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Free NHRA practice questions

These ten questions are pulled straight from the PassCurve NHRA bank and shown exactly as a candidate meets them in a real revision session, nothing held back and nothing simplified for the page. Answer one, then open the reveal underneath to see the correct option, why every option is right or wrong, and the specific guideline the answer rests on.

The Bahrain National Health Regulatory Authority licensing exam is sat in English, so every question here is written in English too, the language you will actually read on exam day. Ten questions from one sitting will not replace a full revision plan, but they are a fast, honest way to see where your knowledge already holds and where it still has gaps. Read the NHRA exam guide for the exam's format, eligibility and scoring, or start a free session in the app now to keep going past these ten.

Every explanation below is evidence based: each one names the specific guideline it rests on and the date that source was last read, so you can check it yourself rather than take our word for it. These questions are written and fact-checked with AI assistance; not individually signed off by a physician.

Internal Medicine

Question 1 of 10 Endocrinology

A 45-year-old Bahraini man presents to a primary care health centre for a routine medical check-up. He has no significant past medical history and takes no medications. His blood pressure is 125/80 mmHg, and his body mass index is 31 kg/m². Laboratory investigations reveal a fasting plasma glucose of 8.2 mmol/L (148 mg/dL) and a hemoglobin A1c of 7.4%. A repeat fasting plasma glucose one week later is 8.4 mmol/L (151 mg/dL). His renal function, liver enzymes, and lipid profile are within normal limits. He has no history of cardiovascular disease. Along with lifestyle modifications, which of the following is the most appropriate initial pharmacological therapy?

  • Glimepiride
  • Pioglitazone
  • Empagliflozin
  • Metformin
Show the answer and explanation

Correct answer: D

  • A. Glimepiride

    Glimepiride is a sulfonylurea. It carries a significant risk of hypoglycemia and weight gain, making it less ideal as an initial monotherapy compared to metformin.

  • B. Pioglitazone

    Pioglitazone is a thiazolidinedione. It can cause weight gain and fluid retention, and is not recommended as the initial first-line therapy over metformin in newly diagnosed, uncomplicated type 2 diabetes.

  • C. Empagliflozin

    Empagliflozin is an SGLT2 inhibitor. While strongly recommended for patients with established cardiovascular disease, heart failure, or chronic kidney disease, it is not typically the preferred first-line monotherapy for an uncomplicated patient.

  • D. Metformin

    Metformin is the generally preferred initial pharmacological agent for the treatment of type 2 diabetes in patients without established cardiovascular disease, chronic kidney disease, or heart failure. It is highly effective, well-tolerated, and weight-neutral.

TAKEAWAY

Metformin remains the preferred initial pharmacological treatment for type 2 diabetes in patients without established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease.

American Diabetes Association (ADA) Standards of Care in Diabetes · Section 9: Pharmacologic Approaches to Glycemic Treatment (checked 16 August 2026)

Question 5 of 10 Endocrinology

A 28-year-old Bahraini woman is referred to the endocrinology clinic at a government hospital for evaluation of elevated serum calcium, which was incidentally discovered during a pre-employment medical fitness screening. She is completely asymptomatic, with no history of bone pain, fatigue, polyuria, or nephrolithiasis. Her family history is notable for her father having mild, lifelong asymptomatic hypercalcemia. Laboratory investigations reveal: Serum calcium: 11.2 mg/dL (Normal: 8.5–10.5 mg/dL) Serum albumin: 4.0 g/dL (Normal: 3.5–5.0 g/dL) Intact parathyroid hormone (PTH): 62 pg/mL (Normal: 15–65 pg/mL) 25-hydroxyvitamin D: 36 ng/mL (Normal: 20–50 ng/mL) Serum creatinine: 0.8 mg/dL (Normal: 0.6–1.1 mg/dL) A 24-hour urine collection shows a calcium excretion of 60 mg/day (Normal: 100–300 mg/day). The calculated calcium-to-creatinine clearance ratio is 0.005. What is the most appropriate next step in the management of this patient?

