeable dark circles under the eyes. They have difficulty with sleep, mainly with staying asleep. It takes about 20 minutes to fall asleep, but after about 5 hours, they wake up and cannot fall asleep again for several hours. This pattern has negatively affected job performance, and they feel tired all the time. They once took diphenhydramine for sleep but had to miss work because of extreme drowsiness in the morning. They wonder whether they could take any other medications. Other medical problems include hypothyroidism (levothyroxine 125 mcg at bedtime), hypertension (hydrochlorothiazide 25 mg in the morning), chronic back pain (ibuprofen 800 mg three times daily), and MDD (citalopram 20 mg in the morning). Which adverse effect of zolpidem would carry the greatest potential for harm in this patient? A. Orthostasis. B. Disorientation. C. Abnormal behaviors while asleep. D. Seizures with high doses of the drug

Answer 147

Psychiatry & Mental Health C

Question 148

A 50-year-old patient with a 25-year history of alcohol dependence was found unconscious after a drinking binge. The patient was first admitted to the medical unit for alcohol withdrawal symptoms before being transferred to the substance dependence unit. The last drink was 6 hours ago, and fluids have been initiated. The patient has had three alcohol withdrawal seizures in the past and an episode of delirium tremens. Significant hepatitis is also present, and liver function tests show AST 275 U/L and ALT 130 U/L. Additional laboratory test values include albumin 4.2 g/ dL, alkaline phosphatase 152 IU/L, and g-glutamyl transferase 470 units/L. Which symptom are you most likely to observe in the medical unit in this patient on admission? A. Alcohol craving. B. Delirium tremens. C. Increased heart rate. D. Seizures.

Answer 148

Psychiatry & Mental Health C

Question 149

A 50-year-old patient with a 25-year history of alcohol dependence was found unconscious after a drinking binge. The patient was first admitted to the medical unit for alcohol withdrawal symptoms before being transferred to the substance dependence unit. The last drink was 6 hours ago, and fluids have been initiated. The patient has had three alcohol withdrawal seizures in the past and an episode of delirium tremens. Significant hepatitis is also present, and liver function tests show AST 275 U/L and ALT 130 U/L. Additional laboratory test values include albumin 4.2 g/ dL, alkaline phosphatase 152 IU/L, and g-glutamyl transferase 470 units/L. Which agent is best for this patient’s alcohol withdrawal symptoms? A. Chlordiazepoxide. B. Clonazepam. C. Diazepam. D. Lorazepam

Answer 149

Psychiatry & Mental Health D

Question 150

A 50-year-old patient with a 25-year history of alcohol dependence was found unconscious after a drinking binge. The patient was first admitted to the medical unit for alcohol withdrawal symptoms before being transferred to the substance dependence unit. The last drink was 6 hours ago, and fluids have been initiated. The patient has had three alcohol withdrawal seizures in the past and an episode of delirium tremens. Significant hepatitis is also present, and liver function tests show AST 275 U/L and ALT 130 U/L. Additional laboratory test values include albumin 4.2 g/ dL, alkaline phosphatase 152 IU/L, and g-glutamyl transferase 470 units/L. Which medication is best for this patient’s alcohol dependence? A. Acamprosate. B. Diazepam. C. Disulfiram. D. Naltrexone.

Answer 150

Psychiatry & Mental Health A

Question 151

A 34-year-old wants to stop using oxycodone. They have been buying it off the street and are using 160 mg daily. The patient has no interest in methadone maintenance but wants to enroll in an outpatient program. The last oxycodone dose was 24 hours ago. The patient is having some anxiety and muscle aches. Treatment will start in the clinic. Which is best to initiate in this patient? A. Buprenorphine 2 mg. B. Buprenorphine 4 mg. C. Buprenorphine/naloxone 2 mg/1 mg. D. Buprenorphine/naloxone 4 mg/1 mg

Answer 151

Psychiatry & Mental Health D

Question 152

E.S. is a 25-year-old electrician. He has had several episodes of memory lapses. His wife reports lip smacking and chewing movements during these spells. An electroencephalogram (EEG) reveals focal epileptiform spike waves. Which medication would be best for E.S.? A. Ethosuximide. B. Levetiracetam. C. Phenobarbital. D. Clobazam

Answer 152

Neurology B

Question 153

B.V. is a 48-year-old woman brought to your ED for the treatment of status epilepticus. Her blood glucose is 50 mg/dL on fingerstick. Which medication would be the best next treatment for B.V.? A. Lorazepam. B. Dextrose. C. Thiamine. D. Diazepam

Answer 153

Neurology C

Question 154

J.H. is a 42-year-old man with focal-onset seizures with loss of awareness for which he was prescribed levetiracetam. He comes to the clinic with concerns of agitation. He says his wife is also concerned because he is very irritable and, at times, depressed. Which best assesses J.H.’s condition? A. Discontinue levetiracetam; he is having adverse effects. B. Increase the levetiracetam dose; he is having focal seizures. C. Continue levetiracetam; it is controlling his seizures. D. Obtain a levetiracetam serum concentration; he is probably supratherapeutic.

Answer 154

Neurology A

Question 155

T.O. is a 68-year-old man who suddenly lost consciousness at home. His partner calls 911, and emergency medical technicians arrive within 10 minutes. According to the medical record, he experienced slurred speech and right arm weakness about 30 minutes before losing consciousness. He is treated for hypertension Which test would be best before initiating pharmacotherapy for T.O.? A. Cerebral angiogram. B. CT scan of head. C. Coagulation panel. D. Echocardiogram.

Answer 155

Neurology B

Question 156

T.O. is a 68-year-old man who suddenly lost consciousness at home. His partner calls 911, and emergency medical technicians arrive within 10 minutes. According to the medical record, he experienced slurred speech and right arm weakness about 30 minutes before losing consciousness. He is treated for hypertension. T.O. is diagnosed with a major ischemic stroke and treated with alteplase. He regains consciousness and is transferred to rehabilitation. Which treatment would be best for 3 months to prevent another stroke? A. Aspirin and clopidogrel. B. Aspirin and dipyridamole. C. Apixaban. D. Warfarin.

Answer 156

Neurology A

Question 157

P.P. is a 75-year-old woman who was diagnosed with Parkinson disease 8 years ago. During this visit to the clinic, she notes that her movements are slower and she feels stiffer. She has also experienced a worsening gait with two or three falls in the past 6 months. Her writing has also become small and illegible. She takes carbidopa/levodopa 25/100 mg 2 tablets four times daily. Which of P.P.’s symptoms would best be controlled by pharmacotherapy? A. Gait disturbances. B. Falls. C. Handwriting. D. Rigidity

Answer 157

Neurology D

Question 158

P.P. is a 75-year-old woman who was diagnosed with Parkinson disease 8 years ago. During this visit to the clinic, she notes that her movements are slower and she feels stiffer. She has also experienced a worsening gait with two or three falls in the past 6 months. Her writing has also become small and illegible. She takes carbidopa/levodopa 25/100 mg 2 tablets four times daily. P.P. notes that her symptoms seem worse before her next dose of carbidopa/levodopa. Which agent would best be added at this visit? A. Istradefylline. B. Entacapone. C. Apomorphine. D. Quetiapine.

Answer 158

Neurology B

Question 158

W.S. is a 70-year-old man with newly diagnosed Parkinson disease who is initiated on carbidopa/ levodopa. His symptoms are well controlled, but he has concerns of nausea and vomiting. Which intervention would be best to reduce his nausea and vomiting? A. Initiate promethazine. B. Initiate metoclopramide. C. Decrease carbidopa/levodopa. D. Initiate trimethobenzamide.

Answer 158

Neurology D

Question 159

R.M. is a 42-year-old man with headaches, which he describes as a tight band around his head. The headaches occur three or four times a week. Which medication would be the best acute treatment for R.M. to use for his headaches? A. Naproxen. B. Sumatriptan. C. Dihydroergotamine. D. Lithium

Answer 159

Neurology A

Question 159

R.M. is a 42-year-old man with headaches, which he describes as a tight band around his head. The headaches occur three or four times a week. R.M is requesting a preventive medication to help reduce his headache frequency. Which agent would be best to recommend? A. Amitriptyline. B. Valproate. C. Topiramate. D. Frovatriptan.

Answer 159

Neurology A

Question 160

L.M. is a 43-year-old man diagnosed with relapsing-remitting multiple sclerosis (MS) 2 years ago. He has taken glatiramer acetate since then. However, his exacerbations have not discernibly decreased. He has spasticity in his legs, which has caused several falls in the past month, and fatigue that worsens as the day progresses Which medication would be best for L.M.’s spasticity? A. Diazepam. B. Baclofen. C. Carisoprodol. D. Metaxalone

Answer 160

Neurology B

Question 160

L.M. is a 43-year-old man diagnosed with relapsing-remitting multiple sclerosis (MS) 2 years ago. He has taken glatiramer acetate since then. However, his exacerbations have not discernibly decreased. He has spasticity in his legs, which has caused several falls in the past month, and fatigue that worsens as the day progresses Which medication would be best for L.M.’s fatigue? A. Propranolol. B. Lamotrigine. C. Amantadine. D. Ropinirole

Answer 160

Neurology C

Question 160

L.M. is a 43-year-old man diagnosed with relapsing-remitting multiple sclerosis (MS) 2 years ago. He has taken glatiramer acetate since then. However, his exacerbations have not discernibly decreased. He has spasticity in his legs, which has caused several falls in the past month, and fatigue that worsens as the day progresses Which medication would be best for L.M.’s MS? A. Cyclophosphamide. B. Methylprednisolone. C. Azathioprine. D. Fingolimod.

Answer 160

Neurology D

Question 161

B.T. is a 62-year-old man with obesity (weight 122 kg) who comes to the clinic with concerns of burning in the soles of his feet. These symptoms began about 3 months ago. They are worse at night and keep him from sleeping. On examination, he has decreased sensation in both feet up to the ankles bilaterally and good strength throughout his feet and legs. His ankle reflexes are decreased. He has hypertension treated with lisinopril 10 mg/day Which most likely caused B.T.’s pain and decreased sensation? A. Diabetic neuropathy. B. Chronic inflammatory demyelinating polyneuropathy. C. Entrapped nerve. D. Genetic neuropathy.

