Can You Ace Our 9 Most Commonly-Missed NP Practice Questions?

Our Most Commonly-Missed ANCC/AANP Practice Questions (With Detailed Explanations)

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Question #1

A 26-year-old patient has been diagnosed with folliculitis from frequent hot tub use. Their symptoms do not improve with topical medications and hot tub avoidance. The nurse practitioner should prescribe:

A) Ciprofloxacin (Cipro)

B) Cephalexin (Keflex)

C) Doxycycline (Vibramycin)

D) Trimethoprim-sulfamethoxazole (Bactrim DS)

Correct answer: A

Folliculitis is most often caused by staphylococcal bacteria. However, certain patient risk factors can result in folliculitis from alternative pathogens. This patient’s frequent use of hot tubs places them at risk for folliculitis from Pseudomonas. Hot-tub folliculitis can typically be managed with skin hygiene and hot tub avoidance, but if there is persistence of the skin rash, ciprofloxacin (Cipro) (A) is the antibiotic of choice.

Folliculitis is an infection of the skin that occurs most frequently in hairy areas. It is the result of inflammation of the hair follicle. Patients will present with small pustules surrounding skin follicles. These areas will typically be itchy and have a burning sensation. The diagnosis is often based on examination of the skin. A culture can be taken of the pustules to identify the causative pathogen. Bacterial cultures can also help to differentiate folliculitis from similar skin manifestations, including acne and heat rashes. Mild folliculitis can often be treated with skin hygiene and topical agents (e.g., mupirocin ointment). Extensive folliculitis or mild presentations that do not respond to local treatment may require use of systemic antibiotics.

Why are the other choices incorrect?

This patient has hot tub exposure, which is a major risk factor for Pseudomonas. Cephalexin (Keflex) (B), doxycycline (Vibramycin) (C), and trimethoprim-sulfamethoxazole (Bactrim DS) (D) do not cover Pseudomonas. These drugs would all be acceptable antibiotics for the management of folliculitis not associated with hot tub use. 

Question #2

A patient is diagnosed with secondary hyperparathyroidism. Which of the following underlying conditions is the most likely cause of this disorder?

A) Parathyroid adenoma

B) Multiple endocrine neoplasia type 1 

C) Chronic kidney disease

D) Prior neck irradiation

Correct answer: C

Secondary hyperparathyroidism occurs when the parathyroid glands are functioning normally but are forced to increase parathyroid hormone (PTH) production in response to chronically low calcium levels caused by another condition. In other words, the problem is not the parathyroid glands themselves, but an external process that disrupts calcium balance. Chronic kidney disease (C) is the most common and most definitive cause of secondary hyperparathyroidism. Reduced kidney function leads to phosphate retention and decreased activation of vitamin D, both of which lower serum calcium levels and continuously stimulate PTH release.

Parathyroid hormone helps maintain calcium balance by increasing calcium release from bone, increasing calcium reabsorption in the kidneys, and promoting activation of vitamin D to improve intestinal calcium absorption. When calcium levels remain low over time, PTH levels stay elevated as a compensatory response. Persistent stimulation can lead to bone loss and, in long-standing cases, enlargement of the parathyroid glands with loss of normal feedback control, a progression known as tertiary hyperparathyroidism. Treatment focuses on correcting calcium and phosphate abnormalities and addressing vitamin D deficiency rather than removing the parathyroid glands.

Why are the other choices incorrect?

Parathyroid adenoma (A) causes autonomous overproduction of PTH and is the most common cause of primary hyperparathyroidism. Multiple endocrine neoplasia type 1 (B) is associated with multigland parathyroid disease leading to primary hyperparathyroidism. Prior neck irradiation (D) increases the risk of parathyroid adenoma formation and is therefore associated with primary, not secondary, hyperparathyroidism.

Question #3

A 55-year-old patient with a history of diabetes, hypertension, and cigarette smoking presents to review their recent lab results. The LDL level is 70 mg/dL, and their triglyceride level is 400 mg/dL. The patient has been taking atorvastatin (Lipitor) 20 mg daily for 6 months. Which of the following is the best next step in the management of this condition?