  • Initiation of cinacalcet therapy
  • Referral for minimally invasive parathyroidectomy
  • Parathyroid sestamibi scintigraphy
  • Reassurance and clinical observation
Show the answer and explanation

Correct answer: D

  • A. Initiation of cinacalcet therapy

    Cinacalcet is a calcimimetic agent utilized in cases of severe hypercalcemia due to parathyroid carcinoma or severe secondary hyperparathyroidism in chronic kidney disease. It is not indicated for the benign, asymptomatic hypercalcemia seen in FHH.

  • B. Referral for minimally invasive parathyroidectomy

    Parathyroidectomy is the definitive treatment for symptomatic or selected asymptomatic patients with Primary Hyperparathyroidism (PHPT). However, it is fundamentally ineffective and contraindicated in FHH, as removing parathyroid tissue does not correct the underlying defective calcium-sensing receptor.

  • C. Parathyroid sestamibi scintigraphy

    Parathyroid sestamibi scintigraphy is a preoperative localization study used after the decision for parathyroid surgery has been made in confirmed primary hyperparathyroidism. Because FHH does not require surgery, imaging is inappropriate and unnecessary.

  • D. Reassurance and clinical observation

    The patient has Familial Hypocalciuric Hypercalcemia (FHH), characterized by mild hypercalcemia, inappropriately normal or slightly elevated PTH, and low urinary calcium excretion with a calcium-to-creatinine clearance ratio < 0.01. It is an autosomal dominant benign condition caused by a mutation in the calcium-sensing receptor (CaSR) gene. The standard of care is reassurance and observation; no medical or surgical intervention is required.

TAKEAWAY

Familial hypocalciuric hypercalcemia (FHH) presents with mild hypercalcemia, normal-to-mildly elevated PTH, and a calcium-to-creatinine clearance ratio < 0.01. It is a benign condition requiring only reassurance and observation; parathyroidectomy is contraindicated.

Harrison's Principles of Internal Medicine, 21st Edition · Chapter 409: Hypercalcemia and Primary Hyperparathyroidism (checked 16 August 2026)

Question 9 of 10 Gastroenterology

A 45-year-old Bahraini male presents to a primary care health centre for a routine check-up. He has a 5-year history of type 2 diabetes mellitus and hypertension. His body mass index is 34 kg/m². He does not consume alcohol. He is asymptomatic, and his physical examination is unremarkable. Laboratory investigations reveal: Alanine aminotransferase (ALT): 68 U/L (Normal: 7–55) Aspartate aminotransferase (AST): 42 U/L (Normal: 8–48) Alkaline phosphatase (ALP): 85 U/L (Normal: 40–129) Hepatitis B surface antigen: Negative Anti-HCV antibodies: Negative An abdominal ultrasound demonstrates increased hepatic echogenicity (a "bright liver") with normal biliary ducts. Which of the following is the most likely diagnosis?

  • Metabolic dysfunction-associated steatotic liver disease
  • Autoimmune hepatitis
  • Primary biliary cholangitis
  • Hereditary hemochromatosis
Show the answer and explanation

Correct answer: A

  • A. Metabolic dysfunction-associated steatotic liver disease

    The patient has the classic triad of obesity, type 2 diabetes, and a 'bright liver' on ultrasound with mild transaminitis (ALT > AST). In the absence of alcohol use and viral hepatitis, Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is the most likely diagnosis.

  • B. Autoimmune hepatitis

    Autoimmune hepatitis typically presents with significantly higher transaminases (often >1000 U/L during flares), positive autoantibodies (like ANA or ASMA), and is more common in females. It does not typically present as isolated steatosis on ultrasound.

  • C. Primary biliary cholangitis

    Primary biliary cholangitis is characterized by a cholestatic pattern of liver injury (significantly elevated alkaline phosphatase) and positive anti-mitochondrial antibodies, primarily affecting middle-aged women.

  • D. Hereditary hemochromatosis

    Hereditary hemochromatosis causes hepatic iron overload, which does not typically appear as a 'bright liver' (steatosis) on ultrasound. It is diagnosed via elevated ferritin, high transferrin saturation, and HFE gene mutation testing.

TAKEAWAY

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common cause of incidentally discovered mild transaminitis in patients with metabolic syndrome features (obesity, type 2 diabetes) and negative viral serologies.

AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease · Diagnosis and Assessment (checked 16 August 2026)

Obstetrics and Gynaecology

Question 2 of 10 Gynaecology

A 28-year-old Bahraini woman presents to a gynaecology clinic at a government hospital with an 18-month history of inability to conceive. She reports irregular menstrual cycles occurring every 45 to 60 days and noticeable hair growth on her chin and chest. Her body mass index is 33 kg/m². Pelvic ultrasound reveals bilaterally enlarged ovaries with multiple small peripheral follicles. Her husband's semen analysis is normal, and a hysterosalpingogram confirms bilateral tubal patency. Following lifestyle modifications and weight loss counseling, which of the following is the most appropriate first-line pharmacological treatment for ovulation induction in this patient?

  • Clomiphene citrate
  • Letrozole
  • Human menopausal gonadotropin
  • Metformin
Show the answer and explanation

Correct answer: B

  • A. Clomiphene citrate

    Clomiphene citrate was traditionally the first-line agent but is now considered second-line to letrozole for PCOS due to lower cumulative live birth rates.

  • B. Letrozole

    Letrozole, an aromatase inhibitor, is the recommended first-line pharmacological treatment for ovulation induction in women with PCOS. It is associated with higher live birth and ovulation rates compared to clomiphene citrate.

  • C. Human menopausal gonadotropin

    Gonadotropins are a second- or third-line option for ovulation induction in PCOS, used when oral agents fail, due to the higher risk of multiple gestations and ovarian hyperstimulation syndrome.

  • D. Metformin

    Metformin improves insulin sensitivity and may improve menstrual cyclicity, but it is not recommended as a primary first-line agent for ovulation induction to achieve pregnancy compared to letrozole.

TAKEAWAY

Letrozole is the first-line pharmacological therapy for ovulation induction in women with Polycystic Ovary Syndrome (PCOS) seeking pregnancy.

ACOG Practice Bulletin No. 194: Polycystic Ovary Syndrome · Management of Infertility (checked 16 August 2026)

Question 6 of 10 Obstetrics

A 24-year-old Bahraini woman, G1P0, presents to the antenatal clinic at 12 weeks of gestation for her first booking visit. She has a known history of homozygous sickle cell disease (HbSS). Her disease has been clinically stable, with her last vaso-occlusive crisis occurring two years ago. She has no history of acute chest syndrome, stroke, or chronic kidney disease. She currently takes folic acid 5 mg daily. Her vital signs are normal. Laboratory investigations reveal a hemoglobin level of 8.1 g/dL and a reticulocyte count of 8%. Which of the following is the most appropriate management plan regarding red blood cell transfusion for this patient during her pregnancy?

  • Reserve red blood cell transfusion for acute complications or severe symptomatic anemia.
  • Initiate prophylactic serial red blood cell transfusions immediately.
  • Plan for a single prophylactic red blood cell transfusion at 36 weeks of gestation.
  • Perform a prophylactic automated red blood cell exchange transfusion now.
Show the answer and explanation

Correct answer: A

  • A. Reserve red blood cell transfusion for acute complications or severe symptomatic anemia.

    In pregnant women with sickle cell disease, conservative management is standard. Blood transfusions should be reserved for specific indications, including severe symptomatic anemia, acute chest syndrome, stroke, or recurrent severe vaso-occlusive crises.

  • B. Initiate prophylactic serial red blood cell transfusions immediately.

    Routine prophylactic serial transfusions are not recommended in uncomplicated pregnancies for women with sickle cell disease. They increase the risk of alloimmunization, iron overload, and delayed hemolytic transfusion reactions without significantly improving fetal outcomes.

  • C. Plan for a single prophylactic red blood cell transfusion at 36 weeks of gestation.

    A single prophylactic transfusion prior to delivery is not routinely indicated for asymptomatic anemia in sickle cell disease. Transfusion should be guided by specific clinical indications rather than gestational age.

  • D. Perform a prophylactic automated red blood cell exchange transfusion now.

    Prophylactic exchange transfusion is not indicated for stable, uncomplicated sickle cell disease in pregnancy. It is generally reserved for severe, life-threatening complications such as acute chest syndrome or acute stroke.

