Is exam day around the corner, and you’re still wondering how to handle Step 1 practice questions? If the anxiety is creeping in, don’t worry. A lot of other students are in the same boat. The good news is you’ll have a better chance of answering questions correctly if you follow a few tips and tricks!
In this post, we’ll cover strategies for tackling Step 1 practice questions that’ll enable you to walk into exam day brimming with confidence. As you’ll see, cracking the exam isn’t just about how much you know—it’s about the strategies you use when answering questions!
What to Know About Step 1 Practice Questions
As a rule of thumb, approach questions the same way every time and build this routine as you work on practice questions. The consistency will make you more efficient on test day and will prevent you from overlooking details. (They’ll be more on this shortly.)
First-Order Questions
First-order questions test direct recall of a fact.
Example: “What is the mechanism of action of linezolid?”
Second-Order Questions
Second-order questions build on that fact and apply it to a clinical scenario.
Example: “Which other antibiotic has a similar mechanism of action (MOA) as linezolid?”
This second-order question requires you to know linezolid’s MOA and deduce which drug shares it.
Third-Order Questions
Third-order questions require multiple layers of reasoning, linking pathophysiology, diagnosis, and management.
Example: “A patient with a MRSA infection recently started an antibiotic. He presents with sweating, hypertension, tachycardia, clonus, and tremors. What other medication would you expect to see in their chart?”
Here, you identify the presentation as serotonin syndrome, recognize linezolid as the antibiotic with that side effect, and determine which additional drugs (SSRIs, MAOIs, ondansetron, etc.) contribute to the syndrome.
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How to Approach Step 1 Practice Questions
Now that you know what types of questions you’ll encounter, let’s look at some tricks that can help you answer them correctly.
Obviously, while these tips will help you tackle questions and narrow answer choices, it’s essential to have a solid grasp of the content to pass Step 1 and succeed in clinical rotations. No amount of strategy is going to help if you don’t know the material!
That said, here are four ways to approach questions that’ll help you get to the right answer:
1. Read the actual question first.
Step 1 is a marathon, not a sprint. Over eight hours of lengthy clinical vignettes, fatigue is inevitable. One of the best tips is to read the actual question first so that when you tackle the long stem, you’re already thinking ahead, filtering out red herrings, and highlighting key information. This will save you time and energy in the long run.
For example, if the question is about a drug’s mechanism of action, you can often skip straight to identifying the medication rather than working through the full clinical diagnosis. The same applies to statistical problems. If you know the question is asking for an odds ratio, you can start setting up the formula before you even finish the prompt.
Here’s an example that illustrates the usefulness of reading the actual question first:
Practice Question #1
A 56-year-old female presents with hematemesis to the ED. She was found at the bus stop by a passerby who had called for an ambulance. Her skin is pale, HR 110, BP 100/70, and she continues to vomit bright red blood.
You are unable to obtain a history from her as she is not alert or orientated. However, the passerby informed EMS that there were multiple empty cans of beer near where the patient was lying. Appropriate resuscitation measures are performed. The patient’s conditions stabilize and you consult the GI team to perform an upper endoscopy. The results of the endoscopy finds a linear mucosal tear at the gastroesophageal junction.
The patient’s actions that directly caused this mucosal tear can also result in which of the following acid-base disturbances?
A) Metabolic alkalosis
B) Anion gap metabolic acidosis
C) Respiratory acidosis
D) Respiratory alkalosis
E) Non-anion gap metabolic acidosis
Question Analysis
First, do you know what kind of question this is? Think back to the examples we discussed above.
If you said it’s a second-order question, you’re correct! That’s because you first need to identify what causes mucosal tears and the resulting acid-base disturbances.
Now, if you read the actual question (in bold italics) first, you would save time on the long clinical vignette. That’s because you could focus only on the relevant details.
In this example, the line stating “endoscopy finds a linear mucosal tear at the gastroesophageal junction” indicates a Mallory-Weiss tear. The most common cause is forceful vomiting, and the typical acid-base disturbance is metabolic alkalosis (choice A).
In this example, you didn’t need to focus on the patient’s presentation, vital signs, or clinical management. By reading the question first, you would have saved yourself considerable time and effort.
2. Identify pertinent positives and negatives.
Identifying relevant positives and negatives is also a great way to arrive at the right answer. For example:
Practice Question #2
A 1-week-old male newborn is brought to the pediatrician for his routine exam. He was born via cesarean delivery at 40 weeks and 2 days without any complications. The patient’s height and weight are within normal limits. When the cardiac exam is performed, a systolic ejection murmur with a wide, fixed, split S2 heart sound is heard over the second intercostal space.The rest of the physical exam is unremarkable. Which of the following congenital heart defects does this newborn have?