A) Prescribe icosapent ethyl (Vascepa) 

B) Continue the current treatment

C) Increase atorvastatin (Lipitor) to 40 mg daily

D) Prescribe ezetimibe (Zetia)

Correct answer: A

The patient in the vignette has hypertriglyceridemia and is at a high risk for atherosclerotic cardiovascular disease (ASCVD) because they have diabetes and hypertension and smoke cigarettes. The first-line option for the treatment of this patient is to optimize their LDL level with a statin medication. If their triglycerides remain persistently elevated despite optimization of the LDL level, the best next step is to prescribe icosapent ethyl (Vascepa) (A). If the triglycerides remain elevated despite treatment with icosapent ethyl (Vascepa), the next step would be to initiate a fibric acid derivative, such as fenofibrate (Tricor).

Hypertriglyceridemia is a condition commonly identified as part of the lipid panel. A diet high in carbohydrates, especially added sugars, alcohol consumption, and a sedentary lifestyle are risk factors for hypertriglyceridemia. Secondary causes of high triglycerides include insulin resistance, hypothyroidism, and medications (e.g., thiazide diuretics, glucocorticoids, beta-blockers, antiretroviral agents, second-generation antipsychotics). Elevated triglycerides contribute to pancreatitis and are considered an enhancing risk factor for ASCVD. Lifestyle modifications and control of secondary causes are foundational to the management of hypertriglyceridemia. Patients should be encouraged to increase their activity levels, reduce or eliminate alcohol and sugar, and stop smoking.

Why are the other choices incorrect?

This persistently elevated triglyceride level requires further management. Thus, it would not be correct to continue the current treatment (B). The current statin intensity is adequately controlling the LDL level, so it is not necessary to increase atorvastatin (Lipitor) to 40 mg daily (C). Ezetimibe (Zetia) (D) is a second-line agent prescribed as an adjunct to statin medications to treat persistently elevated LDLs, but it is not used to treat triglycerides.

Question #4

A 22-year-old patient presents to the office and reports lower extremity swelling after having finished a course of amoxicillin for the treatment of strep throat 2 weeks ago. The patient has 2+ lower extremity edema and is found to have serum creatinine of 1.4 mg/dL, potassium of 5.0 mEq/L, and 2+ hematuria. Which of the following is the best plan of care in treating this patient’s suspected diagnosis? 

A) Check a throat culture

B) Refer the patient to a nephrologist

C) Prescribe amlodipine (Norvasc)

D) Send the patient to the ED for further care

Correct answer: B

Poststreptococcal glomerulonephritis (PSGN) is a nephrologic condition characterized by glomerular injury, preceded a few weeks by a streptococcal skin or throat infection. While some patients are asymptomatic, the most common presenting signs and symptoms include edema, gross hematuria, and hypertension. The treatment of PSGN is generally supportive, including the treatment of the symptoms, such as volume overload and hypertension. Some patients may experience acute kidney injury (AKI) (i.e., elevated creatinine) and, in rare cases, may require dialysis. Patients with severe AKI, refractory hypertension, uncontrolled volume overload, or electrolyte derangements may need to be referred to a nephrologist (B) for further care.

PSGN most commonly occurs in children between 5 and 12 years of age and affects twice as many boys as girls. The diagnosis of PSGN is typically made clinically based on symptoms and documentation of a prior streptococcal infection. Biopsy of the kidney is rarely indicated, but it may be necessary if the diagnosis is unclear. Most patients’ symptoms resolve within 1 week of presentation.

Why are the other choices incorrect?

If a streptococcal infection is still present at the time of PSGN diagnosis, antibiotic therapy should be initiated. Since the patient in this clinical vignette has already had appropriate treatment for strep throat 2 weeks earlier and did not mention persistent symptoms, there is no indication that the patient requires a throat culture (A). Amlodipine (Norvasc) (C) is a calcium channel blocker used to treat hypertension. There is no mention of the patient’s blood pressure  being elevated in the clinical vignette, so this drug would not be the best answer choice. There are no indications that the patient in this clinical vignette needs to be referred to the ED for further care (D).

Question #5

A 51-year-old patient with COPD who is on tiotropium (Spiriva) presents for routine follow-up. The patient notes improvement in dyspnea and has not had a COPD exacerbation in the past 6 months. Which of the following physical exam findings would further suggest the effectiveness of COPD treatment?

