100+ Free COMLEX Level 3 Practice Questions

Pass your COMLEX-USA Level 3 exam on the first try — instant access, no signup required.

✓ No registration✓ No credit card✓ No hidden fees✓ Start practicing immediately

~96-98% first-attempt for first-time eligible candidates Pass Rate

100+ Questions

100% Free

1 / 100

Question 1

Score: 0/0

A 70-year-old with chronic AF on warfarin (INR 3.5) develops new spontaneous bleeding from his nose. INR is 6.5. He is hemodynamically stable with no active bleeding from other sites. What is the appropriate management?

Continue warfarin at current dose

IV vitamin K

4F-PCC immediately

Hold warfarin, give oral vitamin K 2.5-5 mg, monitor INR, ENT consultation if bleeding persists; resume anticoagulation at lower dose once stable

to track

Same family resources

Explore More COMLEX-USA Osteopathic Licensing Examinations

Continue into nearby exams from the same family. Each card keeps practice questions, study guides, flashcards, videos, and articles in one place.

COMLEX-USA Level 2-CE

Practice Questions100 questions

2026 Statistics

Key Facts: COMLEX Level 3 Exam

Up to 420

MCQs + 26 CDM Cases

NBOME Level 3 format

$910

Registration Fee

NBOME Bulletin 2025-2026

350

Passing Standard Score

NBOME scale 9-999, mean ~520

~96-98%

First-Attempt Pass Rate

NBOME annual technical reports

Jan 2027

Single-Day Transition

NBOME enhancement announcement

PGY-1/2

Typical Test Year

During DO residency training

COMLEX-USA Level 3 is the final step for full DO licensure, typically taken during PGY-1 or PGY-2 of residency. The 2026 exam delivers up to 420 MCQs plus 26 CDM cases over two days at Pearson VUE; the passing standard score is 350 on the 9-999 scale (mean ~520 for first-time takers). The exam follows the COMLEX-USA Master Blueprint with osteopathic principles and OMM integrated throughout (~10-15% of items). The 2025-2026 NBOME registration fee is $910 — the highest of the three COMLEX levels — and Level 3 transitions to a 1-day, 8-hour format in January 2027.

Sample COMLEX Level 3 Practice Questions

Try these sample questions to test your COMLEX Level 3 exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1A 65-year-old man in your residency clinic with NYHA class II HFrEF (EF 30%) is on lisinopril 20 mg, carvedilol 25 mg BID, and furosemide 40 mg daily. His K is 4.5, Cr 1.1, BP 118/72. What is the most appropriate next step to optimize GDMT?

A.Add digoxin

B.Switch lisinopril to sacubitril-valsartan, add spironolactone, and add dapagliflozin

C.Add amlodipine

D.Increase furosemide dose

Explanation: Optimal HFrEF therapy includes the four pillars: ARNI (sacubitril-valsartan replacing ACE-I), beta-blocker, MRA (spironolactone), and SGLT2 inhibitor (dapagliflozin). This combination provides the largest mortality benefit. Wash out ACE-I for 36 hours before starting ARNI to avoid angioedema. Check K and renal function 1-2 weeks after MRA initiation.

2A 72-year-old hospitalized with community-acquired pneumonia (CURB-65 = 3) is treated with ceftriaxone and azithromycin. The attending asks about adjunctive OMT. Which OMT technique has Level I evidence supporting its use in elderly hospitalized pneumonia (MOPSE trial)?

A.Cervical HVLA

B.Lymphatic pump techniques (thoracic, pedal) plus paraspinal inhibition

C.Cranial vault hold

D.Sacral rocking

Explanation: The Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) showed that lymphatic pump, paraspinal inhibition, and rib raising reduced length of stay and antibiotic duration in elderly hospitalized pneumonia. AOA pneumonia guideline supports OMT as adjunctive care. Avoid HVLA in frail elderly.

