The set follows the task weights of the 2024 blueprint: 19 Assess, 16 Diagnose, 16 Plan and 9 Evaluate questions, against 32%, 26.5%, 26.5% and 15% of the scored exam. Every patient in it is an adult, from the early twenties to eighty. Children's and pregnancy items are practiced on the CPNP-PC and WHNP-BC sets.
The task and system pages use different questions, so once you finish, the Assess page and the system pages still hold new material.
60 questions across the four tasks
0 / 60 answered60 questions
Tap an option: why each one is right or wrong appears under it.
Assess · 32%
A 65-year-old man is unconscious after a suspected overdose. Which technique best examines his pupils?
A bright light with direct and consensual responses checked in each eye separates afferent (optic nerve) from efferent (third nerve) defects; pinpoint pupils suggest opioids, and fixed dilated pupils suggest herniation or anticholinergic toxicity.
Room light makes small differences and sluggish reactions hard to see.
Resting size alone misses an afferent or efferent defect and gives no information about brainstem function.
Watching only the illuminated eye misses the consensual response, which is needed to separate an optic nerve lesion from a third nerve lesion.
A 52-year-old man who drinks heavily has a progressively unsteady, wide-based gait. He cannot perform tandem walking and heel-to-shin testing is abnormal, but finger-to-nose testing is normal and speech is clear. He is unsteady even with his eyes open. Which structure is most likely affected?
Basal ganglia disease causes parkinsonism or chorea, not wide-based ataxia.
Truncal and gait ataxia with normal finger-to-nose testing in a heavy drinker points to alcohol-related degeneration of the cerebellar vermis.
Cerebellar hemisphere lesions cause limb ataxia on the same side, so finger-to-nose would be abnormal.
Dorsal column loss causes sensory ataxia that worsens with eyes closed; he is unsteady even with his eyes open.
A 62-year-old had a syncopal episode. Which historical component is most critical to obtain?
A missed meal is a minor contributor and does not identify a cardiac cause.
Warm surroundings can provoke a vasovagal faint, but this single detail is less informative than the overall circumstances.
The circumstances (exertion, standing, urination), the prodrome (warmth, nausea, or none), and the position at onset separate reflex syncope from orthostatic and cardiac causes.
Tiredness that day is nonspecific and does not separate benign from dangerous causes.
A 45-year-old is assessed for possible anemia. Which symptom inquiry is most critical?
Dry skin is nonspecific and is not a symptom that shows how anemia is affecting her.
A seasonal cough relates to allergies or infection, not anemia.
Joint aches suggest a rheumatologic or viral process, not anemia itself.
Fatigue and breathlessness with exertion reflect reduced oxygen delivery and are the main symptoms that show the effect of anemia, along with any bleeding history.
You suspect mitral stenosis in a patient with an early diastolic sound and a low-pitched apical murmur. Which patient position and stethoscope technique best accentuates this murmur?
Leaning forward with the diaphragm at the base brings out aortic regurgitation, a high-pitched diastolic murmur at the base.
Turning the patient to the left brings the apex close to the chest wall, and the bell picks up the low-pitched diastolic rumble and opening snap of mitral stenosis.
The right sternal border is the aortic area, and the diaphragm is for high-pitched sounds.
Squat-to-stand is used to bring out hypertrophic cardiomyopathy and mitral valve prolapse; the diaphragm misses the low-pitched rumble.
A 70-year-old has abdominal distension, colicky pain, and no passage of flatus for 2 days. Which auscultation finding best supports mechanical small-bowel obstruction?
In early mechanical obstruction, bowel proximal to the blockage contracts against it, producing high-pitched, tinkling rushes.
Normal bowel sounds do not fit colicky pain, distension, and no flatus, which point to an obstruction.
An epigastric bruit suggests renal or mesenteric artery stenosis; it is a vascular finding, not a sign of luminal obstruction.
Silent abdomen develops late in obstruction or with ileus and peritonitis; treating absent sounds as the typical early sign confuses ileus with mechanical obstruction.
A 60-year-old man reports intermittent chest discomfort. Which feature of the pain most strongly suggests myocardial ischemia rather than a noncardiac cause?
Substernal pressure that comes with exertion and eases with rest is the classic pattern of angina and the most predictive of myocardial ischemia.
Burning pain after meals that worsens lying flat suggests reflux.
Fleeting stabbing pain lasting seconds is unlikely to be ischemic.
Pain reproduced by pressing on the chest wall suggests a musculoskeletal cause.
While examining a 68-year-old man with suspected heart failure at 45° elevation, the NP sees a pulsation in the right side of the neck. Which feature indicates that it is the internal jugular vein rather than the carotid artery?
The jugular venous pulse is usually not palpable and has two soft waves; a single brisk palpable upstroke is the carotid artery.
The jugular venous level falls as the patient sits up; a pulse that keeps its height is arterial.
The jugular venous level normally falls during inspiration; a rise (Kussmaul sign) is a pathologic finding, not the feature that identifies a vein.
Light pressure at the base of the neck obliterates the venous pulsation, while the carotid pulse cannot be stopped this way.