A) Areas of silent chest during lung auscultation

B) Cyanosis of the fingertips

C) Decreased forced expiratory time

D) Increased forced expiratory time

Correct answer: C

Airflow limitation is a hallmark finding in patients with COPD. Air trapping will result in prolonged expiration as an effort to remove trapped air from the lungs. Medications used for the chronic management of COPD prevent air trapping by opening the airways and decreasing inflammation and bronchodilation. When a patient with COPD has increased air movement, decreased wheezing, and decreased forced expiratory time (C) on physical exam, this presentation suggests adequate COPD management.

COPD is a term used for chronic bronchitis, emphysema, or a combination of both. These are chronic lung diseases hallmarked by bronchoconstriction and increased sputum production. The number one risk factor for COPD is tobacco smoking. Symptoms will usually start between the ages of 50 and 60 years old. Patients will typically present with dyspnea, particularly on exertion. Chronic coughing with increased sputum production is also frequently noted. On physical exam, wheezing and prolonged expiratory time are the most common findings. A barrel chest and cyanosis can be present in severe disease. The diagnosis is made by pulmonary function testing. This test will show a partially reversible FEV1 and decreased total lung capacity in severe cases. The primary goals of COPD management are symptom reduction and the prevention of exacerbations. Smoking cessation is the first and most important aspect of COPD management, as it will prevent further lung destruction and slow disease progression. Long-acting beta-agonists and other long-acting bronchodilators are the mainstays of chronic COPD treatment. Short-acting beta-agonists and oral glucocorticoids are typically used in the management of acute exacerbations.

Why are the other choices incorrect?

Areas of silent chest during lung auscultation (A) are seen during severe COPD exacerbations and do not suggest adequate COPD control. Cyanosis of the fingertips (B) often reflects poor control of COPD symptoms. Increased forced expiratory time (D) is seen with increased air trapping, which would suggest poor control of COPD symptoms.

Question #6

A 55-year-old patient with a history of gout and chronic kidney disease presents for a gout flare. Which of the following would be the most appropriate first-line therapy for this patient?

A) Ibuprofen (Motrin)

B) Colchicine (Colcrys)

C) Prednisone

D) Allopurinol (Aloprim)

Correct answer: C

Gout is an inflammatory arthritis that results from a buildup of uric acid in the joints. Due to decreased temperatures, the distal joints (e.g., great toe, fingers) are most commonly affected. Gout flares occur when uric acid forms crystals in the joints. Initial treatments for gout flares include ibuprofen (Motrin), colchicine (Colcrys), and Prednisone (C). Patients with chronic kidney disease (CKD) should avoid ibuprofen (Motrin) and colchicine (Colcrys) if possible due to prostaglandin inhibition, which can decrease blood flow to the kidneys.

Factors that can increase the patient’s risk of having a gout flare include consumption of high-purine foods (e.g., alcohol, red meat), diuretics, arthritis in a joint, and initiation of urate-lowering therapy. Clinical findings of gout flares include redness, warmth, swelling, and severe pain in the joint. If the diagnosis of a gout flare is uncertain, joint aspiration should be performed. Synovial fluid can rule out septic arthritis, as it can present similarly, and can identify the presence of uric acid crystals. Laboratory testing for gout during a flare can be normal and does not rule out the diagnosis. If patients have frequent gout flares, daily uric acid-lowering medications (e.g., allopurinol [Aloprim]) may be required.

Why are the other choices incorrect?

Ibuprofen (Motrin) (A) and colchicine (Colcrys) (B) are considered first-line therapies for gout flares, but they would not be preferred in a patient with CKD. Allopurinol (Aloprim) (D) is used as maintenance therapy for gout and not for gout flares.

Question #7

What method of cervical cancer screening is preferred by the American Cancer Society?