TAKEAWAY

Routine prophylactic red blood cell transfusion is not recommended for stable pregnant women with sickle cell disease; it is reserved for acute complications or severe symptomatic anemia.

Williams Obstetrics, 26th Edition · Chapter 59: Anemia and Coagulopathies (Sickle Cell Anemia - Pregnancy Complications) (checked 16 August 2026)

Question 10 of 10 Gynaecology

A 27-year-old woman with a history of beta-thalassemia major presents to a gynaecology clinic in Bahrain for evaluation of primary infertility and secondary amenorrhea. She has not had a menstrual period for three years. She receives regular blood transfusions but admits to poor compliance with her iron chelation therapy over the past five years. Her body mass index is 21 kg/m². Pelvic ultrasound reveals a normal-appearing uterus and bilateral ovaries with antral follicles. Laboratory investigations show: Follicle-stimulating hormone (FSH): 1.2 mIU/mL Luteinizing hormone (LH): 0.8 mIU/mL Estradiol: 18 pg/mL Prolactin: 12 ng/mL Thyroid-stimulating hormone (TSH): 2.1 mIU/L Serum ferritin: 4,200 ng/mL The patient and her husband strongly desire pregnancy. Semen analysis is normal. What is the most appropriate next step in management to induce ovulation in this patient?

  • Administration of oral letrozole
  • Administration of exogenous gonadotropins
  • Administration of oral clomiphene
  • Pulsatile administration of GnRH
Show the answer and explanation

Correct answer: B

  • A. Administration of oral letrozole

    Letrozole is an aromatase inhibitor that lowers systemic estrogen levels, triggering increased endogenous FSH release from the pituitary gland. Like clomiphene, letrozole relies on a functioning hypothalamic-pituitary axis and is ineffective for ovulation induction in patients with central pituitary failure due to iron overload.

  • B. Administration of exogenous gonadotropins

    Patients with beta-thalassemia major and poor chelation compliance develop severe iron overload. Iron preferentially deposits in the anterior pituitary gland, leading to the destruction of gonadotroph cells and resulting in hypogonadotropic hypogonadism (low FSH, low LH, low estradiol). Because the pituitary gland itself is damaged and cannot produce endogenous gonadotropins, direct stimulation of the ovaries with exogenous gonadotropins (e.g., hMG or recombinant FSH followed by hCG) is the only effective method to induce ovulation.

  • C. Administration of oral clomiphene

    Clomiphene citrate is a selective estrogen receptor modulator that induces ovulation by blocking estrogen negative feedback at the hypothalamus and pituitary, thereby increasing endogenous FSH and LH release. It requires an intact and functioning hypothalamic-pituitary-ovarian axis. It is completely ineffective in patients with hypogonadotropic hypogonadism.

  • D. Pulsatile administration of GnRH

    Pulsatile Gonadotropin-Releasing Hormone (GnRH) therapy is effective for conditions where the primary defect is in the hypothalamus (e.g., Kallmann syndrome, functional hypothalamic amenorrhea). In thalassemia major, the primary defect is iron deposition in the anterior pituitary gland. Consequently, the damaged pituitary cannot respond to pulsatile GnRH, making this therapy ineffective.

TAKEAWAY

In patients with beta-thalassemia major, poor iron chelation leads to iron deposition in the anterior pituitary gland, causing hypogonadotropic hypogonadism. Ovulation induction in these patients requires direct ovarian stimulation using exogenous gonadotropins, as the damaged pituitary cannot respond to clomiphene, letrozole, or pulsatile GnRH.

Fritz & Speroff's Clinical Gynecologic Endocrinology and Infertility, 9th Edition · Section III: Infertility - Induction of Ovulation (checked 16 August 2026)

Pediatrics

Question 3 of 10 Neonatology

A full-term male infant is delivered vaginally at 39 weeks of gestation at a government maternity hospital in Bahrain. Immediately after birth, the infant is crying vigorously, has a heart rate of 140 beats per minute, and exhibits active muscle tone. The amniotic fluid was clear. Which of the following is the most appropriate next step in management?