A 35-year-old man has 12 hours of abdominal pain. The nurse practitioner is examining him to decide whether he needs emergency referral. Which finding most reliably indicates peritoneal irritation?
Tympany in the left upper quadrant is the normal gastric air bubble.
Hyperactive bowel sounds suggest gastroenteritis or early obstruction, not peritonitis, where sounds are reduced.
Mild deep tenderness is common in nonsurgical abdominal pain and does not show peritonitis.
Pain when the heel is jarred (a positive heel-drop or jar test) shows that moving the peritoneum hurts, a reliable sign of peritoneal irritation such as appendicitis.
A 52-year-old woman has 20 hours of constant right upper quadrant pain with nausea and a temperature of 37.9°C. She has right upper quadrant tenderness. Ultrasound shows several gallstones without gallbladder wall thickening or pericholecystic fluid, and the sonographic Murphy sign is equivocal. Liver enzymes and bilirubin are normal. Which study best confirms or excludes acute cholecystitis?
When ultrasound is equivocal, a HIDA scan that fails to fill the gallbladder confirms cystic duct obstruction and acute cholecystitis; normal filling excludes it.
MRCP images the bile ducts for stones; it is less accurate than HIDA for cystic duct obstruction.
CT is less sensitive than ultrasound or HIDA for acute cholecystitis and adds radiation and contrast.
ERCP is a therapeutic procedure for bile duct stones or cholangitis, not a test for cholecystitis, and it carries a pancreatitis risk.
A 29-year-old woman with bloating, diarrhea, and iron deficiency has a negative tissue transglutaminase IgA while eating gluten. Her total serum IgA is undetectable. What is the most appropriate next test for celiac disease?
In IgA deficiency, IgG-based tests (tTG-IgG or DGP-IgG) are used while the patient still eats gluten.
A negative IgA test is meaningless with undetectable IgA, and IgA deficiency is itself more common in celiac disease.
With undetectable IgA, any IgA-based test will be falsely negative; repeating it in 3 months gives the same result.
Endomysial antibodies of the IgA class are also falsely negative when total IgA is absent.
A 60-year-old man with alcohol-related cirrhosis and ascites has a temperature of 38.1°C, mild diffuse abdominal tenderness, and new confusion. Diagnostic paracentesis is performed. Which result establishes the diagnosis of spontaneous bacterial peritonitis?
A SAAG of 1.1 g/dL or higher shows portal hypertension as the cause of ascites; it does not diagnose infection.
Low ascitic protein raises the risk of SBP, which is why prophylaxis is considered, but it does not diagnose it.
An ascitic neutrophil (PMN) count of 250 cells/mm³ or more diagnoses spontaneous bacterial peritonitis, and antibiotics start at once without waiting for culture.
Peripheral leukocytosis is nonspecific; SBP is diagnosed from the ascitic fluid.
A 70-year-old man who smokes and drinks alcohol daily has 4 months of difficulty swallowing that began with meat and bread and now includes soft foods. He has lost 8 kg. He has no heartburn history and no regurgitation of undigested food. What is the most likely diagnosis?
Dysphagia that progresses from solids to soft foods over months, with weight loss, in an older smoker and drinker suggests esophageal cancer (squamous cell type with this exposure); urgent endoscopy is needed.
A peptic stricture follows years of reflux and causes slowly progressive solid-food dysphagia, usually without major weight loss.
Achalasia causes dysphagia to both solids and liquids from the start, with regurgitation of undigested food.
Eosinophilic esophagitis causes food impaction in younger people with atopy, without weight loss.
A 45-year-old man has fever, severe headache, and neck stiffness. Before lumbar puncture, which finding indicates that head CT should be performed first?
A new focal deficit (or papilledema, altered consciousness, a new seizure, or immunocompromise) suggests a mass effect, so CT comes before LP; empiric antibiotics are given first rather than delayed.
High fever is expected in meningitis and is not an indication for imaging before LP.
Photophobia is common in meningitis and does not indicate increased intracranial pressure from a mass.
Kernig sign suggests meningeal irritation; it does not indicate mass effect.
A 57-year-old man has 3 months of gait unsteadiness and clumsy hands. Examination shows 3+ patellar and biceps reflexes with a few beats of ankle clonus. Which additional set of findings is consistent with the same type of lesion?
Dysmetria and intention tremor are cerebellar signs, not upper motor neuron signs.
Flaccid weakness with a downgoing toe is a lower motor neuron pattern, the opposite of brisk reflexes and clonus.
Hyperreflexia, clonus, spasticity, and a Babinski sign together form the upper motor neuron pattern, here likely cervical myelopathy.
Atrophy and fasciculations are lower motor neuron signs.
A 58-year-old man has fever and a productive cough. Over the right lower posterior chest, when he says 'ee,' the nurse practitioner hears 'ay.' Which finding is this?
Hearing 'ee' as 'ay' over a lung area is egophony, a sign of consolidation or compressed lung above an effusion.
Whispered pectoriloquy is when whispered words are heard clearly; it is tested by whispering, not by saying 'ee'.
Bronchophony is spoken words sounding louder and clearer, without the change of 'ee' to 'ay'.
Tactile fremitus is felt with the hand, not heard with the stethoscope.
A 30-year-old develops sudden left-sided pleuritic chest pain and dyspnea after a long flight. Which examination finding would most support a pneumothorax over pneumonia?
Bibasilar fine crackles suggest heart failure or interstitial disease.
Dullness with bronchial breath sounds is consolidation, as in pneumonia.
A collapsed lung with air in the pleural space gives a hyperresonant note with absent breath sounds on that side.
Increased fremitus and egophony are signs of consolidation; a pneumothorax reduces fremitus.
A 55-year-old with heavy alcohol use presents with jaundice. Which additional finding on assessment most suggests advanced (decompensated) liver disease?
Mild RUQ tenderness suggests hepatitis or a biliary process, not decompensation.
Ankle edema is common and nonspecific, with cardiac, renal, venous, and drug causes.
Palmar erythema occurs in compensated chronic liver disease and pregnancy and does not indicate decompensation.
Ascites with dilated abdominal wall veins (caput medusae) shows portal hypertension and marks decompensated cirrhosis.
A 42-year-old woman has 3 months of bilateral hand pain with morning stiffness lasting over an hour. There is soft swelling and tenderness of the MCP and PIP joints of both hands. Which laboratory result would most strongly support the suspected diagnosis?
Symmetric MCP and PIP synovitis with prolonged morning stiffness for 3 months suggests rheumatoid arthritis, and anti-CCP antibodies are highly specific for it.
HLA-B27 relates to spondyloarthritis, which affects the spine and large joints asymmetrically.
Uric acid relates to gout, which is usually episodic and monoarticular, not symmetric small-joint synovitis.
Anti-dsDNA supports lupus, which causes nonerosive arthritis with rash, cytopenias, or kidney disease.
A 38-year-old man has had attacks of excruciating right orbital pain with ipsilateral tearing, conjunctival injection, and nasal congestion once or twice daily for 2 weeks. Each attack lasts about 45 minutes, and he paces during them. Which is the most effective abortive treatment?
Strictly one-sided orbital attacks with autonomic signs and restlessness are cluster headache, and high-flow oxygen (100% at 12 to 15 L/min by nonrebreather) aborts most attacks within 15 minutes.
Butalbital combinations are not effective for cluster headache and cause overuse headache.
NSAIDs are not effective for cluster attacks.
Oral sumatriptan works too slowly for attacks under an hour; subcutaneous sumatriptan or nasal zolmitriptan are the triptan forms used.
A 23-year-old man has 10 days of fever, sore throat, diffuse maculopapular rash on the trunk, painful oral ulcers, and generalized lymphadenopathy. He reports a new male sexual partner 4 weeks ago and inconsistent condom use. The heterophile antibody test is negative. What is the most likely diagnosis?
Secondary syphilis causes a rash often involving the palms and soles with painless mucous patches, not painful ulcers.
Fever, pharyngitis, rash, painful oral ulcers, and lymphadenopathy 2 to 4 weeks after a sexual exposure, with a negative heterophile test, is acute HIV; an HIV antigen/antibody test plus viral load is needed.
CMV causes a mono-like illness with a negative heterophile test, but painful oral ulcers and a rash after sexual exposure point to HIV.
Mononucleosis usually gives a positive heterophile test, and painful mucocutaneous ulcers are not typical.
A 66-year-old man has 2 years of gradually worsening, painless inability to straighten his right ring and small fingers. Examination shows firm palmar nodules with thick cords extending into those fingers and fixed flexion at the MCP joints, and he cannot lay his palm flat on a table. Sensation and intrinsic hand strength are normal. What is the most likely diagnosis?
Painless palmar nodules and cords with fixed MCP flexion of the ring and small fingers, and a positive tabletop test, are Dupuytren contracture.
Trigger finger catches and locks during flexion but can usually be straightened, without cords or a fixed contracture.
Ulnar claw hand comes with intrinsic weakness and sensory loss, which are normal here.
A tendon sheath ganglion is a small, firm nodule without cords or fixed contractures.
A 62-year-old man reports a sudden shower of floaters and flashing lights in the right eye, followed by a gray curtain rising across the inferior visual field over hours. The eye is painless and not red. On dilated exam an elevated, billowing sheet of retina and a superior horseshoe-shaped tear are seen. What is the most likely diagnosis?
Central retinal artery occlusion causes sudden painless loss of vision with a pale retina and a cherry-red spot, without flashes or a curtain.
Posterior vitreous detachment causes floaters and flashes, but not a curtain over the vision or a detached retina on exam.
Flashes and floaters followed by a spreading curtain, with a billowing detached retina and a horseshoe tear, are a rhegmatogenous retinal detachment, which needs same-day ophthalmology.
Vitreous hemorrhage blurs vision diffusely and hides the retina; it does not show an elevated sheet of retina.
A 63-year-old man with a 40-pack-year smoking history reports painless gross hematuria and a 10-lb weight loss. CT of the abdomen with contrast shows a 4.5-cm solid, enhancing mass in the right kidney. The bladder appears normal. What is the most likely diagnosis?
A complex hemorrhagic cyst does not enhance like a solid tumor.
A solid enhancing renal mass with hematuria and weight loss in a smoker is renal cell carcinoma until proven otherwise.
Urothelial cancer of the bladder causes painless hematuria, but the CT shows a solid renal mass and a normal bladder.
Angiomyolipoma contains fat on CT and is often found incidentally, not with weight loss.
A 34-year-old woman presents with 2 months of dry cough, mild exertional dyspnea, and fatigue. She has never smoked. Examination reveals tender, raised red nodules on both shins and no wheeze. Chest X-ray shows bilateral hilar lymphadenopathy, and serum calcium is mildly elevated. What is the most likely diagnosis?
Pneumonia causes fever and focal consolidation over days, not 2 months of symptoms with bilateral hilar nodes.
Hodgkin lymphoma can cause hilar nodes, but erythema nodosum and hypercalcemia in a young nonsmoker point to sarcoidosis.
Bilateral hilar lymphadenopathy with erythema nodosum, dry cough, and mild hypercalcemia in a young adult is typical of sarcoidosis (Löfgren syndrome when arthritis and fever are present).
TB usually causes upper lobe infiltrates or cavities with night sweats and weight loss, and it is less likely to produce symmetric hilar nodes with erythema nodosum.
A 74-year-old woman has 1 day of a hot, swollen right knee. She is afebrile. Arthrocentesis shows cloudy fluid with 18,000 WBC/mm³, a negative Gram stain, and rhomboid-shaped crystals that are weakly positively birefringent under polarized light. Which is the most likely diagnosis?
An OA flare produces noninflammatory fluid, with WBC usually under 2,000/mm³ and no crystals.
Gout crystals are needle-shaped and strongly negatively birefringent.
Septic arthritis usually causes higher fluid WBC counts and a positive Gram stain or culture; crystals with these properties point elsewhere, though infection and crystals can coexist.
Rhomboid, weakly positively birefringent crystals are calcium pyrophosphate, which defines pseudogout (acute CPP crystal arthritis).
A 68-year-old presents with painless jaundice, a 15-pound weight loss, acholic stools, and dark urine. Exam reveals a palpable, nontender gallbladder (Courvoisier sign), and imaging shows dilation of both the common bile duct and the pancreatic duct (double-duct sign). Which is the most likely diagnosis?
Cholangiocarcinoma can cause painless jaundice, but the double-duct sign localizes the obstruction to the pancreatic head.
Painless jaundice, weight loss, a palpable nontender gallbladder, and dilation of both the bile duct and the pancreatic duct point to pancreatic head cancer.
Primary sclerosing cholangitis causes multifocal strictures in younger people with IBD, not a double-duct sign with weight loss.
Choledocholithiasis usually causes painful jaundice and a shrunken, scarred gallbladder rather than a palpable one.
A 30-year-old woman has 8 months of crampy abdominal pain relieved by defecation, bloating, and loose stools 3 times a day. She has no weight loss, bleeding, nocturnal symptoms, recent travel, or family history of colon cancer or IBD. CBC is normal. Which additional testing is most appropriate?
SIBO breath testing is not part of the routine evaluation of IBS.
Ova and parasite testing is not recommended unless there is travel or a specific exposure; at most a Giardia test is considered.
Colonoscopy is not needed in suspected IBS-D without alarm features in a 30-year-old.
In suspected IBS with diarrhea, the ACG recommends celiac serology and fecal calprotectin (or lactoferrin) to exclude celiac disease and IBD before making a positive diagnosis.
A 28-year-old woman has 3 weeks of bloating, foul-smelling greasy diarrhea, sulfur-tasting burps, and a 3-kg weight loss. Her symptoms began 10 days after a backpacking trip where she drank stream water. She is afebrile and has no blood in the stool. What is the most likely diagnosis?
Lactose intolerance causes bloating and diarrhea after dairy, not greasy stools that start after drinking stream water.
Greasy, foul-smelling diarrhea, bloating, sulfur-tasting burps, and weight loss starting 1 to 2 weeks after drinking untreated stream water are giardiasis; a stool antigen or PCR test confirms it.
Celiac disease does not start abruptly after a trip, and it would not follow a single water exposure.
C. difficile follows antibiotic use and causes watery diarrhea, often with fever and leukocytosis.
A 20-year-old woman started minocycline for acne 1 week ago and takes it at bedtime with a sip of water. For 2 days she has had sharp retrosternal pain when swallowing, even liquids. She is otherwise healthy, with no fever, thrush, or HIV risk factors. What is the most likely diagnosis?
HSV esophagitis occurs mainly in immunocompromised patients.
Eosinophilic esophagitis causes solid-food dysphagia and food impaction in atopic patients, not sudden pain after starting a new pill.
Minocycline (like doxycycline) taken at bedtime with little water can stick in the esophagus and cause a chemical ulcer with sharp pain on swallowing; it is prevented by taking it upright with a full glass of water.
Candida esophagitis occurs in immunocompromised patients, often with oral thrush, which she does not have.
A 40-year-old man has ankylosing spondylitis with inflammatory back pain, 1 hour of morning stiffness, and radiographic sacroiliitis. He has no peripheral arthritis, and his kidney function is normal. Which is the most appropriate initial treatment?
Methotrexate is not effective for axial spondyloarthritis.
Long-term systemic steroids are not recommended for axial disease.
NSAIDs at full dose plus exercise and physical therapy are first-line for ankylosing spondylitis; a TNF inhibitor follows if two NSAIDs fail.
Sulfasalazine helps peripheral arthritis in spondyloarthritis but not axial disease.
A 24-year-old sexually active woman has 4 days of fever and pain that migrates between her wrists and knees. Exam shows tenderness and swelling along the extensor tendons of the right wrist, and a few painless pustules on an erythematous base on her forearms. She has no urinary or eye symptoms. Which diagnosis is most likely?
Reactive arthritis follows a GI or genitourinary infection by weeks with conjunctivitis or urethritis, and it does not cause pustules with tenosynovitis.
Migratory arthralgia, tenosynovitis, and a few painless pustules in a sexually active young adult are the triad of disseminated gonococcal infection; NAAT of mucosal sites and blood cultures are needed, and ceftriaxone treats it.
Lupus can cause polyarthritis but not fever with pustules and tenosynovitis.
Septic arthritis from S. aureus usually involves one hot joint, without migratory pain, tenosynovitis, or pustules.
A 32-year-old woman with no chronic illnesses has 3 days of fever, productive cough, and right-sided pleuritic pain. Crackles are heard at the right base, and a chest radiograph shows right lower lobe consolidation. She took no antibiotics in the past 3 months. Vital signs are stable. Which is the most appropriate treatment?
Respiratory fluoroquinolones are reserved for outpatients with comorbidities or for whom other options are not suitable, because of adverse effects and resistance.
A healthy adult with stable vital signs can be treated as an outpatient; admission is not needed.
Pneumonia confirmed on radiograph needs an antibiotic, not supportive care alone.
For a healthy outpatient adult with CAP and no recent antibiotics, high-dose amoxicillin is first-line (ATS/IDSA 2019).
A 29-year-old nurse born in the Philippines, who received BCG as an infant, has a positive interferon-gamma release assay on pre-employment screening. She has no cough, fever, night sweats, or weight loss, and her HIV test is negative. Chest radiograph is normal. What is the most likely diagnosis?
Most nontuberculous mycobacteria do not cause a positive IGRA, and they cause lung disease with symptoms or radiographic changes.
IGRAs use antigens absent from BCG, so a positive result is not explained by childhood BCG vaccination.
Active TB would cause symptoms or radiographic changes; neither is present.
A positive IGRA with no symptoms and a normal chest radiograph is latent TB infection; treatment (for example rifampin for 4 months) prevents progression.
A 42-year-old man has ulcerative colitis extending to the hepatic flexure. He has 4–5 loose stools daily with some blood, no fever or tachycardia, and a normal hemoglobin and albumin. Which is the most appropriate initial therapy?
Infliximab is reserved for moderate to severe disease that has not responded to conventional therapy.
Oral prednisone is used for moderate to severe ulcerative colitis or when mesalamine fails, not as first-line for mild to moderate disease.
Mild to moderate extensive ulcerative colitis is treated first with oral mesalamine at 2.4 to 4.8 g daily.
Azathioprine is a slow-acting maintenance drug, not induction therapy for a flare.
A 55-year-old man with cirrhosis and a platelet count of 70,000/uL has easy bruising. He is hemodynamically stable with no active bleeding. Which plan best reduces his bleeding risk in primary care?
Prophylactic transfusions without bleeding or a planned procedure are not recommended and cause alloimmunization.
Thrombocytopenia from cirrhosis is managed by avoiding NSAIDs, reviewing antiplatelet and anticoagulant use, and counseling on bleeding precautions; platelets are not transfused without bleeding or a procedure.
Vitamin K does not correct the coagulopathy of cirrhosis, which reflects reduced synthesis rather than deficiency.
Stopping every drug without review can remove needed therapies such as beta-blockers or diuretics.
A 62-year-old man with type 2 diabetes has a 2-cm plantar ulcer with 1 cm of surrounding erythema and mild warmth. He has no fever, no deep tissue involvement, and palpable pedal pulses. He has no drug allergies and no MRSA risk factors. Which antibiotic is most appropriate?
A mild diabetic foot infection (erythema 2 cm or less, no systemic signs, no deep involvement) is treated with an oral agent against streptococci and MSSA, such as cephalexin.
IV piperacillin-tazobactam is for moderate to severe infection or Pseudomonas risk, not a mild superficial infection.
Topical mupirocin does not treat cellulitis around a diabetic ulcer; a mild infection needs a systemic agent.
Ciprofloxacin covers streptococci and staphylococci poorly.
A 68-year-old man broke his hip in a fall from standing height 2 months ago and has recovered from surgery. DXA shows a femoral neck T-score of −2.0. eGFR is 60 mL/min/1.73 m², and 25-hydroxyvitamin D is normal. He takes no bone medication. Which is the most appropriate next step?
Calcium and vitamin D are given with, not instead of, an antiresorptive after a hip fracture; waiting 2 years for another DXA leaves a high risk of a second fracture untreated.
A fragility hip fracture is itself diagnostic of osteoporosis; the T-score threshold applies to people without fragility fractures.
A low-trauma hip fracture establishes osteoporosis regardless of the T-score, and zoledronic acid after hip fracture lowers new fractures and mortality.
Testosterone is not a primary osteoporosis treatment and is used only for confirmed hypogonadism.
A 64-year-old man with diabetes (HbA1c 10.1%) has nonpurulent cellulitis of the left lower leg that spread despite 72 hours of oral cefadroxil. Today his temperature is 101.8°F, heart rate is 108 beats/min, and BP is 118/74 mm Hg. There is no abscess on bedside ultrasound. What is the most appropriate next step?
Continuing an oral antibiotic that has failed, now with fever and tachycardia, delays effective treatment.
Spread despite 72 hours of an appropriate antibiotic, with fever and tachycardia in a poorly controlled diabetic, meets criteria for admission and IV antibiotics.
Switching to another oral drug at home ignores the systemic signs that call for IV therapy.
TMP-SMX adds MRSA coverage, but nonpurulent cellulitis with systemic signs after failed oral therapy needs IV treatment.
A 45-year-old man has 2 days of low back pain after lifting furniture. The pain worsens with movement and does not radiate. He has no fever, weight loss, cancer history, saddle anesthesia, bladder symptoms, or neurologic deficits. Which is the most appropriate management?
Opioids do not improve acute low back pain outcomes more than NSAIDs and add dependence risk.
Acute mechanical low back pain without red flags is managed by staying active with superficial heat and an NSAID (ACP 2017).
Imaging is not indicated for acute low back pain without red flags.
Bed rest slows recovery; staying active is recommended.
A 68-year-old man with hip osteoarthritis has persistent pain and difficulty walking despite acetaminophen, topical NSAIDs, and physical therapy. Radiographs show severe joint-space narrowing. What is the most appropriate next step?
Long-term opioids are not recommended for osteoarthritis and carry fall and dependence risks.
Persistent pain and functional limitation despite conservative therapy, with severe radiographic changes, justify orthopedic referral for total hip arthroplasty.
Avoiding weight-bearing causes deconditioning and does not slow osteoarthritis.
Capsaicin has no recommendation for hip osteoarthritis (ACR 2019 supports it for the knee), and a 3-month delay leaves severe, function-limiting disease without a surgical opinion.
A 45-year-old man has persistent dizziness with head turns, visual motion sensitivity, and difficulty concentrating 3 months after a mild traumatic brain injury from a bicycle fall. Neurologic exam is normal, and head CT on the day of injury was negative. Which is the most appropriate management?
A normal exam and a negative CT on the day of injury do not call for repeat imaging before therapy.
Meclizine suppresses vestibular compensation and causes sedation; it is not used long term.
Persistent dizziness with head movement and visual motion sensitivity after concussion is treated with vestibular rehabilitation, which speeds recovery.
Prolonged strict rest delays recovery from concussion; graded activity is recommended.
A 32-year-old woman with chronic daily headache takes over-the-counter combination analgesics on most days of the month and is diagnosed with medication-overuse headache. What is the most appropriate plan?
Substituting another acute drug at the same frequency keeps medication-overuse headache going.
A steroid bridge may help withdrawal, but it does not replace stopping the overused analgesic.
Preventive drugs work poorly while overuse continues; the overused drug must be stopped or limited.
Stopping the overused analgesic and starting preventive therapy is the treatment of medication-overuse headache.
A 68-year-old man with BPH taking tamsulosin and finasteride for 1 year has had two episodes of acute urinary retention requiring catheterization and one febrile UTI. Post-void residual is 350 mL, and creatinine is normal. Which is the most appropriate next step?
Tadalafil improves symptoms modestly but does not prevent retention.
Switching between 5-alpha reductase inhibitors gives no meaningful added benefit.
Oxybutynin is an antimuscarinic that worsens retention.
Recurrent retention and a febrile UTI with a large residual volume despite combination therapy are indications for surgical treatment of BPH.
A 68-year-old man who smoked for 30 years has a one-time screening ultrasound showing a 3.4-cm infrarenal abdominal aortic aneurysm. He is asymptomatic, BP is controlled, and he still smokes. Which plan is most appropriate?
An aneurysm needs surveillance because it can grow.
For an aneurysm of 3.0 to 3.9 cm, smoking cessation and repeat ultrasound in about 3 years are recommended (SVS), because smoking speeds growth.
Elective repair is advised at 5.5 cm or more in men, rapid growth, or symptoms; 3.4 cm is far below that.
A 6-month interval is used for aneurysms of 5.0 to 5.4 cm.
A 38-year-old man has 2 days of sore throat, fever to 38.9°C, tonsillar exudates, and tender anterior cervical nodes without cough. A rapid antigen test is positive for group A streptococcus. As a child he developed a mild, non-itchy maculopapular rash on amoxicillin, with no hives, swelling, or breathing difficulty. Which treatment is most appropriate?
Amoxicillin-clavulanate is broader than needed for streptococcal pharyngitis and adds GI adverse effects.
Azithromycin is reserved for severe penicillin allergy, and macrolide resistance among streptococci is rising.
A remote, mild, non-urticarial rash is a low-risk history, so a first-generation cephalosporin such as cephalexin for 10 days is recommended for strep pharyngitis (IDSA).
Clindamycin is reserved for patients with a history of anaphylaxis or a severe reaction to penicillin.
A 26-year-old woman on day 3 of amoxicillin for acute bacterial sinusitis developed generalized hives, lip swelling, wheezing, and a blood pressure of 84/50 mm Hg within an hour of a dose. She was treated with IM epinephrine and has recovered. Amoxicillin is stopped. Which antibiotic is most appropriate to complete treatment of her sinusitis?
Cefadroxil shares amoxicillin's R1 side chain; after penicillin anaphylaxis a cephalosporin with a similar side chain is avoided (2022 AAAAI/ACAAI drug allergy parameter).
Amoxicillin-clavulanate contains amoxicillin and would reexpose her to the drug that caused anaphylaxis.
Macrolides are not recommended for bacterial sinusitis because of high pneumococcal resistance.
After anaphylaxis to amoxicillin, doxycycline is an appropriate alternative for acute bacterial sinusitis in adults (IDSA), avoiding beta-lactams with a similar side chain.
A 22-year-old man who emigrated from the Philippines a year ago has 3 weeks of productive cough, fevers, night sweats, and a 4.5-kg weight loss. Chest x-ray shows a right upper lobe cavitary infiltrate, and a sputum smear is positive for acid-fast bacilli. HIV testing is negative. Which treatment is most appropriate while cultures are pending?
Isoniazid alone treats latent infection; using it for active disease promotes resistance.
Rifampin alone for 4 months is a latent TB regimen; monotherapy for active disease causes resistance.
A fluoroquinolone alone for 10 days is not TB treatment, and it can delay diagnosis and select for resistance.
Smear-positive cavitary TB is treated with four drugs (rifampin, isoniazid, pyrazinamide, ethambutol) during the intensive phase, with public health reporting.
A 55-year-old man was treated as an outpatient for community-acquired pneumonia with amoxicillin plus azithromycin 72 hours ago. He now has worsening dyspnea, new confusion, respiratory rate 30/min, BP 88/56 mm Hg, and SpO2 89% on room air. Chest radiograph shows spreading consolidation. What is the most appropriate next step?
Outpatient CT delays the urgent care he needs.
Switching to another oral antibiotic at home ignores hypotension, hypoxemia, and new confusion.
Worsening pneumonia with confusion, a respiratory rate of 30, hypotension, and hypoxemia means severe CAP and needs emergency admission.
Changing to another oral antibiotic and waiting 48 hours leaves a deteriorating patient untreated as sepsis develops.
A 72-year-old man is found to have an asymptomatic right internal carotid artery stenosis of 50% on duplex ultrasound during evaluation of a neck bruit. He has no history of stroke or TIA. What is the most appropriate management plan?
Stenting is not indicated for moderate asymptomatic stenosis.
Endarterectomy for asymptomatic stenosis is considered only for severe (70% or more) narrowing in selected patients, never urgently.
Anticoagulation does not reduce stroke from carotid atherosclerosis and adds bleeding risk.
Asymptomatic carotid stenosis under 60% to 70% is managed medically with a statin, an antiplatelet drug, and blood pressure and risk-factor control.
A 50-year-old man with erectile dysfunction was prescribed sildenafil 50 mg. He says it 'does not work well' after trying it 3 times, each shortly after a large, high-fat dinner. He has no chest pain and takes no nitrates. BP is 128/80 mm Hg. What is the most appropriate next step?
A prosthesis is a last resort after medical options fail.
A high-fat meal delays and reduces sildenafil absorption; taking it on an empty stomach about an hour before sex and titrating the dose comes before calling it a failure.
Nitrates with a PDE5 inhibitor can cause severe hypotension and are contraindicated.
Injection therapy is a later option after oral drugs are optimized.
A 30-year-old man with a BMI of 38 kg/m² and hypertension has taken phentermine-topiramate at the full 15/92-mg dose for 12 weeks alongside a structured diet and exercise program. He has lost 3% of his body weight and tolerates the drug. What is the most appropriate next step?
Less than 5% weight loss after 12 weeks at the full dose means nonresponse; the label advises tapering it off (topiramate is stopped gradually) and trying another option.
Adding orlistat to a failed regimen is not recommended.
Doses above 15/92 mg are not approved.
Continuing a drug that has produced less than 5% weight loss after 12 weeks at full dose exposes him to adverse effects without benefit.
A 62-year-old man with type 2 diabetes has a plantar ulcer under the first metatarsal head treated with offloading and dressings for 4 weeks. The ulcer is now larger, with purulent drainage and surrounding erythema of 1.5 cm. A sterile probe reaches bone. Pedal pulses are palpable, and he is afebrile. What is the most appropriate next step?
A positive probe-to-bone test in an infected diabetic ulcer makes osteomyelitis likely; plain radiographs come first (MRI if unclear), with antibiotics and specialist referral.
Surface swabs grow colonizers and topical antibiotics do not treat deep infection.
A short oral course for a probe-to-bone ulcer undertreats likely osteomyelitis and skips the imaging that defines it.
Changing the dressing ignores an infected ulcer with probable osteomyelitis.
A 26-year-old woman treated for uncomplicated cystitis with nitrofurantoin returns 48 hours later. Which finding most indicates the need to reassess and change antibiotics?
Improving suprapubic discomfort is expected recovery.
New flank pain and fever on nitrofurantoin suggest pyelonephritis; nitrofurantoin does not reach the kidney, so the antibiotic is changed and a culture is sent.
Some frequency can persist for a few days during successful treatment.
A 36-year-old woman with IBS with constipation started linaclotide 290 mcg 1 week ago. Her abdominal pain and bloating are better, but she now has three or four loose stools a day without blood, dizziness, or fever. She has been taking the capsule with her breakfast of eggs and bacon. Which is the most appropriate adjustment?
Her pain and bloating improved, so stopping a drug that works is premature.
Linaclotide is taken on an empty stomach at least 30 minutes before the first meal; taking it with a high-fat meal increases diarrhea.
Switching drugs is premature when the problem is the way the drug is taken.
Adding loperamide treats a side effect that a change in timing can fix.
A 42-year-old woman with mild to moderate left-sided ulcerative colitis has taken oral mesalamine 2.4 g daily for 8 weeks. She still has 4 loose stools a day with occasional blood and urgency. Stool testing for C. difficile is negative, and she is afebrile with normal vital signs. What is the most appropriate next step?
Azathioprine is not used for induction in mild to moderate ulcerative colitis; topical therapy is added first.
Antibiotics have no role in uncomplicated ulcerative colitis.
In left-sided UC that has not responded to oral mesalamine, adding rectal mesalamine is more effective than oral therapy alone.
Loperamide can precipitate toxic megacolon in active colitis and does not treat inflammation.
A 44-year-old man completed 14 days of clarithromycin-based triple therapy for Helicobacter pylori-associated peptic ulcer disease. How should eradication best be confirmed?
Symptom relief does not prove eradication, and persistent infection carries ulcer and cancer risk.
Testing on the last day of therapy gives false negatives because antibiotics and PPIs suppress the organism.
A urea breath test (or stool antigen) at least 4 weeks after treatment, with PPIs held for 2 weeks, confirms eradication.
Serology stays positive after cure and cannot confirm eradication.
An 80-year-old with heart failure has been on a loop diuretic for fluid overload. Which finding indicates that optimal volume status (euvolemia) has been achieved?
Edema that has resolved with a weight that stays stable for several days shows the excess fluid is gone without overdiuresis.
Hypotension after diuresis suggests overdiuresis and volume depletion, not optimal volume status.
A 50% rise in creatinine suggests reduced kidney perfusion from overdiuresis; a small rise can be tolerated, but this is not a sign of euvolemia.
Continued weight loss of about 2 lb a day after the edema has cleared points to ongoing diuresis past euvolemia, toward volume depletion.
A running total sits here; it fills in after your last pick.
Reading a score on this set
Treat the number as a study signal. On test day you get a pass/fail cut score, not a percentage, so no percent on a practice set converts into a pass. The pattern of misses is more useful than the total:
Misses in Assess: you knew the disease but not the next question to ask or the maneuver that settles it. Rework the Assess page.
Misses in Diagnose: usually anchoring on the first clue. The Diagnose page walks through ranking a differential.
Misses in Plan: often a prescription where the stem wanted a referral or teaching (Plan).
Misses clustered in one organ system: go to that system's page and its quiz.
NPCB's own practice exam beside test day
Table 1. The board sells its practice exams separately; they are the only practice forms NPCB writes.[1][2]
Fact
Value
Source
Read on
Board’s own practice test
NPCB practice exam: $50, 50 questions in 60 minutes, scored as a percentageNPCB sells 7 FNP practice forms; each purchase allows one attempt, and NPCB says the score does not predict a pass on the real exam.
A cut score set by standard setting; NPCB does not report scores as a percentageThe current handbook prints no scale. The 2023 handbook described a scaled score of 200–800 with 500 to pass.
No. This site's authors wrote them against the published blueprint and current clinical guidelines. NPCB items are seen only on its own practice exams and on test day.
Why are there no children in this set?
Pediatric primary care is taught and practiced on the CPNP-PC pages of this site, so each topic lives in one place. The FNP-C itself does include newborns through adolescents, so use the CPNP-PC practice test for that share.
Is this set timed like the exam?
No clock runs here. The exam allows 3 hours for 150 questions, 72 seconds apiece, so time yourself if you want that pressure.