A) Cotesting every every 5 years from 21 to 65 years old

B) Cytology testing every 3 years from 21 to 65 years old

C) Primary human papillomavirus testing every 5 years from 25 to 65 years old

D) Cytology testing every 3 years from 25 to 65 years

Correct answer: C

The USPSTF, the ACOG, and the American Cancer Society all provide recommendations regarding cervical cancer screening. While the USPSTF and the ACOG align closely, the American Cancer Society recommends primary human papillomavirus (HPV) testing every 5 years from 25 to 65 years old (C) as the preferred method of screening for cervical cancer. A primary HPV test is a cervical swab that tests for infection with high-risk types of HPV. This screening strategy is recommended for patients at average risk. This group includes patients who are initiating cervical screening, have had normal past results, or are returning to routine screening after management of abnormal results. Although this method is preferred, the American Cancer Society also considers cytology (i.e., Pap smear) alone and in combination with HPV testing (i.e., cotesting) to be an acceptable screening method.

Cervical cancer has declined over the past several decades due to widespread screening efforts. Persistent infection with HPV types 16 or 18 is the cause of most cervical cancers. HPV has a slow natural disease progression, and thus, initiation of screening at age 25 is adequate for identifying cervical cancer risk. Patients who are ≥ 65 years old with adequate negative screenings in the previous 10 years may stop screening. This decision to stop screening should be a shared decision between the patient and the clinician.

Why are the other choices incorrect?

Cotesting every 5 years from 25 to 65 years old, not 21–65 (A), is considered an acceptable screening option by the American Cancer Society if primary HPV testing is not available. Cytology testing every 3 years from 21 to 65 years old (B) is one of the screening methods recommended by the USPSTF. Cytology testing every 3 years from 25 to 65 years old (D) is considered an acceptable screening option by the American Cancer Society if primary HPV testing is not available.

Question #8

A 22-year-old patient presents to the clinic after sustaining a laceration from stepping on a dirty nail. Their last Tdap booster was at age 18. What is the most appropriate course of action?

A) Irrigate the wound and administer a Tdap booster

B) Irrigate the wound and prescribe ciprofloxacin

C) Irrigate the wound and prescribe prophylactic amoxicillin

D) Irrigate the wound and suture it

Correct answer: B

This patient has a dirty or contaminated wound secondary to the mechanism of injury. The most appropriate course of action in this situation would be irrigating the wound and prescribing ciprofloxacin (B). Puncture wounds through a shoe carry a higher risk for infection, particularly from Pseudomonas aeruginosa and Staphylococcus aureus. Fluoroquinolones, such as ciprofloxacin, are often used due to their pseudomonal coverage.

Uncontaminated wounds are safe to close within the first 6 hours of injury. Any dirty or contaminated wounds and lacerations should not be closed secondary to the risk of infection. Following any laceration, tetanus status should be established, particularly after contact with any metallic foreign body. If a patient has completed their three-dose initial Tdap series and has a clean wound, tetanus should be updated if their last Tdap vaccine or booster was over 10 years ago. If the wound is dirty, tetanus should be updated if the last vaccine or booster was over 5 years ago. In unvaccinated individuals or those with an uncertain vaccine history, a booster and tetanus immune globulin should be given for all wounds.

Why are the other choices incorrect?

This patient’s last Tdap was only 4 years ago, so there is no need to update his tetanus vaccine today (A). Antimicrobial prophylaxis (C) is usually only required with bite wounds, and amoxicillin-clavulanate (Augmentin) is typically used. Suturing a contaminated wound (D) can lead to infection.

Question #9

The nurse practitioner is seeing a 76-year-old man in the office for his annual physical. Which statement made by the patient would prompt further investigation for potential cataracts?

A) “I am having increased difficulty seeing things at a distance”

B) “I am having increased difficulty seeing things nearby”

C) “I feel like the center of my vision is gone”

D) “It feels like my right eye is worsening, but my left eye is not

Correct answer: A

Adults presenting with cataracts will usually report bilateral vision changes. These changes may include difficulty seeing things at a distance (A) when compared to things close by due to the myopic shift that occurs with cataracts. A classic problem that patients present with is the increased difficulty with night driving. They may also have foggy or cloudy vision and the presence of bilateral leukocoria on examination.

Radiation therapy and glucocorticoid treatment may induce cataracts, but a majority develop with age. The only curative treatment for cataracts is removal and replacement of the occluded crystalline lens, a minor and common surgery.

Why are the other choices incorrect?

Increased difficulty seeing near objects (B) is common with visual degradation but not with cataracts. Central vision loss (C) is commonly related to macular degeneration. Single-eye vision degeneration (D) is common and usually not related to cataracts.

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Further Reading

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