Answer 161

Neurology A

Question 161

B.T. is a 62-year-old man with obesity (weight 122 kg) who comes to the clinic with concerns of burning in the soles of his feet. These symptoms began about 3 months ago. They are worse at night and keep him from sleeping. On examination, he has decreased sensation in both feet up to the ankles bilaterally and good strength throughout his feet and legs. His ankle reflexes are decreased. He has hypertension treated with lisinopril 10 mg/day Which treatment would be best for B.T.’s symptoms? A. Carbamazepine 600 mg at bedtime. B. Lidocaine 5% patch applied to soles of feet at bedtime and removed in the morning. C. Acetaminophen 325 mg every 4 hours as needed. D. Valproate 250 mg twice daily.

Answer 161

Neurology B

Question 162

T.M. is a 23-year-old woman with newly diagnosed generalized motor myoclonic-type seizures. She is in good health and takes oral contraceptives Which is the best medication for T.M.’s seizures? A. Valproate. B. Phenytoin. C. Phenobarbital. D. Levetiracetam.

Answer 162

Neurology D

Question 162

T.M. is a 23-year-old woman with newly diagnosed generalized motor myoclonic-type seizures. She is in good health and takes oral contraceptives T.M. is concerned about the impact of levetiracetam on her oral contraceptives. Which response is best? A. Levetiracetam does not alter the effectiveness of your oral contraceptives. B. You should use alternative forms of birth control because levetiracetam decreases oral contraceptive effectiveness. C. You may have breakthrough bleeding, but the effectiveness of the oral contraceptive is not changed. D. Oral contraceptives decrease the effectiveness of levetiracetam, so you need another form of birth control

Answer 162

Neurology A

Question 163

T.M. is a 23-year-old woman with newly diagnosed generalized motor myoclonic-type seizures. She is in good health and takes oral contraceptives Three months later, T.M.’s seizures are reduced in frequency, but continue despite medication adherence and maximized dosing. Which would be the best alternative? A. Lamotrigine. B. Rufinamide. C. Cannabidiol. D. Valproate.

Answer 163

Neurology A

Question 164

J.G. is a 34-year-old patient who presents to the ED in status epilepticus. All of her laboratory values are normal. Which medication is best to use first? A. Valproate. B. Lorazepam. C. Phenytoin. D. Phenobarbital.

Answer 164

Neurology B

Question 165

S.R. is a 37-year-old patient who began taking phenytoin 100 mg 3 capsules orally at bedtime 6 months ago. He has had several seizures since then, the most recent of which occurred 7 days ago. At that time, his phenytoin serum concentration was 8 mcg/mL. The treating physician increased his phenytoin dose to 100 mg 3 capsules orally twice daily. Today, which best represents his expected serum concentration? A. 10 mcg/mL. B. 14 mcg/mL. C. 16 mcg/mL. D. 24 mcg/mL.

Answer 165

Neurology D

Question 165

S.S. is a 7-year-old girl. Her teacher contacts the girl’s parents because of concern about the girl’s “daydreaming” in class. After an evaluation, S.S. is diagnosed with generalized nonmotor (absence) seizures. Which agent is best to treat this type of epilepsy? A. Phenytoin. B. Valproate. C. Carbamazepine. D. Ethosuximide.

Answer 165

Neurology D

Question 166

M.G. has been prescribed levetiracetam. On which adverse effect is it best to counsel M.G.? A. Hepatoxicity. B. Renal stones. C. Depression. D. Word-finding difficulties.

Answer 166

Neurology C

Question 167

J.B. is a 25-year-old man with a history of seizure disorder. He has been treated with carbamazepine for 1 year, and his current carbamazepine concentration is 12 mcg/mL. Which adverse effect is J.B. most likely to have with carbamazepine at this concentration? A. Hepatotoxicity. B. Acne. C. Gingival hyperplasia. D. Diplopia.

Answer 167

Neurology D

Question 168

G.Z., a 26-year-old woman, presents with a 6-month history of “spells.” The spells are all the same, and all begin with a feeling in the abdomen that is difficult for her to describe. This feeling rises toward the head. The patient believes that she will then lose awareness. After a neurologic workup, she is diagnosed with focal seizures evolving to a bilateral, convulsive seizure. The neurologist is considering initiating either carbamazepine or oxcarbazepine. Which is the most accurate comparison of carbamazepine and oxcarbazepine? A. Oxcarbazepine causes more liver enzyme induction than carbamazepine. B. Oxcarbazepine does not cause rash. C. Oxcarbazepine does not cause hyponatremia. D. Oxcarbazepine does not form an epoxide intermediate in its metabolism.

Answer 168

Neurology D

Question 169

G.Z., a 26-year-old woman, presents with a 6-month history of “spells.” The spells are all the same, and all begin with a feeling in the abdomen that is difficult for her to describe. This feeling rises toward the head. The patient believes that she will then lose awareness. After a neurologic workup, she is diagnosed with focal seizures evolving to a bilateral, convulsive seizure. The neurologist is considering initiating either carbamazepine or oxcarbazepine. When you see G.Z. 6 months later for a follow-up, she tells you she is about 6 weeks pregnant. She has had no seizures since starting oxcarbazepine. Which strategy is best for G.Z.? A. Discontinue her seizure medication immediately. B. Change her seizure medication to topiramate. C. Continue her seizure medication. D. Change her seizure medication to lamotrigine

Answer 169

Neurology C

Question 169

L.R. is a 78-year-old woman who presents to the ED for symptoms of right-sided paralysis. She states these symptoms began about 6 hours ago and have not improved. She also has hypertension, breast cancer, diabetes, minimal cognitive impairment, and osteoarthritis. L.R. is diagnosed with a minor stroke by the neurology team. Which best describes whether L.R. is a candidate for tissue plasminogen activator (Alteplase) for the treatment of stroke? A. Yes. B. No, because of advanced age. C. No, her stroke symptoms began too long ago. D. No, her breast cancer is a contraindication for tissue plasminogen activator

Answer 169

Neurology C

Question 169

L.R. is a 78-year-old woman who presents to the ED for symptoms of right-sided paralysis. She states these symptoms began about 6 hours ago and have not improved. She also has hypertension, breast cancer, diabetes, minimal cognitive impairment, and osteoarthritis. L.R. is diagnosed with a minor stroke by the neurology team. Which is the most accurate list of L.R.’s risk factors for stroke? A. Breast cancer, age, osteoarthritis. B. Sex, diabetes, osteoarthritis. C. Minimal cognitive impairment, diabetes, age, sex. D. Age, diabetes, hypertension.

Answer 169

Neurology D

Question 170

L.R. is a 78-year-old woman who presents to the ED for symptoms of right-sided paralysis. She states these symptoms began about 6 hours ago and have not improved. She also has hypertension, breast cancer, diabetes, minimal cognitive impairment, and osteoarthritis. L.R. is diagnosed with a minor stroke by the neurology team. L.R. previously took no home medications. Which is the best treatment at this time for her? A. Metformin and aspirin. B. Celecoxib and clopidogrel. C. Aspirin and clopidogrel. D. Warfarin

Answer 170

Neurology C

Question 171

L.R. is a 78-year-old woman who presents to the ED for symptoms of right-sided paralysis. She states these symptoms began about 6 hours ago and have not improved. She also has hypertension, breast cancer, diabetes, minimal cognitive impairment, and osteoarthritis. L.R. is diagnosed with a minor stroke by the neurology team.. L.R. presents to her community pharmacy to pick up her medication refills (lisinopril, aspirin, clopidogrel, atorvastatin) 2 months after her discharge from the hospital. Which best assesses her dual antiplatelet therapy (DAPT)? A. Appropriate, continue for 90 days after stroke. B. Appropriate, continue as chronic therapy. C. Inappropriate, single antiplatelet therapy should be initiated for 90 days. D. Inappropriate, single antiplatelet therapy should be initiated indefinitely

Answer 171

Neurology D

Question 172

L.T. takes carbidopa/levodopa 25 mg/100 mg orally four times daily and trihexyphenidyl 2 mg orally three times daily for Parkinson disease. L.T.’s wife reports that his movements are very slow and that he is having trouble walking Given these symptoms, which change seems most reasonable? A. Increase carbidopa/levodopa, discontinue trihexyphenidyl. B. Continue carbidopa/levodopa, increase trihexyphenidyl. C. Decrease carbidopa/levodopa, continue trihexyphenidyl. D. Decrease carbidopa/levodopa, increase trihexyphenidyl

Answer 172

Neurology A

Question 172

L.S. is a 42-year-old woman with a medical history of hypertension, type 2 diabetes, renal failure, and mitral valve replacement. She presents to the anticoagulation clinic for her initial visit. Which best reflects her target INR? A. 1.5. B. 2.0. C. 2.5. D. 3.0.

Answer 172

Neurology D

Question 173

L.T. takes carbidopa/levodopa 25 mg/100 mg orally four times daily and trihexyphenidyl 2 mg orally three times daily for Parkinson disease. L.T.’s wife reports that his movements are very slow and that he is having trouble walking Six months later, L.T. returns to the clinic concerned that his carbidopa/levodopa dose is wearing off before his next dose is due, because his tremor and slow movements are worse before the next dose of carbidopa/ levodopa. Which recommendation is best? A. Increase the carbidopa/levodopa dose. B. Decrease the carbidopa/levodopa dose. C. Increase the dosing interval. D. Decrease the dosing interval.

Answer 173

Neurology D

Question 174

P.J. is a 57-year-old man with an 8-year history of Parkinson disease. His current medications include carbidopa/levodopa 50 mg/200 mg orally four times daily, entacapone 200 mg orally four times daily, and amantadine 100 mg three times daily. He presents to the clinic with concerns of reddish orange urine. He fears he has blood in his urine. Which most likely caused this condition? A. Carbidopa/levodopa. B. Entacapone. C. Amantadine. D. Hemorrhagic cystitis.

Answer 174

Neurology B

Question 175

L.L. is a 47-year-old man with Parkinson disease. He takes carbidopa/levodopa 50 mg/200 mg orally four times daily. His wife states that he cannot sit still during the day. He is constantly moving, and she fears his disease is worsening. Which is the best therapy for L.L.? A. Add ropinirole. B. Add selegiline. C. Increase the carbidopa/levodopa dose. D. Decrease the carbidopa/levodopa dose

Answer 175

Neurology D

Question 176

. C.A. is a 70-year-old man with tremors in his right hand that have progressively worsened for the past 6 months. He has difficulty walking. He also has backaches and no longer plays golf. In addition, he is losing his sense of taste. His wife notes that he is moving more slowly and that his handwriting has deteriorated. He is diagnosed with Parkinson disease. Which is the best treatment for C.A.? A. Trihexyphenidyl. B. Apomorphine. C. Carbidopa/levodopa. D. Istradefylline.

Answer 176

Neurology C

Question 176

D.S. is a 49-year-old male computer programmer who describes piercing right-eye pain and lacrimation several times a day for 2–3 days in a row. He will have no episodes for 2–3 weeks but will then have recurrent episodes. In the office, he receives oxygen by nasal cannula during an episode, and his pain is relieved. Which medication would be best for prophylaxis of his headaches? A. Atenolol. B. Valproate. C. Nortriptyline. D. Lithium

Answer 176

Neurology D

Question 177

M.R., a 29-year-old woman, has throbbing right-sided headaches. She experiences nausea, phonophobia, and photophobia with these headaches but no aura. She usually has headaches twice a month. She has hypertension and morbid obesity. She takes hydrochlorothiazide 25 mg/day orally for hypertension, which is the only medication she is taking. Which medication is best for prophylaxis of her headaches? A. Propranolol. B. Indomethacin. C. Topiramate. D. Sumatriptan

Answer 177

Neurology A

Question 177

S.R. is a 54-year-old businessman with squeezing, band-like headaches that occur three or four times weekly. He rates the pain of these headaches as 7/10 and finds acetaminophen, aspirin, ibuprofen, naproxen, ketoprofen, and piroxicam only partly effective. He wants to take a prophylactic drug to prevent his headache disorder. Which medication would be best for prophylaxis of his headaches? A. Propranolol. B. Topiramate. C. Amitriptyline. D. Rizatriptan.

Answer 177

Neurology C

Question 178

M.K. is a 44-year-old woman with right-sided headaches of moderate intensity that are accompanied by severe nausea and vomiting. Which medication would be best for M.K.’s migraine headaches? A. Almotriptan. B. Naratriptan. C. Promethazine. D. Sumatriptan.

Answer 178

Neurology D

Question 179

T.C. is a 30-year-old woman with migraine headaches. Sumatriptan 100 mg provides immediate relief. However, about 2 hours later, her headache symptoms return. Which would be best for her? A. Rizatriptan 5 mg. B. Frovatriptan 2.5 mg. C. Naproxen 250 mg. D. Topiramate 25 mg.

Answer 179

Neurology B

Question 179

S.F. is a 36-year-old woman with a history of MS. This morning, her left arm became progressively weaker over about 3 hours. She was previously healthy except for a broken radius when she was 13 years old and a case of optic neuritis when she was 25. Her current medications include metoprolol 100 mg orally twice daily and fluoxetine 10 mg orally daily. Which would be best for treating S.F.’s exacerbation? A. Interferon beta-1a. B. Glatiramer acetate. C. Methylprednisolone. D. Fingolimod.

Answer 179

Neurology C

Question 180

S.F. is a 36-year-old woman with a history of MS. This morning, her left arm became progressively weaker over about 3 hours. She was previously healthy except for a broken radius when she was 13 years old and a case of optic neuritis when she was 25. Her current medications include metoprolol 100 mg orally twice daily and fluoxetine 10 mg orally daily. Which would be best for S.F. to prevent further exacerbations? A. Methylprednisolone. B. Baclofen. C. Glatiramer acetate. D. No treatment

Answer 180

Neurology C

Question 181

S.F. is a 36-year-old woman with a history of MS. This morning, her left arm became progressively weaker over about 3 hours. She was previously healthy except for a broken radius when she was 13 years old and a case of optic neuritis when she was 25. Her current medications include metoprolol 100 mg orally twice daily and fluoxetine 10 mg orally daily. S.F. elects to start fingolimod. Which would be best to monitor every 6 months while she is taking fingolimod? A. ECG. B. Sodium. C. Pulmonary function tests. D. Renal function tests.

Answer 181

Neurology A

Question 181

B.B. is a 33-year-old woman with recently diagnosed MS. Her neurologist wants you to discuss with her the potential medications to prevent exacerbations. During the discussion, you find that she and her husband are planning to have a child in the next few years and that she is frightened of needles. Which would be best for B.B.? A. Glatiramer acetate. B. Mitoxantrone. C. Teriflunomide. D. Dimethyl fumarate

Answer 181

Neurology D

Question 182

S.B. is a 55-year-old man referred to a neurologist for numbness, burning, and tingling in his feet that have progressively worsened over the past year. On neurologic examination, he has decreased sensations bilaterally to the mid-calf. He takes no medications except for nonprescription analgesics as needed for pain. His BMI is 32 kg/m2 . Which laboratory test would best determine the cause of S.B.’s neuropathy? A. Potassium. B. A1C. C. Serum creatinine. D. WBC

Answer 182

Neurology B

Question 183

S.B. is a 55-year-old man referred to a neurologist for numbness, burning, and tingling in his feet that have progressively worsened over the past year. On neurologic examination, he has decreased sensations bilaterally to the mid-calf. He takes no medications except for nonprescription analgesics as needed for pain. His BMI is 32 kg/m2 Which therapy would be best for S.B.? A. Naproxen. B. Tramadol. C. Nortriptyline. D. Prednisone. .

Answer 183

Neurology C

Question 184

A meta-analysis of treatments for neuropathic pain included data from 26 clinical trials (MedGenMed 2007;9:36). The results of the review included the following data. Treatment No. Needed to Treat Tricyclic antidepressants 2.1 SNRIs 5.1 SSRIs 7 Given these data, which would be most effective for neuropathic pain? A. Duloxetine. B. Sertraline. C. Amitriptyline. D. Venlafaxine

Answer 184

Neurology C

Question 185

A 66-year-old Hispanic man (weight 123.8 kg; body mass index [BMI] 42 kg/m2 ) with a history of dyslipidemia and hypertension received a diagnosis of type 2 diabetes (T2D). After 1 month of exercise and dietary changes and no diabetes medications, his hemoglobin A1C (A1C) and fasting glucose concentration today are 11.5% and 362 mg/dL, respectively. Which set of drugs is best to initiate? A. Metformin and glipizide. B. Glipizide and insulin glulisine. C. Pioglitazone and acarbose. D. Insulin detemir and glulisine.

Answer 185

Endocrine & Metabolic Disorders D

Question 185

A patient weighing 65 kg with symptoms of hyperglycemia and a fasting glucose concentration of 298 mg/dL is given a diagnosis of type 1 diabetes (T1D). The patient’s physician asks for a recommendation of an appropriate starting dose of basal insulin and estimates the total daily insulin (TDI) needs of 0.4 unit/kg/day. Which recommendation is most appropriate? A. 13 units of insulin detemir. B. 13 units of insulin aspart. C. 26 units of insulin glargine. D. 26 units of insulin glulisine.

Answer 185

Endocrine & Metabolic Disorders A

Question 185

A patient with T2D has a blood pressure reading of 152/84 mm Hg, a serum creatinine (SCr) of 1.8 mg/dL, and two recent random urine albumin/ creatinine concentrations of 420 and 395 mg/g. Which class of drugs (barring any contraindications) is best to initiate in this patient? A. Thiazide diuretic. B. Dihydropyridine calcium channel blocker. C. Angiotensin receptor blocker (ARB). D. Non-dihydropyridine calcium channel blocker.

Answer 185

Endocrine & Metabolic Disorders C

Question 185

Which medication is most appropriate for a patient with a diagnosis of Cushing syndrome who has had inadequate symptom relief after surgical resection for a pituitary adenoma? A. Ketoconazole. B. Spironolactone. C. Hydrocortisone. D. Bromocriptine.

Answer 185

Endocrine & Metabolic Disorders A

Question 185

Regarding propylthiouracil and methimazole in the treatment of hyperthyroidism, which statement is most appropriate? A. Propylthiouracil is clinically superior to methimazole in efficacy. B. Propylthiouracil may be associated with greater liver toxicity than methimazole. C. Both agents are equally efficacious in the treatment of Hashimoto disease. D. Both medications should be administered three times daily.

Answer 185

Endocrine & Metabolic Disorders B

Question 185

A physician asks for a recommendation of initial therapy for a patient with T2D. The physician states that metformin is no longer an option for this patient. An A1C obtained today is 9.4% (personal goal 7%), and the patient’s estimated glomerular filtration rate (eGFR) is 29 mL/minute/1.73 m2 . Which agent would be the best recommendation? A. Canagliflozin. B. Alogliptin. C. Insulin glargine. D. Exenatide.

Answer 185

Endocrine & Metabolic Disorders C

Question 186

A woman with T2D has an A1C of 8.6%. She is receiving insulin glargine (60 units once daily at bedtime) and insulin aspart (8 units before breakfast, 7 units before lunch, and 12 units before dinner). She is consistent in her carbohydrate intake at each meal. Her morning fasting plasma glucose (FPG) and premeal blood glucose (BG) readings have consistently averaged 112 mg/dL. Her bedtime readings are averaging 185–200 mg/dL. Which is the best insulin adjustment to improve her overall glycemic control? A. Increase prebreakfast aspart to 10 units. B. Increase predinner aspart to 14 units. C. Increase bedtime glargine to 65 units. D. Increase prelunch aspart to 9 units.

Answer 186

Endocrine & Metabolic Disorders B

Question 187

A 76-year-old woman (weight 47 kg) recently given a diagnosis of Hashimoto disease presents with mild symptoms of lethargy, weight gain, and intolerance to cold. Her thyroid-stimulating hormone (TSH) is 12.2 mIU/L and free thyroxine (T4 ) is below normal limits. She has a history of hypertension and underwent a coronary artery bypass surgery 2 years ago. Which would be the most appropriate initial treatment for this patient? A. Levothyroxine 25 mcg once daily. B. Levothyroxine 75 mcg once daily. C. Liothyronine 25 mcg once daily. D. Liothyronine 75 mcg once daily.

Answer 187

Endocrine & Metabolic Disorders A

Question 188

A 53-year-old woman with a history of Graves disease had ablative therapy 3 years ago, after which she had significant symptom relief and became euthyroid. Her thyroid laboratory values today include TSH 0.12 mIU/L and free T4 3.8 g/dL. She states that many of her previous symptoms have returned but are mild. Which would be the most appropriate treatment for her condition? A. Methimazole. B. Lugol’s solution. C. Propylthiouracil. D. Metoprolol.

Answer 188

Endocrine & Metabolic Disorders A

Question 189

A 65-year-old man with T2D has received metformin 1000 mg twice daily for the past 2 years. His A1C today is 7.8%. His morning FPG readings are consistently at goal. His after-meal glucose readings average 190–200 mg/dL. Which would be most appropriate for this patient? A. Increase metformin to 1000 mg three times daily. B. Add insulin glargine 10 units once daily. C. Change from metformin to insulin glargine 10 units once daily. D. Add saxagliptin 5 mg once daily

Answer 189

Endocrine & Metabolic Disorders D

Question 189

A 34-year-old woman has a BMI of 33 kg/m2 . With dietary changes, she has lost 0.9 kg (2 lb) in 6 months. She exercises regularly but cannot do more because she has two jobs and young children. Her medical history is significant for depression, T2D, and substance abuse. Her current medications include metformin 1000 mg twice daily, insulin glargine 24 units once daily, and sertraline 100 mg once daily. Her A1C is well controlled, but she occasionally has hypoglycemic episodes. She is most concerned about weight loss. Which would be the best recommendation to help her lose weight? A. Continue her diet and exercise routine; additional intervention is unwarranted. B. Initiate liraglutide 3 mg once daily. C. Initiate phentermine/topiramate 3.75/23 mg once daily. D. Initiate orlistat 120 mg three times daily with meals.

Answer 189

Endocrine & Metabolic Disorders D

Question 190

A 53-year-old Hispanic woman has a BMI of 44 kg/m2 and a history of gestational diabetes. Her mother and sister both have T2D. Two weeks ago, her A1C was 7.4%. Her fasting glucose concentration today is 178 mg/dL. She is asymptomatic. Which is the best course of action? A. Diagnose T2D and begin treatment. B. Diagnose T1D and begin treatment. C. Obtain another A1C today. D. Obtain another glucose concentration another day

Answer 190

Endocrine & Metabolic Disorders A

Question 191

A 42-year-old man has a history of T2D. His current therapy includes metformin 1000 mg twice daily and glyburide 10 mg twice daily. Today, his A1C is 6.9% (personal goal is less than 7%), blood pressure is 126/78 mm Hg, and fasting lipid panel is as follows: total cholesterol 212 mg/dL, lowdensity lipoprotein cholesterol (LDL) 98 mg/dL, high-density lipoprotein cholesterol (HDL) 45 mg/dL, and triglycerides (TG) 145 mg/dL. Which would be most appropriate for this patient? A. Add insulin detemir 10 units once daily. B. Add lisinopril 10 mg once daily. C. Add atorvastatin 10 mg once daily. D. Add fenofibrate 145 mg once daily

Answer 191

Endocrine & Metabolic Disorders C

Question 191

A 63-year-old woman has Hashimoto disease. Her thyroid laboratory values today include TSH 10.6 mIU/L (normal 0.5–4.5 mIU/L) and free T4 0.5 ng/dL (normal 0.8–1.9 ng/dL). She feels consistently rundown and has dry skin that does not respond to the use of hand creams. Which is the best drug for initial treatment of her condition? A. Levothyroxine. B. Liothyronine. C. Desiccated thyroid. D. Methimazole.

Answer 191

Endocrine & Metabolic Disorders A

Question 191

A 43-year-old non-pregnant woman has received a diagnosis of Graves disease. She is reluctant to try ablative therapy and wants to try oral pharmacotherapy first. Her thyroid laboratory values today include TSH 0.22 mIU/L (normal 0.5–4.5 mIU/L) and free T4 3.2 ng/dL (normal 0.8–1.9 ng/dL). She is anxious and always feels warm when others say it is too cold. Which is best for initial treatment of her condition? A. Lugol’s solution. B. Propylthiouracil. C. Atenolol. D. Methimazole.

Answer 191

Endocrine & Metabolic Disorders D

Question 192

A 28-year-old woman presents with acne, facial hair growth, and irregular menses that have lasted for 6–7 months. Her medical history includes hypertension and depression. Her pituitary and thyroid tests results have been negative. Her current medications include amlodipine and fluoxetine. Her prolactin concentration today is 112 ng/mL (normal 15–25 ng/mL). Which is the most likely cause of her elevated prolactin concentration? A. Amlodipine. B. Prolactin-secreting adenoma. C. Pregnancy. D. Fluoxetine

Answer 192

Endocrine & Metabolic Disorders D

Question 193

A 44-year-old man has consistently high blood pressure (172/98 mm Hg today), despite his documented adherence to two maximal-dose blood pressure medications. He has frequent headaches, increased thirst, and fatigue. His urine free cortisol is 45 mcg/24 hours (normal range 20–90) and plasma aldosterone/renin ratio is 125 (normal is less than 25). Which most likely caused this patient’s uncontrolled hypertension? A. Cushing syndrome. B. Addison disease. C. Hyperprolactinemia. D. Hyperaldosteronism.

Answer 193

Endocrine & Metabolic Disorders D

Question 194

A patient takes the maximal daily dose of phentermine/topiramate for the treatment of obesity. The patient’s baseline BMI is 36 kg/m2 and weight is 115.7 kg (255 lb). Which best represents the minimum weight loss required to consider continuing treatment with this agent after 3 months of therapy? A. 3.2 kg (7 lb). B. 5.9 kg (13 lb). C. 7.7 kg (17 lb). D. 11.8 kg (26 lb)

Answer 194

Endocrine & Metabolic Disorders B

Question 194

A 64-year-old African American woman has had a 12-kg (27 lb) weight increase during the past year, primarily because of inactivity and a poor diet. Her BMI is 44 kg/m2 . Her mother and sister both have T2D. Her fasting glucose concentration today is 212 mg/dL. Which is the best course of action? A. Diagnose T2D and begin treatment. B. Diagnose T1D and begin treatment. C. Obtain another glucose concentration today. D. Obtain an A1C today in addition to the glucose concentration.

Answer 194

Endocrine & Metabolic Disorders D

Question 195

A 56-year-old man with T2D takes metformin 1000 mg twice daily. He has no other chronic diseases or history of cardiovascular disease. His current vital signs and laboratory results are as follows: blood pressure 148/78 mm Hg, heart rate 74 beats/minute, and A1C 6.9%. Which agent, if added to the current regimen, has the most potential to reduce both microvascular and macrovascular complications in this patient? A. Insulin glargine. B. Lisinopril. C. Glyburide. D. Niacin.

Answer 195

Endocrine & Metabolic Disorders B

Question 196

. A 21-year-old patient (weight 80 kg) is given a diagnosis of T1D after the discovery of elevated glucose concentrations (average 326 mg/dL), and the patient has signs and symptoms of hyperglycemia. Which is the most appropriate initial dose of rapid-acting insulin before breakfast for this patient? (Assume a TDI regimen of 0.5 unit/kg/day.) A. 2 units. B. 4 units. C. 7 units. D. 14 units

Answer 196

Endocrine & Metabolic Disorders C

Question 197

A 55-year-old man with T2D for 6 months has been receiving metformin 1000 mg twice daily since his diagnosis. His A1C today is 8.2%. His morning fasting blood glucose (FBG) readings are consistently at goal. His after-meal glucose readings average 210–230 mg/dL. The patient states that he is worried about his weight and does not want to add a medication that might increase it. Which would be most appropriate for this patient? A. Glyburide. B. Liraglutide. C. Pioglitazone. D. Insulin glargine.

Answer 197

Endocrine & Metabolic Disorders B

Question 198

A 66-year-old man has had T2D for 4 years. His A1C today is 7.7%. He has altered his diet and states that he has been exercising regularly for months. He takes metformin 1000 mg twice daily. Which would best help optimize his glycemic control? A. Continue current medications and counsel to improve his diet and exercise. B. Discontinue metformin and initiate exenatide 5 mcg twice daily. C. Add bromocriptine 0.8 mg at bedtime. D. Add sitagliptin 100 mg once daily to his metformin therapy

Answer 198

Endocrine & Metabolic Disorders D

Question 199

A 66-year-old man is given a diagnosis today of T2D. Two weeks ago, his A1C was 7.5% and SCr was 1.8 mg/dL (eGFR 25 mL/minute/1.73 m2 ). He has a history of hypertension, dyslipidemia, and heart failure with reduced ejection fraction (New York Heart Association class III, ejection fraction 33%). He has 2+ pitting edema bilaterally. In addition to improvements in diet and exercise, which is best to initiate? A. Linagliptin. B. Pioglitazone. C. Exenatide. D. Metformin.

Answer 199

Endocrine & Metabolic Disorders A

Question 200

A patient with newly diagnosed T2D is screened for diabetic nephropathy. The following laboratory values are obtained today: blood pressure 129/78 mm Hg, heart rate 78 beats/minute, urine albumin/creatinine 27 mg/g, and estimated CrCl 94 mL/minute/1.73 m2 . Which would be the most appropriate treatment strategy? A. No change in therapy is warranted. B. Add an angiotensin-converting enzyme (ACE) inhibitor. C. Add a thiazide-like diuretic. D. Reduce daily protein intake.

Answer 200

Endocrine & Metabolic Disorders A

Question 201

A 75-year-old man (height 73 inches, weight 92.5 kg; baseline serum creatinine [SCr] 0.9 mg/dL) presents to your institution with abdominal pain and dizziness. He has a brief history of gastroenteritis and has had nothing to eat or drink for 24 hours. His blood pressure reading while sitting is 120/80 mm Hg, which decreases to 90/60 mm Hg when standing. His heart rate is 90 beats/minute. His basic metabolic panel shows sodium (Na) 135 mEq/L, chloride (Cl) 108 mEq/L, potassium (K) 4.7 mEq/L, carbon dioxide (CO2 ) 26 mEq/L, blood urea nitrogen (BUN) 40 mg/dL, SCr 1.5 mg/ dL, and glucose 188 mg/dL. He has no known drug allergies. Which initial treatment of this patient’s acute kidney injury (AKI) is best? A. Administer furosemide 40 mg intravenously × 1 dose. B. Insert Foley catheter to check for residual urine. C. Administer fluid bolus (500 mL of normal saline solution). D. Administer insulin lispro 3 units subcutaneously

Answer 201

Nephrology C

Question 202

A 44-year-old man is admitted with gram-negative bacteremia. He receives 4 days of parenteral beta-lactam and aminoglycoside therapy and develops acute tubular necrosis (ATN). Antibiotic therapy is adjusted on the basis of culture and sensitivity results. Which laboratory value is most consistent with this presentation? A. BUN/SCr ratio greater than 20:1. B. Urinalysis with no casts visible. C. Fractional excretion of sodium (FENa) more than 2%. D. Urinary sodium less than 20 mEq/L.

Answer 202

Nephrology C

Question 202

Which of the following pharmacokinetic parameters describes a drug that will be most effectively removed by hemodialysis? A. Serum protein binding 90% and volume of distribution of 2.5 L/kg B. Serum protein binding 30% and volume of distribution of 2.5 L/kg C. Serum protein binding 90% and volume of distribution of 0.3 L/kg D. Serum protein binding 30% and volume of distribution of 0.3 L/kg

Answer 202

Nephrology D

Question 203

A 59-year-old patient who has had CKD category G5D (Stage G5 on dialysis) for 10 years has hypertension, coronary artery disease, mild heart failure with reduced ejection fraction (HFrEF), and type 2 diabetes. Medications are as follows: epoetin 10,000 units intravenously three times/week at dialysis, renal multivitamin once daily, atorvastatin 20 mg/day, insulin, and calcium acetate 1334 mg three times daily with meals. Laboratory values are as follows: hemoglobin (Hgb) 9.2 g/dL, parathyroid hormone (PTH) 300 pg/mL, Na 140 mEq/L, K 4.9 mEq/L, SCr 7.0 mg/dL, calcium 9 mg/dL, albumin 3.5 g/dL, and phosphorus 4.8 mg/dL. His serum ferritin concentration is 80 ng/mL and transferrin saturation (TSAT) is 14%. Mean corpuscular volume, mean corpuscular hemoglobin concentration, and white blood cell count (WBC) are all normal. He is afebrile. Which is best for managing this patient’s anemia? A. Increase epoetin. B. Add oral iron. C. Add intravenous iron. D. Maintain current regimen; patient is at goal.

Answer 203

Nephrology C

Question 203

A 60-year-old patient (weight 72 kg) with a history of diabetes and hypertension is in the intensive care unit after having a myocardial infarction about 1 week ago with secondary heart failure. He now has pneumonia. He has been hypotensive for the past 5 days. Before his admission 1 week ago, his SCr was 1.0 mg/dL. His urinary output has steadily been declining for the past 3 days, despite adequate hydration, with 700 mL of urinary output in the past 24 hours. His medications include intravenous dobutamine, nitroglycerin, and cefazolin. Yesterday, his BUN and SCr were 32 and 3.1 mg/dL, respectively; today, they are 41 and 3.9 mg/dL. His urinary osmolality is 290 mOsm/kg. His urinary sodium is 45 mEq/L, and there are tubular cellular casts in his urine. Which type of AKI is this patient most likely experiencing? A. Prerenal azotemia. B. ATN. C. Acute interstitial nephritis (AIN). D. Hemodynamic/functional-mediated AKI.

Answer 203

Nephrology B

Question 204

A 45-year-old man (weight 59 kg, height 70 inches) has a long history of cancer. His SCr is 0.5 mg/dL. Carboplatin will be initiated, for which an accurate estimate of kidney function is critical. Which group of parameters is best to use when estimating kidney function using the Cockcroft-Gault equation? A. Actual body weight and measured SCr. B. Actual body weight and SCr rounded to 1 mg/ dL. C. Ideal body weight and measured SCr. D. Ideal body weight and SCr rounded to 1 mg/dL.

Answer 204

Nephrology A

Question 205

You are evaluating a study comparing epoetin and darbepoetin with respect to their efficacy on mean Hgb concentrations. Both drugs are initiated at the recommended dose, and the Hgb concentration is checked at 4 weeks. Fifty patients are in each group. The mean Hgb in the epoetin group is 12.1 g/dL and is 12.2 g/dL in the darbepoetin group. Which statistical test is best for this comparison? A. Paired t-test. B. Independent (unpaired) t-test. C. Analysis of variance. D. Chi-square test.

Answer 205

Nephrology B

Question 206

A pharmacoeconomic study compared the use of erythropoiesis-stimulating agents with various Hgb concentrations. The primary outcome of this study was cost per quality-adjusted life-year gained. Which best describes this economic evaluation? A. Cost-minimization. B. Cost-effectiveness. C. Cost-benefit. D. Cost-utility

Answer 206

Nephrology D

Question 207

A 58-year-old woman is being evaluated for AKI. Laboratory test results include serum sodium 134 mEq/L, BUN 35 mg/dL, SCr 1.8 mg/dL, urinary sodium 24 mEq/L, and urinary creatinine 14.3 mg/ dL. Which is the best estimate of this patient’s FENa? A. 0.8%. B. 1.25%. C. 2.3%. D. 4.4%.

Answer 207

Nephrology C

Question 208

A 55-year-old man has a history of hypertension. His eGFR is 48 mL/minute/1.73 m2 and urinary albumin/creatinine ratio (ACR) is 28 mg/g. Which best depicts what this patient’s goal blood pressure should be less than, according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines? A. 130/80 mm Hg. B. 140/90 mm Hg. C. 120/80 mm Hg. D. 130/90 mm Hg.

Answer 208

Nephrology B

Question 208

A 66-year-old man has an eGFR of 55 mL/minute/ 1.73 m2 . His ACR is 100 mg/g. His Hgb is currently 13.2 g/dL, with normal red blood cell indices without treatment. Which best reflects the recommended minimum frequency of Hgb monitoring in this patient? A. Monthly. B. Every 3 months. C. Every 6 months. D. Every 12 months.

Answer 208

Nephrology D

Question 209

A 68-year-old patient has diabetes, hypertension, and an eGFR of 40 mL/minute/1.73 m2 . Medications include a renal multivitamin once daily, simvastatin, lisinopril, and hydrochlorothiazide. Laboratory values are as follows: Hgb 11.2 g/dL, immunoassay for PTH 200 pg/mL, Na 138 mEq/L, K 4.9 mEq/L, calcium 8.6 mg/dL, albumin 3.5 g/dL, phosphorus 5.8 mg/dL, and 25-hydroxyvitamin D 45 ng/mL. Which is best to prevent CKD–mineral and bone disorder (MBD) in this patient? A. Ergocalciferol. B. Sevelamer carbonate. C. Calcitriol. D. Cinacalcet.

Answer 209

Nephrology B

Question 210

A 48-year-old African American man (weight 70 kg) with a history of type 2 diabetes, hypertension, and osteoarthritis is admitted to the intensive care unit after an acute myocardial infarction. He was initially hypotensive, requiring 3 L of intravenous fluid. His blood pressure is now 100/65 mm Hg. Medications before admission include nicotine patch, metformin 500 mg orally twice daily, lisinopril 20 mg/day, acetaminophen 650 mg every 6 hours for joint pain, and aspirin 81 mg/daily. Before admission, his kidney function was normal (SCr 1.0 mg/dL); however, during the past 24 hours, his kidney function has declined (BUN 20 mg/dL, SCr 2.1 mg/dL). Serum sodium is 140 mEq/L and serum potassium is 4.4 mEq/L. Urinary volume has been 300 mL over the past 12 hours through urinary catheter. His urine shows muddy casts. His urinary sodium is 45 mEq/L and urinary creatinine is 20 mg/dL. He has edema and pulmonary congestion. Which is the best assessment of this patient’s AKI? A. KDIGO stage 1 AKI. B. KDIGO stage 2 AKI. C. KDIGO stage 3 AKI. D. Too early to assess for AKI.

Answer 210

Nephrology B

Question 211

A 48-year-old African American man (weight 70 kg) with a history of type 2 diabetes, hypertension, and osteoarthritis is admitted to the intensive care unit after an acute myocardial infarction. He was initially hypotensive, requiring 3 L of intravenous fluid. His blood pressure is now 100/65 mm Hg. Medications before admission include nicotine patch, metformin 500 mg orally twice daily, lisinopril 20 mg/day, acetaminophen 650 mg every 6 hours for joint pain, and aspirin 81 mg/daily. Before admission, his kidney function was normal (SCr 1.0 mg/dL); however, during the past 24 hours, his kidney function has declined (BUN 20 mg/dL, SCr 2.1 mg/dL). Serum sodium is 140 mEq/L and serum potassium is 4.4 mEq/L. Urinary volume has been 300 mL over the past 12 hours through urinary catheter. His urine shows muddy casts. His urinary sodium is 45 mEq/L and urinary creatinine is 20 mg/dL. He has edema and pulmonary congestion. Which best depicts this patient’s FENa? A. 0.32%. B. 0.67% C. 1.5%. D. 3.4%.

Answer 211

Nephrology D

Question 212

A 48-year-old African American man (weight 70 kg) with a history of type 2 diabetes, hypertension, and osteoarthritis is admitted to the intensive care unit after an acute myocardial infarction. He was initially hypotensive, requiring 3 L of intravenous fluid. His blood pressure is now 100/65 mm Hg. Medications before admission include nicotine patch, metformin 500 mg orally twice daily, lisinopril 20 mg/day, acetaminophen 650 mg every 6 hours for joint pain, and aspirin 81 mg/daily. Before admission, his kidney function was normal (SCr 1.0 mg/dL); however, during the past 24 hours, his kidney function has declined (BUN 20 mg/dL, SCr 2.1 mg/dL). Serum sodium is 140 mEq/L and serum potassium is 4.4 mEq/L. Urinary volume has been 300 mL over the past 12 hours through urinary catheter. His urine shows muddy casts. His urinary sodium is 45 mEq/L and urinary creatinine is 20 mg/dL. He has edema and pulmonary congestion. Which is the best classification of this patient’s AKI? A. Prerenal azotemia. B. Intrinsic renal disease. C. Postrenal obstruction. D. Functional AKI.

Answer 212

Nephrology B

Question 213

A 48-year-old African American man (weight 70 kg) with a history of type 2 diabetes, hypertension, and osteoarthritis is admitted to the intensive care unit after an acute myocardial infarction. He was initially hypotensive, requiring 3 L of intravenous fluid. His blood pressure is now 100/65 mm Hg. Medications before admission include nicotine patch, metformin 500 mg orally twice daily, lisinopril 20 mg/day, acetaminophen 650 mg every 6 hours for joint pain, and aspirin 81 mg/daily. Before admission, his kidney function was normal (SCr 1.0 mg/dL); however, during the past 24 hours, his kidney function has declined (BUN 20 mg/dL, SCr 2.1 mg/dL). Serum sodium is 140 mEq/L and serum potassium is 4.4 mEq/L. Urinary volume has been 300 mL over the past 12 hours through urinary catheter. His urine shows muddy casts. His urinary sodium is 45 mEq/L and urinary creatinine is 20 mg/dL. He has edema and pulmonary congestion. Which medication should be discontinued because of its risk for worsening kidney function in this patient? A. Lisinopril. B. Metformin. C. Acetaminophen. D. Aspirin.

Answer 213

Nephrology A

Question 214

A 48-year-old African American man (weight 70 kg) with a history of type 2 diabetes, hypertension, and osteoarthritis is admitted to the intensive care unit after an acute myocardial infarction. He was initially hypotensive, requiring 3 L of intravenous fluid. His blood pressure is now 100/65 mm Hg. Medications before admission include nicotine patch, metformin 500 mg orally twice daily, lisinopril 20 mg/day, acetaminophen 650 mg every 6 hours for joint pain, and aspirin 81 mg/daily. Before admission, his kidney function was normal (SCr 1.0 mg/dL); however, during the past 24 hours, his kidney function has declined (BUN 20 mg/dL, SCr 2.1 mg/dL). Serum sodium is 140 mEq/L and serum potassium is 4.4 mEq/L. Urinary volume has been 300 mL over the past 12 hours through urinary catheter. His urine shows muddy casts. His urinary sodium is 45 mEq/L and urinary creatinine is 20 mg/dL. He has edema and pulmonary congestion. Which is most appropriate to add at this time? A. Intravenous 0.9% sodium chloride. B. Hydrochlorothiazide. C. Furosemide. D. Fluid restriction

Answer 214

Nephrology C

Question 215

A 67-year-old man is referred for intermittent chest pain. His medical history is significant for CKD KDIGO category G3a, type 2 diabetes, and hypertension. Medications include enalapril, hydrochlorothiazide, and pioglitazone. Laboratory values include SCr 1.8 mg/dL, glucose 189 mg/dL, Hgb 12 g/dL, and hematocrit (Hct) 36%. His physical examination is normal. The treatment plan is elective cardiac catheterization. Which is best for hydration? A. 0.9% sodium chloride. B. 0.45% sodium chloride. C. 5% dextrose/0.45% sodium chloride. D. Oral hydration with water.

Answer 215

Nephrology A

Question 216

After the administration of radiocontrast, which best represents the optimal time to reevaluate renal function to assess for the development of contrast-associated nephropathy? A. 6 hours. B. 24 hours. C. 4 days. D. 7 days

Answer 216

Nephrology B

Question 217

A 55-year-old man has a history of hypertension and newly diagnosed type 2 diabetes. He denies alcohol use but does smoke cigarettes (1 pack/day). His medications include atenolol 50 mg/day and a multivitamin. At your pharmacy, his blood pressure is 149/92 mm Hg. His ACR is 400 mg/g. A recent SCr is 1.9 mg/dL, which is consistent with a value measured 3 months earlier. His eGFR is 50 mL/minute/1.73 m2 . Which category best reflects his kidney disease, according to the KDIGO criteria? A. G2. B. G3a. C. G3b. D. G4

Answer 217

Nephrology B

Question 218

A 55-year-old man has a history of hypertension and newly diagnosed type 2 diabetes. He denies alcohol use but does smoke cigarettes (1 pack/day). His medications include atenolol 50 mg/day and a multivitamin. At your pharmacy, his blood pressure is 149/92 mm Hg. His ACR is 400 mg/g. A recent SCr is 1.9 mg/dL, which is consistent with a value measured 3 months earlier. His eGFR is 50 mL/minute/1.73 m2 . Using the KDIGO categorization, which best assesses this patient’s albuminuria? A. Category A1. B. Category A2. C. Category A3. D. Nephrotic-range proteinuria.

Answer 218

Nephrology C

Question 219

A 55-year-old man has a history of hypertension and newly diagnosed type 2 diabetes. He denies alcohol use but does smoke cigarettes (1 pack/day). His medications include atenolol 50 mg/day and a multivitamin. At your pharmacy, his blood pressure is 149/92 mm Hg. His ACR is 400 mg/g. A recent SCr is 1.9 mg/dL, which is consistent with a value measured 3 months earlier. His eGFR is 50 mL/minute/1.73 m2 . Assuming that nonpharmacologic approaches have been optimized, which is best to limit the progression of his kidney disease? A. Add nifedipine. B. Add diltiazem. C. Add enalapril. D. Increase atenolol

Answer 219

Nephrology C

Question 220

A 55-year-old man has a history of hypertension and newly diagnosed type 2 diabetes. He denies alcohol use but does smoke cigarettes (1 pack/day). His medications include atenolol 50 mg/day and a multivitamin. At your pharmacy, his blood pressure is 149/92 mm Hg. His ACR is 400 mg/g. A recent SCr is 1.9 mg/dL, which is consistent with a value measured 3 months earlier. His eGFR is 50 mL/minute/1.73 m2 . Enalapril is added to this patient’s regimen. Two weeks later, he returns for a follow-up. His blood pressure is 139/89 mm Hg. A repeat SCr is 2.3 mg/dL, and serum potassium is 5.2 mEq/L. Which is the best recommendation for this patient? A. Add chlorthalidone 50 mg/day. Monitor blood pressure, SCr, and K+ in 2 weeks. B. Change enalapril to diltiazem extended release. Monitor blood pressure, SCr, and K+ in 2 weeks. C. Change enalapril to valsartan. Monitor blood pressure, SCr, and K+ in 2 weeks. D. Increase atenolol. Monitor blood pressure, SCr, and K+ in 2 weeks.

Answer 220

Nephrology A

Question 221

A study compared use of an ARB alone and in combination with an ACEI in patients with CKD. Acute kidney injury occurred in 80 of 724 patients (11%) receiving monotherapy and 130 of 724 patients (18%) receiving combination therapy. Given this information, which most accurately depicts the number of patients needed to harm? A. 7. B. 14. C. 50. D. 105.

Answer 221

Nephrology B

Question 222

A 70-year-old man is being assessed for HD access. He has a history of diabetes and hypertension but is otherwise healthy. Which HD access modality is best to use in this patient? A. Subclavian catheter. B. Tenckhoff catheter. C. Arteriovenous graft. D. Arteriovenous fistula

Answer 222

Nephrology D

Question 223

A patient undergoing long-term HD has intradialytic hypotension. After nonpharmacologic approaches have been optimized, which medication is best to manage his low blood pressure? A. Levocarnitine. B. Sodium chloride tablets. C. Fludrocortisone. D. Midodrine.

Answer 223

Nephrology D

Question 224

A patient with CKD on peritoneal dialysis presents with fever and abdominal pain. She also notes that her peritoneal dialysate has become cloudy. Laboratory evaluation of dialysate reveals many white blood cells, primarily neutrophils. Gram stain and culture of the fluid are ordered. According to the 2022 International Society for Peritoneal Dialysis Peritonitis Recommendations, which is the best empiric therapy for this patient? A. Intravenous metronidazole plus gentamicin. B. Intravenous clindamycin plus vancomycin. C. Cefazolin plus ceftazidime instilled intraperitoneally. D. Vancomycin instilled intraperitoneally

Answer 224

Nephrology C

Question 225

A 60-year-old patient on HD has had ESRD for 10 years. His HD access is a left arteriovenous fistula. He has a history of hypertension, coronary artery disease, mild HFrEF, type 2 diabetes, and a seizure disorder. Medications are as follows: epoetin alfa 14,000 units intravenously three times/week at dialysis, a renal multivitamin once daily, atorvastatin 20 mg/day, insulin, calcium acetate 2 tablets three times daily with meals, phenytoin 300 mg/day, and intravenous iron 100 mg/month. Laboratory values are as follows: Hgb 10.2 g/dL, PTH 800 pg/mL, Na 140 mEq/L, K 4.9 mEq/L, SCr 7.0 mg/dL, calcium 9.5 mg/dL, albumin 2.5 g/dL, and phosphorus 7.8 mg/dL. Serum ferritin is 550 ng/mL, and TSAT is 32%. The red blood cell count indices are normal. His WBC is normal, and he is afebrile Which is most likely contributing to this patient’s relative epoetin resistance? A. Hyperparathyroidism. B. Iron deficiency. C. Phenytoin therapy. D. Infection

Answer 225

Nephrology A

Question 226

A 60-year-old patient on HD has had ESRD for 10 years. His HD access is a left arteriovenous fistula. He has a history of hypertension, coronary artery disease, mild HFrEF, type 2 diabetes, and a seizure disorder. Medications are as follows: epoetin alfa 14,000 units intravenously three times/week at dialysis, a renal multivitamin once daily, atorvastatin 20 mg/day, insulin, calcium acetate 2 tablets three times daily with meals, phenytoin 300 mg/day, and intravenous iron 100 mg/month. Laboratory values are as follows: Hgb 10.2 g/dL, PTH 800 pg/mL, Na 140 mEq/L, K 4.9 mEq/L, SCr 7.0 mg/dL, calcium 9.5 mg/dL, albumin 2.5 g/dL, and phosphorus 7.8 mg/dL. Serum ferritin is 550 ng/mL, and TSAT is 32%. The red blood cell count indices are normal. His WBC is normal, and he is afebrile In addition to diet modification and emphasizing adherence, which is best fo r managing this patient’s hyperparathyroidism? A. Increase calcium acetate. B. Change calcium acetate to sevelamer and add cinacalcet. C. Hold calcium acetate and add intravenous vitamin D analog. D. Add intravenous vitamin D analog.

Answer 226

Nephrology B

Question 227

A 40-year-old patient on dialysis with a history of grand mal seizures takes phenytoin 300 mg/day. His albumin concentration is 3.0 g/dL. His total phenytoin concentration is 5.0 mcg/mL. Which best interprets the phenytoin concentrations? A. Subtherapeutic; a dose increase is needed. B. Therapeutic; no dosage adjustment is needed. C. Toxic; a dose reduction is needed. D. Not interpretable.

Answer 227

Nephrology B

Question 228

P.E. is a 56-year-old man who comes to the clinic with a 3-day history of fever, chills, pleuritic chest pain, malaise, and productive cough. In the clinic, his temperature is 102.1°F (38.9°C) (all other vital signs are normal). His chest radiograph reveals consolidation in the right lower lobe. His white blood cell count (WBC) is 14,400 cells/mm3 , but all other laboratory values are normal. He is given a diagnosis of community-acquired pneumonia (CAP). He has not received any antibiotics in 5 years and has no chronic disease states. Which is the best empiric therapy for P.E.? A. Doxycycline 100 mg orally twice daily. B. Cefuroxime axetil 250 mg orally twice daily. C. Levofloxacin 750 mg orally daily. D. Trimethoprim/sulfamethoxazole double strength orally twice daily

Answer 228

ID 1 A

Question 229

H.W. is a 38-year-old woman who presents with a fever, malaise, dry cough, nasal congestion, and severe headaches. Her symptoms began suddenly 3 days ago, and she has been in bed since then. She reports no other illness in her family, but several people have recently called in sick at work. It is influenza season. Which is best for H.W.? A. Azithromycin 500 mg, followed by 250 mg daily orally for 4 more days. B. Amoxicillin/clavulanic acid 875 mg orally twice daily for 5 days. C. Oseltamivir 75 mg twice daily orally for 5 days. D. Symptomatic treatment only.

