Free FNP practice questions

1. A. Transition her off the ACE inhibitor now to an agent with an established safety record in pregnancyCorrect

   Correct. ACE inhibitors and ARBs are fetotoxic — associated with renal dysgenesis, oligohydramnios, skull hypoplasia and fetal death, particularly with second- and third-trimester exposure. A patient actively trying to conceive may present already pregnant, so the change is made before conception rather than after a positive test. Labetalol, methyldopa and nifedipine are the conventional alternatives.

2. B. Continue lisinopril and stop it as soon as a pregnancy test is positive

   Incorrect. This is the most tempting distractor because it sounds responsive, but a pregnancy is typically confirmed several weeks after conception — so this plan guarantees a window of first-trimester exposure. Switch pre-conception.

3. C. Substitute an ARB, which lacks the fetal risks of ACE inhibitors

   Incorrect. ARBs carry the same fetotoxicity as ACE inhibitors through the same mechanism — blockade of the fetal renin-angiotensin system. Substituting one for the other changes nothing about the risk.

4. D. Discontinue all antihypertensive therapy and manage with lifestyle measures until she conceives

   Incorrect. Stage 2 hypertension left untreated raises the risk of preeclampsia, placental abruption, fetal growth restriction and maternal end-organ damage. The goal is a safer agent, not no agent.

Educational objective: ACE inhibitors and ARBs are both contraindicated in pregnancy; in a patient planning conception, switch to a pregnancy-compatible agent before she conceives rather than after a positive test.

1. A. Continue metformin at a reduced dose and monitor renal function more frequentlyCorrect

   Correct. Metformin is contraindicated below an eGFR of 30 and should not be *initiated* between 30 and 45, but it may be continued at a reduced dose — commonly capped at 1,000 mg daily in this range — with closer renal monitoring in a patient already established on it. This patient is taking 2,000 mg daily, so the dose comes down while you assess the cause of the decline.

2. B. Stop metformin immediately, as any eGFR below 45 is an absolute contraindication

   Incorrect. An eGFR between 30 and 45 is a threshold for not *initiating* metformin and for reviewing the dose in someone already taking it — not an absolute contraindication. The absolute cut-off is an eGFR below 30.

3. C. Continue the current dose unchanged, since the A1c is near target

   Incorrect. Glycaemic control does not override a safety threshold. Reduced clearance raises metformin levels and lactic acidosis risk, so the dose warrants review regardless of how good the A1c looks.

4. D. Increase metformin to 1,000 mg three times daily to protect against further A1c rise

   Incorrect, and unsafe. The dose should be going down, not up, and this also exceeds the usual maximum daily dose.

Educational objective: Metformin is contraindicated below an eGFR of 30 and should not be initiated between 30 and 45, but may be continued at a reduced dose with closer monitoring in a patient already established on it.

1. A. Airflow obstruction consistent with COPD, confirmed by the post-bronchodilator FEV1/FVC below 0.70Correct

   Correct. A post-bronchodilator FEV1/FVC below 0.70 establishes persistent airflow limitation, which together with the exposure history and symptoms confirms COPD. The FEV1 of 68% predicted then grades severity, and the fact that the ratio is measured *after* a bronchodilator is what makes the obstruction persistent rather than reversible.

2. B. A restrictive ventilatory defect, indicated by the reduced FEV1

   Incorrect. Restriction reduces FVC and leaves the FEV1/FVC ratio normal or elevated; a reduced ratio is the signature of obstruction. A low FEV1 alone cannot distinguish the two — the ratio does.

3. C. Asthma, since the FEV1 is reduced and symptoms are respiratory

   Incorrect. Asthma characteristically shows significant post-bronchodilator reversibility. Here obstruction persists after bronchodilator in a patient with heavy smoking exposure and progressive rather than episodic symptoms.

4. D. Normal spirometry, since the FEV1 remains above 65% predicted

   Incorrect. An FEV1 percentage in isolation says nothing about whether a defect exists; the ratio of 0.62 is unambiguously abnormal.

Educational objective: Read the FEV1/FVC ratio first: a post-bronchodilator ratio below 0.70 establishes persistent obstruction, and only then does FEV1 percent predicted grade its severity.

1. A. New urinary retention with saddle anaesthesiaCorrect

   Correct. Urinary retention with saddle anaesthesia suggests cauda equina syndrome — a surgical emergency in which delay risks permanent bladder, bowel and sexual dysfunction. This warrants urgent imaging and immediate referral, not a conservative trial.

2. B. Pain that worsens with prolonged sitting and eases when walking

   Incorrect. Positional variation is typical of mechanical back pain and is reassuring rather than alarming. It supports conservative management.

3. C. Paraspinal muscle tenderness with a normal neurological examination

   Incorrect. Muscular tenderness with an intact neurological examination is the usual finding in mechanical low back pain and does not itself justify imaging.

4. D. Symptom onset after a weekend of moving furniture

   Incorrect. A clear mechanical precipitant in a patient without neurological deficit points toward musculoskeletal strain. It is context, not a red flag.

Educational objective: Screen every low back pain presentation for red flags; new urinary retention with saddle anaesthesia suggests cauda equina syndrome and requires emergent evaluation.

1. A. Report the suspicion to child protective services, as reasonable suspicion — not proof — is the reporting thresholdCorrect

   Correct. Nurse practitioners are mandated reporters, and the standard for reporting is reasonable suspicion. Injuries in varying stages of healing at sites unusual for accidental trauma, with a history inconsistent with the findings and the child’s development, meet that threshold. Investigating is the agency’s role, not the clinician’s.

2. B. Gather more evidence over the next several visits before deciding whether to report

   Incorrect. Waiting for certainty inverts the standard and leaves a child at risk in the interim. Reasonable suspicion is enough, and the obligation is triggered now.

3. C. Confront the parent directly and report only if the explanation remains unsatisfactory

   Incorrect. Making the report conditional on a parent’s response is not the standard, and a confrontation can escalate risk to the child before any protective mechanism is in place.

4. D. Refer to a specialist and let the specialist make the report

   Incorrect. The mandated-reporter duty is personal and non-delegable. It rests with the clinician who forms the suspicion.

Educational objective: Mandated reporting is triggered by reasonable suspicion, not proof, and the duty is personal — it cannot be deferred, conditioned on a parent’s explanation, or delegated.

1. A. Obtain a creatine kinase level and assess for alternative causes and interacting medicationsCorrect

   Correct. Symmetrical proximal myalgia on a statin warrants a creatine kinase level to separate benign myalgia from myopathy or rhabdomyolysis, alongside a review for interacting drugs and other contributors such as hypothyroidism or vitamin D deficiency. The result then determines whether the statin can continue, be switched, or must be stopped.

2. B. Stop the statin permanently and document a statin allergy

   Incorrect on both counts. Most statin-associated muscle symptoms are tolerable or manageable by switching agent or dose, and this patient has a strong secondary-prevention indication. Muscle symptoms are also not an allergy, and labelling them as one wrongly forecloses an entire drug class.

3. C. Reassure the patient that myalgia is expected and make no changes

   Incorrect. Muscle symptoms are common, but dismissing them without a creatine kinase risks missing myopathy — and unaddressed myalgia is a leading reason patients silently stop taking a statin they need.

4. D. Add coenzyme Q10 and reassess in three months

   Incorrect. Evidence for coenzyme Q10 in statin-associated muscle symptoms is weak, and a three-month deferral leaves a potential myopathy unevaluated.

Educational objective: Evaluate statin-associated muscle symptoms with a creatine kinase and a search for contributors before abandoning a drug with a strong indication — and never record muscle symptoms as an allergy.