A) Coarctation of the aorta
B) Atrial septal defect
C) Patent ductus arteriosus
D) Pulmonic stenosis
E) Ventricular septal defect
Question Analysis
Note: From reading the question first, we know we’re trying to identify a congenital heart defect.
Now let’s pick out pertinent positives and negatives in the stem. A “systolic ejection murmur with a fixed split S2 heart sound heard over the second intercostal space” is a key positive pointing to atrial septal defect (choice B), as this murmur is characteristic of that defect.
This murmur also helps us rule out other options:
- PDA would present as a “continuous machine-like murmur.”
- Pulmonic stenosis presents as a “crescendo-decrescendo systolic ejection murmur with a wide split heard loudest at the upper left sternal border.”
- VSD presents as a “holosystolic murmur heard loudest at the left lower sternal border.”
A normal palpation of femoral pulses is a pertinent negative for coarctation of the aorta, which would present with diminished femoral pulses.
By keeping the answer choices in mind as you read the stem, you can quickly highlight the pertinent positives and negatives, eliminate options, and get to the correct diagnosis.
3. Narrow your options with the process of elimination.
You’ve seen it before: two answer choices look correct, the clock is ticking, and suddenly Step 1 feels less like an exam and more like a mind game. Too often, we focus only on memorizing details, but mastering Step 1 means learning how to dissect the clinical vignette and eliminate distractors.
Narrow your options by comparing the key findings in the question stem to the hallmark features of each answer choice.
One of the trickiest question styles is the one with multiple facets requiring you to select “increase” or “decrease.” Start with the information you know and rule out answer choices that don’t align.
Here’s an example:
Practice Question #3
An 84-year-old man presents with urinary frequency, nocturia, weak stream, and difficulty initiating urination. On a digital rectal exam, the prostate is enlarged, smooth, and non-tender. After the initiation of therapy, which of the following changes would most likely occur in this patient?
- Testosterone (T)
- Dihydrotestosterone (DHT)
- Estradiol (E)
A) 1. Decrease, 2. decrease, 3. decrease
B) 1. Decrease, 2. decrease, 3. increase
C) 1. Decrease, 2. increase, 3. increase
D) 1. Increase, 2. decrease, 3. increase
E) 1. Increase, 2. increase, 3. decrease
Question Analysis
This is an example of a third-order question. First, based on the history and physical exam, we must recognize the patient has benign prostate hyperplasia. Then we need to recognize the treatment for this condition is finasteride. Finally, we need to identify how finasteride affects levels of testosterone, DHT, and estradiol.
We recall that finasteride inhibits the enzyme 5-alpha reductase, which blocks the conversion of testosterone into the more potent androgen, DHT. With this knowledge, we can eliminate answer choices A, B, C, and E, hence allowing us to select answer choice D. Even though we may be unsure how finasteride affects the estradiol concentration, by using the process of elimination and our baseline clinical knowledge, we can arrive at the correct answer.
You can also narrow down answer choices by eliminating options that essentially say the same thing. For instance, if a question asks about the mechanism of action of penicillin and two answer choices are “inhibits the 30S ribosomal subunit” and “blocks bacterial protein synthesis,” you can rule out both. They describe the same mechanism, which actually applies to aminoglycosides, not penicillin.
4. Skip questions you don’t know the answer to (for now).
Of course, there are going to be times when you just don’t know the answer. Take this for example:
Practice Question #4
A 47-year-old M presents with a fever, scattered bruises over his extremities, and blood oozes from his arterial line sites.
Concerned about a cancerous origin, you obtain a bone marrow aspirate that shows immature myeloid cells with blue, needle-shaped rods. Which chromosomal translocation would you expect these cells to have?
A) t (14;18)
B) t (9;22)
C) t (8;14)
D) t (15;17)
E) t (11;14)
Question Analysis
Needle-shaped rods, known as Auer rods, are a sign of acute myeloid leukemia. But what if on test day you hit a blank and can’t recall the chromosomal translocation?
Take a deep breath. Reassure yourself that you only need to get ~60-65% of the questions correct to pass Step 1. Flag and skip the question for now. Don’t dwell on it or panic.
The best thing you can do in these moments is regroup and focus on the questions you know the answer to. That way you get as many points as you can. You can always circle back to answer questions during whatever time you have at the end of the block.
Final Thoughts
If you understand the material but still find the questions challenging, keep practicing to build confidence and test-taking skills. When doing practice questions, develop a consistent strategy that works best for you and apply it to every question. This will allow you to head into test day with confidence, knowing you have a reliable strategy for tackling questions.
Best of luck with your prep, and be sure to reach out to Blueprint tutors for more personalized Step 1 support!
For more (free!) Step 1 content, check out these other posts on the blog:
