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Question 1 S. is a 59-year-old female who has been followed for several years for aortic regurgitation. Serial echocardiography has demonstrated normal ventricular function, but the patient was lost to follow-up for the last 16 months and now presents complaining of activity intolerance and weight gain. Physical examination reveals a grade IV/VI diastolic aortic murmur and 2+ lower extremity edema to the midealf. The AGACNP considers which of the following as the most appropriate management strategy? A. Serial echocardiography every 6 months B. Begin a calcium channel antagonist C. Begin an angiotensin converting enzyme (ACE) inhibitor D. Surgical consultation and intervention. Question 2 An ascending thoracic aneurysm of > 5,5 cm is universally considered an indication for surgical repair, given the poor outcomes with sudden rupture. Regardless of the aneurysm’s size, all of the following are additional indications for immediate operation except: A. Comorbid Marfan’s syndrome B. Enlargement of > 1 em since diagnosis C. Crushing chest pain D. History of giant cell arteritis Question 3 Jasmine is a 31-year-old female who presents with neck pain. She has a long history of injection drug use and admits to injecting opiates into her neck. Physical examination reveals diffuse tracking and scarring. Today Jasmine has a distinct inability to turn her neck without pain. throat pain, and a temperature of 102.1°F. She appears ill and has foul breath. In order to evaluate for a deep neck space infection, the AGACNP orders: A. Anteroposterior neck radiography B. CT sean of the neck C. White blood cell (WBC) differential D. Aspiration and culture of fluid Question 4 Mr. Draper is a 39-year-old male recovering from an extended abdominal procedure. As a result of a serious motor vehicle accident, he has had repair of a small bowel perforation, splenectomy, and repair of a hepatic laceration. He will be on total parenteral nutrition postoperatively. The One of the earliest findings for a patient in hypovolemic shock is: A. A drop in systolic blood pressure (SBP) < 10 mm Hg for > 1 minute when sitting up B. A change in mental status C, SaO2 of < 88% D. Hemoglobin and hematoerit (H&H) <9 g/dL and 27% Question 7 Traumatic diaphragmatic hernias present in both acute and chronic forms. Patients with a more chronic form are most likely to be present with: A. Respiratory insufficiency B. Sepsis C. Bowel obstruction D. Anemia Question 8 The AGACNP is managing a patient in the ICU who is being treated for a pulmonary embolus. Initially the patient was stable. awake. alert, and oriented, but during the last several hours the patient has become increasingly lethargic. At change of shift. the oncoming staff nurse appreciates a profound change in the patient’s mental status from the day before. Vital signs and hemodynamic parameters are as follows: BP 88/54 mm Hg Pulse 110 bpm Respiratory rate 22 breaths per minute SaQ2 93% on a 50% mask Systemic vascular resistance (SVR) 1600 dynes - sec/em5 Cardiac index 1.3 L/min Pulmonary capillary wedge pressure (PCWP) 8 mm Hg This clinical picture is most consistent with which shock state? A. Hypovolemic B. Cardiogenic C. Distributive D. Obstructive Question 9 When counseling patients to prevent postoperative pulmonary complications. the AGACNP knows that with respect to smoking cessation. the American College of Surgeons and National Surgical Quality Improvement Program guidelines are clear that patients who stop smoking weeks before surgery have no inereased risk of smokingrelated pulmonary complications. Jared V. is a 35-year-old male who presents for evaluation of a dry cough. He reports feeling well overall but notices that he gets out of breath more easily than he used to when playing soccer. A review of systems yields results that are essentially benign, although the patient does admit to an unusual rash on his legs. Physical examination reveals scattered erythematous nodules on both shins. There is no drainage, discomfort. or iteh. Additionally, diffuse, mildly enlarged lymph nodes are appreciated bilaterally. Results of a comprehensive metabolic panel and complete blood count are within normal limits. Twelve-lead ECG reveals sinus bradycardia at 58 bpm. Chest radiography reveals bilateral hilar and mediastinal lymphadenopathy. The AGACNP suspects: A.Bronchiectasis B. Pulmonary fibrosis C. Sarcoidosis D.Lung carcinoma Question 12 Mrs. Miller is a 44-year-old female who is on postoperative day 1 following a total abdominal hysterectomy. Her urine output overnight was approximately 200 mL. The appropriate response for the AGACNP would be to order: A.A urinalysis and culture B. 1 liter of NSS over 8 hours C. Encourage increased mobility D Liberalize salt in the diet Question 13 All of the following are risk factors for spontaneous pneumothorax except: A.Connective tissue disease B. Scuba diving C. Chronic obstructive pulmonary disease (COPD) D.Central line insertion Question 14 The AGACNP is going over preoperative information and instructions with a patient who is having a major transverse abdominal procedure tomorrow morning. The patient is very nervous and is asking a lot of questions. The AGACNP prescribes a sleeping agent because he knows that anxiety and sleeplessness may: A.Lead to hypoxia due to hyperventilation B. Increase the physiologic stress response postoperatively D.Myotomy and partial fundoplication Question 17 Mr. Liu is a 52-year-old male who has a history of thyroidectomy. He presents complaining of numbness and tingling in his legs and feet and generalized fatigue. Physical examination reveals a positive Chvostek’s sign. Which of the following laboratory studies should be ordered first? A.Renal function tests B. Parathyroid hormone C. Caleium D.Magnesium. Question 18 V. is a 75-year-old male patient who, during a recent wellness evaluation, was found to have a new onset grade II/VI crescendo-decrescendo cardiac murmur at the 2nd intercostal space. right sternal border. He is symptom free and reports no limitations to his usual daily activity. He specifically denies activity intolerance or near syncope. and he is very active physically. Echocardiography reveals a mild aortic calcification. The AGACNP knows that ongoing management for R. V. must include: A.Annual or biannual serial echocardiography B. Modification of activity level C. Baseline cardiac catheterization D. Statin therapy Question 19 The lower esophageal sphincter is characterized by periods of intermittent relaxation called transient lower esophageal sphincter relaxations. These relaxations are independent of the relaxation triggered by swallowing and are the most common cause of: A. Physiologic reflux B. Symptomatic esophagitis C. Barrett’s metaplasia D.Esophageal carcinoma Question 20 D.Hiatal hernia Question 22 Which of the following treatment modalities has no role in the treatment of shock? A.Lactated Ringer’s B. Fresh frozen plasma (FFP) C, Vasopressors D.Colloid solutions Question 23 The development of coronary artery disease (CAD) and, ultimately. plaque formation is a multifactorial process that includes endothelial injury from hypertension, cigarette smoking. and dyslipidemia. These events lead to endothelial cell dysfunction, which is theorized to result in: A. Decreased nitric oxide production B. Smooth muscle cell atrophy C. Collagen degradation D.Enlarged arterial lumen Question 24 Mr. Comstock is a 71-year-old male who presents with a general sense of feeling weak and unwell: he thinks he has the flu even though he received a flu vaccination this year. He describes a vague collection of symptoms. including weakness, nausea, dizziness, and “getting out of breath” very easily. He says he can barely climb the steps anymore without stopping to rest. Of the possible differential diagnoses, coronary artery disease (CAD) is high among the probabilities because of his age and gender. His physical examination is unremarkable except that he appears weak. His vital signs are as follows: temperature 98.0°F. pulse 100 bpm. respiratory rate 16 b.p.m., and BP 178/100 mm Hg. A chest radiograph is within normal limits with no acute pulmonary infection. A 12-lead ECG reveals inverted T waves in leads V1 to V5. The AGACNP is suspicious that most of his symptoms are: A. Psychosomatic B. Early congestive heart failure (CHF) C. Anginal equivalents D.Normal age-related changes Question 25 Mrs. Carpenter is a 59-year-old female who presents with an acute myocardial infarction. She is acutely short of breath and has coarse rales on auscultation. Physical examination reveals a grade Question 27 Mrs. McCallum is a 48-year-old female who presents for evaluation of a vague set of gastrointestinal symptoms. She feels generally well and has always been healthy. but lately she has had a lot of heartbum and a sense of reflux in her throat. Most recently she has had a recurring sense of food getting stuck in her throat. The AGACNP knows that which diagnostic study should be performed first? ABarium swallow B. Upper endoscopy C. Esophageal manometry D.Ambulatory pH monitoring Question 28 Mr. Key is a 53-year-old male patient who developed empyema following a serious bout of bacterial pneumonia. He presented as septic and was started immediately on intravenous antibiotics and drainage of the sinus cavity. Forty-eight hours later, he is much improved clinically and drainage has receded. The next step in his care would be: A.A CT scan B. Eloesser’s procedure C. Decortication D.Reexpansion Question 29 Mrs. Bowers is a 41-year-old patient who requires surgical management of osteomyelitis. She has a long history of methamphetamine use and has a BMI of 17.9 kg/m2 . She clearly is nutritionally depleted and volume contracted. but she has no clear chronic medical history except for unmedicated hypertension, which may be due to her chronic stimulant use. She denies alcohol use but admits to a 1% pack a day cigarette habit. A primary postoperative concern for Mrs. Bowers is: Axcess bleeding B. Thromboemboli development C. Poor wound healing D Renal failure Question 30 The congenital diaphragmatic hernia that occurs more often in women and does not usually produce symptoms until midlife is known as: A.Zenker’s hernia A.All patients > 40 years of age B. All patients who smoke cigarettes C. All patients having thoracic procedures. D.All patients with cardiac disease Question 33 According to the Carpentier classification scheme of mitral valve regurgitation, a type I regurgitation is most likely due to: A.Cardiomyopathy B. Excessive leaflet motion C. Ruptured papillary muscles D Rheumatic heart disease Question 34 V. is a 37-year-old female who is admitted via the emergency room after her roommate called emergency medical services (EMS). She has no significant medical history and does not know what is wrong with her. She has been feeling generally unwell for the last few days, and today she had an episode of confusion that seared her roommate to the extent that the roommate called EMS. Her physical examination reveals a temperature of 101.9°F, pulse of 110 bpm. respiratory rate of 20 breaths per minute, and blood pressure of 92/58 mm Hg. A comprehensive metabolic panel reveals a slightly elevated blood urea nitrogen (BUN)/creatinine but otherwise is normal. A white blood cell differential reveals a leukocyte count of 14,000 cells/L with neutrophils of 83%. The AGACNP knows that these values are consistent with: A. Systemic inflammatory response syndrome (SIRS) B. High-output septic shock C. Neurogenie shock D.Multiple organ dysfunction syndrome (MODS) Question 35 Which shock state is worsened in the setting of mechanical ventilation? A. Septic B. Cardiac compressive C. Neurogenic D.Cardiogenic Question 36 