  • Perform deep suctioning of the oropharynx and nasopharynx
  • Administer continuous positive airway pressure (CPAP)
  • Dry the infant and place him skin-to-skin with the mother
  • Provide positive pressure ventilation with a bag-mask device
Show the answer and explanation

Correct answer: C

  • A. Perform deep suctioning of the oropharynx and nasopharynx

    Routine suctioning of the airway is no longer recommended for vigorous infants, even if meconium is present. It is certainly not indicated when the amniotic fluid is clear, as unnecessary suctioning can induce vagal bradycardia.

  • B. Administer continuous positive airway pressure (CPAP)

    CPAP is indicated for spontaneously breathing infants who exhibit labored breathing or persistent cyanosis. This infant is crying vigorously without any signs of respiratory distress.

  • C. Dry the infant and place him skin-to-skin with the mother

    According to the Neonatal Resuscitation Program (NRP) guidelines, a term newborn who is vigorous (crying or breathing well) and has good muscle tone should receive routine care. This includes drying the baby and placing him skin-to-skin with the mother to maintain normal body temperature and promote bonding.

  • D. Provide positive pressure ventilation with a bag-mask device

    Positive pressure ventilation is indicated for infants who are apneic, gasping, or have a heart rate below 100 beats per minute. This infant is crying vigorously and has a normal heart rate of 140 beats per minute.

TAKEAWAY

A vigorous, full-term newborn with good muscle tone and a heart rate >100 bpm requires only routine care consisting of warming, drying, and skin-to-skin contact with the mother.

Neonatal Resuscitation Program (NRP) 8th Edition · Chapter 3: Initial Steps of Newborn Care (checked 16 August 2026)

Question 7 of 10 Pediatric Infectious Diseases

A 6-year-old Bahraini boy with a known history of sickle cell disease presents to the emergency department with a 3-day history of fever (39.2°C) and severe right thigh pain. He is refusing to bear weight on his right leg. Physical examination reveals swelling, warmth, and marked tenderness over the distal right femur. Laboratory investigations show a white blood cell count of 18,000/mm³ and a C-reactive protein of 120 mg/L. Magnetic resonance imaging of the right femur is consistent with acute osteomyelitis. Blood and bone aspirate cultures are obtained. Which of the following is the most appropriate empiric intravenous antibiotic regimen?

  • Cefazolin and gentamicin
  • Ampicillin and cefotaxime
  • Penicillin and clindamycin
  • Ceftriaxone and vancomycin
Show the answer and explanation

Correct answer: D

  • A. Cefazolin and gentamicin

    Cefazolin covers methicillin-susceptible S. aureus (MSSA) but is inadequate for MRSA and lacks reliable coverage against Salmonella. Gentamicin is not optimal for bone penetration and is not standard for acute pediatric osteomyelitis.

  • B. Ampicillin and cefotaxime

    This regimen is often used for neonatal sepsis and meningitis to cover Listeria and Gram-negative rods. It lacks adequate coverage for Staphylococcus aureus, a leading cause of osteomyelitis.

  • C. Penicillin and clindamycin

    While clindamycin provides excellent bone penetration and coverage for S. aureus (including community-acquired MRSA), penicillin does not cover Salmonella species, leaving a critical gap in treating a patient with sickle cell disease.

  • D. Ceftriaxone and vancomycin

    Patients with sickle cell disease have a unique susceptibility to osteomyelitis caused by both Salmonella species and Staphylococcus aureus. Empiric therapy must cover both pathogens. A third-generation cephalosporin (ceftriaxone) covers Salmonella, while vancomycin provides robust coverage against S. aureus, including methicillin-resistant strains (MRSA).

TAKEAWAY

In children with sickle cell disease, acute osteomyelitis is most commonly caused by Salmonella species and Staphylococcus aureus. Empiric antibiotic therapy must include a third-generation cephalosporin and an anti-staphylococcal agent.