Answer 229

ID 1 D

Question 230

A study is designed to assess the risk of pneumococcal pneumonia in older adults 10 years or more after receiving their last pneumococcal vaccination, compared with older adults who have never received any pneumococcal vaccinations. Which study design is best? A. Case series. B. Case-control study. C. Prospective cohort study. D. Randomized controlled trial.

Answer 230

ID 1 B

Question 231

A.B. is a 63-year-old woman who presents to the emergency department with left leg pain and erythema. The pain and erythema have worsened over the past 24 hours. The left leg is significantly swollen with a large area of erythema and large bullae extending from the thigh to the upper leg. There is crepitus within the soft tissue. A.B. is found to have rapidly progressing necrotizing fasciitis. A.B. has normal renal function and no known drug allergies. Which is the best empiric therapy for A.B.? A. Vancomycin 15 mg/kg intravenously every 12 hours. B. Piperacillin/tazobactam 4.5 g intravenously every 8 hours. C. Vancomycin 15 mg/kg intravenously every 12 hours plus meropenem 1 g intravenously every 8 hours plus clindamycin 900 mg intravenously every 8 hours. D. Linezolid 600 mg intravenously every 12 hours plus ceftriaxone 1 g intravenously every 24 hours plus azithromycin 500 mg intravenously daily

Answer 231

ID 1 C

Question 231

N.R. is a 28-year-old woman who presents to the clinic with a 2-day history of dysuria, frequency, and urgency. She has no significant medical history, and the only drug she takes is an oral contraceptive. Which is the best empiric therapy for N.R.? A. Nitrofurantoin extended release (ER) 100 mg orally twice daily for 3 days. B. Ciprofloxacin 500 mg orally twice daily for 7 days. C. Trimethoprim/sulfamethoxazole double strength orally twice daily for 3 days. D. Cephalexin 500 mg orally four times daily for 3 days.

Answer 231

ID 1 C

Question 232

B.Y. is an 85-year-old woman who is bedridden and lives in a nursing home. She is chronically catheterized, and her urinary catheter was last changed 3 weeks ago. Today, her urine is cloudy, and a urinalysis reveals many bacteria. B.Y. is not noticing any symptoms. A urine culture is obtained. Which option is best for B.Y.? A. No antibiotic therapy because she is chronically catheterized and has no symptoms. B. No antibiotic therapy, but the catheter should be changed. C. Ciprofloxacin 500 mg orally twice daily for 7 days and change the catheter. D. Ciprofloxacin 500 mg orally twice daily for 14–21 days without a change in catheter.

Answer 232

ID 1 A

Question 232

R.K. is a 36-year-old woman who presents to the emergency department with a severe headache and neck stiffness. Her temperature is 99.5°F (37.5°C). After a negative computed tomographic scan of the head, a lumbar puncture reveals the following: glucose 54 mg/dL (peripheral, 104 mg/dL), protein 88 mg/dL, and WBC 220 cells/mm3 (100% lymphocytes). The Gram stain reveals no organisms. Which option is best for R.K.? A. This is aseptic meningitis, and no antibiotics are necessary. B. Administer ceftriaxone 2 g intravenously every 12 hours until the cerebrospinal fluid (CSF) cultures are negative for bacteria. C. Administer ceftriaxone 2 g intravenously every 12 hours and vancomycin 15 mg/kg intravenously every 12 hours until the CSF cultures are negative for bacteria. D. Administer acyclovir 500 mg intravenously every 8 hours until the CSF culture results are negative for bacteria.

Answer 232

ID 1 C

Question 233

V.E. is a 44-year-old man who presents to the emergency department with a warm, erythematous, and painful right lower extremity. There is no raised border at the edge of the infection. Three days ago, he scratched his leg on a barbed wire fence on his property (no puncture wound associated with the fence). His temperature has been as high as 101.8°F (38°C) with chills. Doppler studies of his lower extremity are negative. Blood cultures are negative. Which is the best empiric therapy for V.E.? A. Cefazolin 1 g intravenously every 8 hours. B. Penicillin G 2 million units intravenously every 4 hours. C. Piperacillin/tazobactam 3.375 g intravenously every 6 hours. D. Doxycycline 100 mg orally twice daily.

Answer 233

ID 1 A

Question 234

N.L. is a 28-year-old woman with no significant medical history. She reports to the emergency department with fever and severe right lower quadrant abdominal pain. The pain had been dull for the past few days, but it suddenly became severe during the past 8 hours. Her temperature is 103.5°F (39.7°C), and she has rebound tenderness on abdominal examination. She is taken to surgery immediately, where a perforated appendix is diagnosed and repaired. Which is the best follow-up antibiotic regimen? A. Vancomycin 1000 mg intravenously every 12 hours plus metronidazole 500 mg intravenously every 8 hours. B. Cefazolin 1 g intravenously every 8 hours plus ciprofloxacin 400 mg intravenously every 12 hours. C. Ceftriaxone 1 g intravenously every 24 hours plus metronidazole 500 mg intravenously every 8 hours. D. No antibiotics needed after surgical repair of a perforated appendix.

Answer 234

ID 1 C

Question 234

L.G. is a 49-year-old woman with a history of mitral valve prolapse. She presents to her physician’s office with malaise and a low-grade fever. Her physician notes that her murmur is louder than usual and orders blood cultures and an echocardiogram. A large vegetation is observed on L.G.’s mitral valve, and her blood cultures are growing Enterococcus faecalis (susceptible to all antibiotics). Which is the best therapy for L.G.? A. Penicillin G plus gentamicin for 2 weeks. B. Vancomycin plus ceftriaxone for 2 weeks. C. Ampicillin plus ceftriaxone for 6 weeks. D. Cefazolin plus gentamicin for 4–6 weeks

Answer 234

ID 1 C

Question 235

O.R. is a 73-year-old man who presents to the emergency department with a 3-day history of fever, chills, frequency, urgency, and perineal pain. A urinalysis reveals many bacteria. A rectal examination reveals a swollen, tender prostate. He is given a diagnosis of acute bacterial prostatitis. Which is the best regimen for this patient? A. Amoxicillin/clavulanate 875 orally twice daily for 14 days. B. Trimethoprim/sulfamethoxazole double strength orally twice daily for 7 days. C. Cefprozil 500 mg orally twice daily for 21 days. D. Ciprofloxacin 500 mg orally twice daily for 28 days.

Answer 235

ID 1 D

Question 235

J.M. is a 72-year-old woman with a history of atrial fibrillation, hypertension, a right total hip replacement 8 months earlier, and Crohn disease. She has no drug allergies. She presents to the hospital with increasing pain in her prosthetic hip over the past month. There is concern about hip osteomyelitis. Bone cultures are growing methicillin-sensitive Staphylococcus aureus. J.M. has normal renal function and no known drug allergies. Which is the best antibiotic regimen for this patient? A. Vancomycin 1000 mg intravenously every 12 hours plus rifampin 300 mg orally twice daily for 2 weeks. B. Cefazolin 2 g intravenously every 8 hours plus rifampin 300 mg orally twice daily for 6 weeks followed by long-term oral antibiotics. C. Nafcillin 1 g intravenously every 4 hours for 6 weeks. D. Daptomycin 6 mg/kg intravenously daily for 6 weeks followed by long-term oral antibiotics.

Answer 235

ID 1 B

Question 236

R.L. is a 68-year-old man who presents to the emergency department with coughing and shortness of breath. His symptoms, which began 4 days ago, have worsened during the past 24 hours. He is coughing up yellow-green sputum, and he has chills, with a temperature of 102.4°F (39°C). His medical history includes coronary artery disease with a myocardial infarction 5 years ago, congestive heart failure, hypertension, and osteoarthritis. He rarely drinks alcohol and has not smoked since his myocardial infarction. He lives at home with his wife. His medications on admission include lisinopril 10 mg/day, hydrochlorothiazide 25 mg/day, and acetaminophen 650 mg four times/day. On physical examination, he is alert and oriented, with the following vital signs: temperature 101.8°F (38°C), heart rate 100 beats/minute, respiratory rate 32 breaths/minute, and blood pressure 142/94 mm Hg. His laboratory results are normal except for blood urea nitrogen (BUN) 32 mg/dL (serum creatinine [SCr] 1.23 mg/dL). A chest radiograph reveals infiltrates in the right lower lobe. A sputum specimen is not available. If R.L. were hospitalized, which would be the best empiric therapy for him? A. Ampicillin/sulbactam 3 g intravenously every 6 hours. B. Piperacillin/tazobactam 4.5 g intravenously every 6 hours plus gentamicin 180 mg intravenously every 12 hours. C. Ceftriaxone 2 g intravenously every 24 hours plus azithromycin 500 mg intravenously every 24 hours. D. Doxycycline 100 mg intravenously every 12 hours.

Answer 236

ID 1 C

Question 236

B.K. is a 58-year-old woman (height 66 inches, weight 82 kg) who is scheduled to undergo a total knee replacement tomorrow. She has no significant medical history and no drug allergies. Which is the best surgical prophylaxis regimen for this patient? A. Cefazolin 2 g within 1 hour of the incision and no doses postoperatively. B. Cefazolin 2 g within 4 hours of the incision and three doses every 8 hours postoperatively. C. Cefazolin 1 g within 1 hour of the incision and three doses every 8 hours postoperatively. D. Cefazolin 1 g within 4 hours of the incision and no doses postoperatively.

Answer 236

ID 1 A

Question 237

B.P. is a 66-year-old woman who underwent a two-vessel coronary artery bypass graft 8 days ago and has been on a ventilator in the surgical intensive care unit since then. Her temperature is now rising and her chest radiograph reveals a new infiltrate in the right lower lobe. Her medical history includes coronary artery disease with a myocardial infarction 2 years ago, COPD, and hypertension. All antipseudomonal antibiotics in the institution are active against at least 90% of strains. B.P. has no known drug allergies. Which is the best empiric therapy for B.P.? A. Ceftriaxone 2 g intravenously every 24 hours plus gentamicin 7 mg/kg intravenously every 24 hours plus linezolid 600 mg intravenously every 12 hours. B. Piperacillin/tazobactam 4.5 g intravenously every 6 hours. C. Levofloxacin 750 mg intravenously every 24 hours plus linezolid 600 mg intravenously every 12 hours. D. Cefepime 2 g intravenously every 8 hours plus tobramycin 7 mg/kg intravenously every 24 hours plus vancomycin 15 mg/kg intravenously every 12 hours.