Nelson Textbook of Pediatrics, 21st Edition · Section 16: Infectious Diseases (Bone and Joint Infections - Osteomyelitis) (checked 16 August 2026)

Surgery

Question 4 of 10 Urology

A 24-year-old Bahraini male with a known history of sickle cell disease presents to the emergency department with a painful, rigid erection that has persisted for 6 hours. He denies any sexual activity, trauma, or use of phosphodiesterase type 5 inhibitors prior to onset. On examination, the corpora cavernosa are rigid and exquisitely tender, while the corpus spongiosum and glans penis are flaccid. He has been given adequate intravenous analgesia and hydration. What is the most appropriate next step in management?

  • Intracavernous injection of phenylephrine and corporeal aspiration
  • Automated red blood cell exchange transfusion
  • Systemic administration of terbutaline
  • Placement of a distal penoscrotal shunt (Winter's procedure)
Show the answer and explanation

Correct answer: A

  • A. Intracavernous injection of phenylephrine and corporeal aspiration

    The first-line specific intervention for acute ischemic priapism (including sickle cell-associated priapism) after initial analgesia is corporeal aspiration with or without irrigation, combined with the intracavernous injection of a sympathomimetic agent like phenylephrine. This directly reverses the ischemia and prevents irreversible fibrosis.

  • B. Automated red blood cell exchange transfusion

    While exchange transfusion may be used as an adjunctive treatment for severe sickle cell crises to lower Hemoglobin S percentage, it does not rapidly decompress the corpora cavernosa and should not delay immediate urologic intervention for ischemic priapism.

  • C. Systemic administration of terbutaline

    Oral or systemic terbutaline is generally ineffective for ischemic priapism lasting more than 4 hours. It is not recommended over direct intracavernous aspiration and sympathomimetic injection.

  • D. Placement of a distal penoscrotal shunt (Winter's procedure)

    Surgical shunting is indicated only if conservative management and repeated aspiration/injection with sympathomimetics fail to resolve the ischemic priapism. It is not the immediate next step.

TAKEAWAY

The first-line specific treatment for ischemic priapism, including sickle cell-induced priapism, is corporeal aspiration combined with intracavernous injection of a sympathomimetic agent such as phenylephrine.

American Urological Association (AUA) Guidelines on the Diagnosis and Management of Priapism · Acute Ischemic Priapism Management (checked 16 August 2026)

Question 8 of 10 Emergency and Trauma

A 24-year-old man is brought to the emergency department of a government hospital following a high-speed motor vehicle collision on the King Fahd Causeway. On arrival, his blood pressure is 78/50 mmHg, and his heart rate is 130/min. His airway is patent, and breath sounds are equal bilaterally. His abdomen is distended and diffusely tender. A focused assessment with sonography for trauma (FAST) scan demonstrates a significant amount of free fluid in the hepatorenal recess. The patient remains hypotensive despite the administration of 1 liter of warmed crystalloid solution and the initiation of a massive transfusion protocol. Which of the following is the most appropriate next step in management?

  • Computed tomography of the abdomen
  • Diagnostic peritoneal lavage
  • Immediate exploratory laparotomy
  • Pelvic angiography and embolization
Show the answer and explanation

Correct answer: C

  • A. Computed tomography of the abdomen

    CT of the abdomen is the gold standard for evaluating hemodynamically stable trauma patients but is contraindicated in patients who are hemodynamically unstable, as it delays definitive surgical hemorrhage control.

  • B. Diagnostic peritoneal lavage

    Diagnostic peritoneal lavage (DPL) can detect intra-abdominal bleeding but is invasive and time-consuming. It is reserved for situations where FAST is equivocal or unavailable. Since the FAST is already positive, DPL is unnecessary.

  • C. Immediate exploratory laparotomy

    According to ATLS guidelines, a hemodynamically unstable patient with blunt abdominal trauma and a positive FAST scan requires immediate exploratory laparotomy to control intra-abdominal hemorrhage.

  • D. Pelvic angiography and embolization

    Angiography is indicated for hemodynamically unstable patients with pelvic fractures and negative FAST scans, or stable patients with specific solid organ injuries. In the presence of a positive FAST and instability, laparotomy takes priority.

TAKEAWAY

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST scan require immediate exploratory laparotomy.

Advanced Trauma Life Support (ATLS) Student Course Manual · 10th Edition, Chapter 5: Abdominal and Pelvic Trauma (checked 16 August 2026)

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