Answer 237

ID 1 D

Question 237

S.C. is a 46-year-old woman who presents to the clinic with purulent nasal discharge, nasal and facial congestion, headaches, fever, and dental pain. Her symptoms began about 10 days ago, improved after about 4 days, and then worsened again a few days later. Which is the best empiric therapy for S.C.? A. Cefpodoxime proxetil 200 mg orally twice daily. B. Clindamycin 300 mg orally four times daily. C. Amoxicillin/clavulanate 875 mg/125 mg orally twice daily. D. No antibiotic therapy needed.

Answer 237

ID 1 C

Question 238

G.N. returns to the clinic in 6 months with no urinary symptoms, but her chief concern is now an ulcer on her right foot. She recently returned from a vacation in Florida and thinks she might have stepped on something while walking barefoot on the beach. Her foot is not sore but is red and swollen around the deep ulcer. Her medications are the same as in Patient Case 4. Vital signs are stable, and there is nothing significant on physical examination except for the right foot ulcer. Laboratory values are within normal limits (SCr 0.86 mg/dL). Which is the best empiric therapy for G.N.? A. Nafcillin 2 g intravenously every 6 hours for 6–12 weeks. B. Tobramycin 120 mg intravenously every 12 hours plus levofloxacin 750 mg intravenously every 24 hours for 1–2 weeks. C. Piperacillin/tazobactam 3.375 g intravenously every 6 hours for 1–2 weeks. D. Below-the-knee amputation followed by ceftriaxone 1 g intravenously every 24 hours for 1 week.

Answer 238

ID 1 C

Question 238

G.N. is a 62-year-old woman who presents to the emergency department with a 3-day history of urinary frequency and dysuria. During the past 24 hours, she has had nausea, vomiting, and flank pain. G.N. has a history of type 2 diabetes, which is poorly controlled, with some diabetes-related complications. G.N. also has hypertension and a history of several episodes of deep venous thrombosis. Her medications include glyburide 5 mg orally daily, enalapril 10 mg orally twice daily, warfarin 3 mg orally daily, and metoclopramide 10 mg orally four times daily. On physical examination, she is alert and oriented, with the following vital signs: temperature 102.8°F (39°C), heart rate 120 beats/minute, respiratory rate 16 breaths/minute, supine blood pressure 140/75 mm Hg, and standing blood pressure 110/60 mm Hg. Her laboratory values are within normal limits except for elevated international normalized ratio 2.7, BUN 26 mg/dL, SCr 1.88 mg/dL, and WBC 12,000 cells/mm3 (78 polymorphonuclear leukocytes, 7 band neutrophils, 10 lymphocytes, and 5 monocytes). Her urinalysis reveals turbidity, 2+ glucose, pH 7.0, protein 100 mg/dL, 50–100 WBCs, positive nitrites, 3–5 red blood cells, and many bacteria and positive for casts. Which is the best empiric therapy for G.N.? A. Trimethoprim/sulfamethoxazole double strength orally twice daily for 7 days. Monitor INR carefully. B. Ciprofloxacin 400 mg intravenously twice daily and then 500 mg orally twice daily for a total of 7 days. Monitor INR carefully. C. Gentamicin 140 mg intravenously every 24 hours for 3 days. D. Tigecycline 100 mg once, then 50 mg intravenously every 12 hours and then doxycycline 100 mg orally twice daily for a total of 10 days.

Answer 238

ID 1 B

Question 239

W.A. is a 55-year-old man who is admitted with weight loss, malaise, and severe back pain and spasms that have progressed during the past 2 months. He has also experienced loss of sensation in his lower extremities. Four months before this admission, he had surgery for a fractured tibia, followed by an infection treated with unknown antibiotics. W.A. has hypertension and a history of diverticulitis. On physical examination, he is alert and oriented, with the following vital signs: temperature 99.4°F (37.4°C), heart rate 88 beats/minute, respiratory rate 14 breaths/minute, and blood pressure 130/85 mm Hg. His laboratory values are within normal limits, except for WBC 14,300 cells/mm3 , erythrocyte sedimentation rate 89 mm/hour, and C-reactive protein 12 mg/dL. Magnetic resonance imaging reveals bony destruction of lumbar vertebrae 1 and 2, which is confirmed by a bone scan. A computed tomography–guided bone biopsy reveals gram-positive cocci in clusters. Which is the best therapy for W.A.? A. Vancomycin 15 mg/kg intravenously every 12 hours for 6 weeks. B. Nafcillin 2 g intravenously every 6 hours for 2 weeks. C. Levofloxacin 750 mg orally every 24 hours for 6 weeks. D. Ampicillin/sulbactam 3 g intravenously every 6 hours for 2 weeks.

Answer 239

ID 1 A

Question 240

D.M. is a 21-year-old university student who presents to the emergency department with the worst headache of his life. During the past few days, he has felt slightly ill but has been able to go to class regularly and eat and drink adequately. This morning, he awoke with a terrible headache and pain whenever he moved his neck. He has no significant medical history and takes no medications. He cannot remember the last time he received a vaccination. On physical examination, he is in extreme pain (10/10) with the following vital signs: temperature 102.4°F (39.1°C), heart rate 110 beats/minute, respiratory rate 18 breaths/minute, and blood pressure 130/75 mm Hg. His laboratory values are within normal limits, except for WBC 22,500 cells/mm3 (82 polymorphonuclear leukocytes, 11 band neutrophils, 5 lymphocytes, and 2 monocytes). A computed tomography scan of the head is normal, so a lumbar puncture is performed with the following results: glucose 44 mg/dL (peripheral, 110), protein 220 mg/dL, and WBC 800 cells/mm3 (85% neutrophils, 15% lymphocytes). Which is the best empiric therapy for D.M.? A. Penicillin G 4 million units intravenously every 4 hours. B. Ceftriaxone 2 g intravenously every 12 hours. C. Ceftriaxone 2 g intravenously every 12 hours plus dexamethasone 10 mg intravenously every 6 hours. D. Ceftriaxone 2 g intravenously every 12 hours plus vancomycin 1000 mg intravenously every 8 hours plus dexamethasone 10 mg intravenously every 6 hours.

Answer 240

ID 1 D

Question 241

D.M.’s CSF cultures grew N. meningitidis. Which is the best recommendation for meningitis prophylaxis? A. The health care providers in close contact with D.M. should receive rifampin 600 mg orally every 12 hours for four doses. B. Everyone in D.M.’s dormitory and in all of his classes should receive rifampin 600 mg orally every 24 hours for 4 days. C. Everyone in the emergency department at the time of D.M.’s presentation should receive the meningococcal conjugate vaccine. D. Everyone in the emergency department at the time of D.M.’s presentation should receive rifampin 600 mg orally every 12 hours for four doses.

Answer 241

ID 1 A

Question 242

. T.S. is a 48-year-old man who presents to the emergency department with fever, chills, nausea and vomiting, anorexia, lymphangitis in his right hand, and lower back pain. He has no significant medical history except for kidney stones 4 years ago. He has no known drug allergies. He is homeless and was a person with substance use disorder (intravenous heroin) for the past year but quit 2 weeks ago. On physical examination, he is alert and oriented, with the following vital signs: temperature 100.8°F (38°C), heart rate 114 beats/minute, respiratory rate 12 breaths/minute, and blood pressure 127/78 mm Hg. He has a faintsystolic ejection murmur, and his right hand is erythematous and swollen. His laboratory values are all within normal limits. He had an HIV test 1 year ago, which was negative. One blood culture was obtained in the emergency department that later grew MSSA. Two more cultures were obtained 24 hours after the first culture and are now both growing gram-positive cocci in clusters. A transesophageal echocardiogram reveals vegetation on the mitral valve. Which is the best therapeutic regimen for T.S.? A. Nafcillin therapy for 7–10 days. B. Nafcillin plus rifampin plus gentamicin therapy for 6 weeks or longer. C. Nafcillin plus gentamicin therapy for 2 weeks of both antibiotics. D. Nafcillin therapy for 6 weeks

Answer 242

ID 1 D

Question 242

Six months after treatment of his endocarditis, T.S. is visiting his dentist for a tooth extraction. Which antibiotic is best for prophylaxis? A. Tooth extractions do not warrant endocarditis prophylaxis. B. Administer amoxicillin 2 g 1 hour before the extraction. C. Administer amoxicillin 3 g 1 hour before the extraction and 1.5 g every 6 hours for four doses after the extraction. D. T.S. is not at increased risk of endocarditis and does not need prophylactic antibiotics

Answer 242

ID 1 B

Question 243

R.K. is a 72-year-old man who presents to the emergency department with a 2-day history of redness and swelling of his upper right extremity. He scraped his arm while clearing some brush in his yard. Although the scratch was initially healing, the area around the injury has become red and warm to the touch over the past few days, and the redness appears to be spreading. His medical history includes gastroesophageal reflux disease, hypertension, hyperlipidemia, and osteoarthritis. R.K. is taking pantoprazole 40 mg orally daily, lisinopril 20 mg orally daily, atorvastatin 40 mg orally daily, and acetaminophen 500 mg orally as needed. R.K. has no known drug allergies. R.K. is hospitalized and sent home after a few days with a prescription for oral clindamycin for his cellulitis. Two weeks after completing therapy for his cellulitis, R.K. has watery diarrhea. R.K. goes to the emergency department, and his C. difficile toxin is positive. His WBC is 24,500 cells/mm3 , albumin is 2.8 g/dL, and SCr is 1.74 mg/dL (normally around 0.90 mg/dL). Which is the best therapeutic regimen for R.K.? A. Metronidazole 500 mg orally three times daily for 7 days. B. Vancomycin 125 mg orally four times daily for 10 days. C. Fidaxomicin 200 mg orally twice daily for 14 days. D. Rifaximin 400 mg orally twice daily for 7 days.

Answer 243

ID 1 B

Question 243

You are a pharmacist who works closely with the surgery department to optimize therapy for patients undergoing surgical procedures at your institution. The surgeons provide you with principles of surgical prophylaxis that they believe are appropriate. Which is the best practice for optimizing surgical prophylaxis? A. Antibiotics should be redosed for extended surgical procedures; redose if the surgery lasts longer than 4 hours or involves considerable blood loss. B. All patients should be given antibiotics for 24 hours after the procedure; this will optimize prophylaxis. C. Preoperative antibiotics can be given up to 4 hours before the incision; this will make giving the antibiotics logistically easier. D. Vancomycin is the antibiotic of choice for surgical wound prophylaxis because of its long half-life and activity against MRSA.

Answer 243

ID 1 A