3CDM-style: A 58-year-old man with new-onset atrial fibrillation (HR 130, BP 110/70) presents to your ED. Which initial workup items are MOST appropriate? (Select all that apply for CDM)

A.TSH, echocardiogram, CHA2DS2-VASc score, and CMP/troponin

B.Cardiac catheterization immediately

C.Routine head CT

D.Bone marrow biopsy

Explanation: Initial AF workup: TSH (rule out hyperthyroidism), echocardiogram (LA size, EF, valvular disease, LV thrombus), CHA2DS2-VASc for stroke risk stratification, CMP (electrolytes, renal function for DOAC dosing), and troponin if chest pain. Rate control with beta-blocker or non-DHP CCB if stable. Anticoagulation per CHA2DS2-VASc.

4A 45-year-old post-op day 2 from open colectomy develops abdominal distension, absent bowel sounds, and inability to pass flatus. KUB shows distended small bowel loops without obstruction. What is the most appropriate management including OMT adjuncts?

A.NG tube decompression, IV fluids, ambulation, plus rib raising and mesenteric release OMT

B.Immediate repeat surgery

C.Oral antibiotics only

D.Total parenteral nutrition without intervention

Explanation: Post-operative ileus is managed with NG decompression, IV fluids and electrolyte correction (especially K, Mg), early ambulation, minimizing opioids, and chewing gum. OMT adjuncts include rib raising (sympathetic inhibition), mesenteric release/lift (lymphatic drainage), and sacral rocking (parasympathetic stimulation). Multiple osteopathic studies show reduced ileus duration with OMT.

5A 28-year-old G2P1 at 39 weeks gestation in your residency presents with severe headache, BP 168/112, and 4+ proteinuria. She has hyperreflexia. After IV labetalol and magnesium sulfate, what is the definitive treatment?

A.Continue expectant management to term

B.Delivery (induction or cesarean depending on fetal/cervical status)

C.Outpatient bed rest

D.ACE inhibitor

Explanation: Severe preeclampsia at >=37 weeks is an indication for delivery. Magnesium sulfate prevents eclamptic seizures (target 4-7 mg/dL). Labetalol or hydralazine controls severe HTN (SBP >=160 or DBP >=110). Definitive cure is delivery of the placenta. Mode of delivery depends on cervical status, fetal status, and obstetric factors.

6An 80-year-old in your nursing home rounds is found with new confusion, low-grade fever (38.0 C), and a urinalysis with 50 WBC/HPF and positive nitrites. CAM is positive for delirium. What is the most appropriate management?

A.Begin appropriate antibiotic, search for and treat reversible causes, avoid benzodiazepines, ensure orientation cues and family presence

B.Restrain the patient

C.High-dose haloperidol IV

D.Lumbar puncture immediately

Explanation: Delirium from UTI: treat the underlying infection with appropriate antibiotic (consider local antibiogram; nitrofurantoin avoided if creatinine clearance <60), correct contributing factors (dehydration, electrolytes, medications), use non-pharmacologic approaches first (reorientation, family presence, sleep hygiene, mobility, hearing/vision aids). Avoid benzodiazepines (worsen delirium except in alcohol/BZD withdrawal). Low-dose haloperidol reserved for severe agitation threatening safety.

7A 55-year-old with chronic low back pain presents to your residency clinic. Imaging shows mild degenerative disc disease. Per the AOA 2016 guideline for low back pain, what is the role of OMT?

A.Strong recommendation: OMT reduces pain and improves function in acute and chronic non-specific low back pain

B.OMT is contraindicated in any back pain

C.OMT replaces all other treatments

D.OMT is only useful for radicular pain

Explanation: The AOA 2016 clinical practice guideline for low back pain (published in JAOA) gives a strong recommendation for OMT in both acute and chronic non-specific low back pain. Techniques include HVLA, muscle energy, counterstrain, myofascial release, and soft tissue. OMT is one part of multimodal management including exercise, education, and graduated return to activity. Imaging is not routinely required unless red flags are present.

8CDM-style: A 65-year-old presents with chronic low back pain for 6 months. Which RED FLAGS would prompt urgent imaging? (Select all appropriate)

A.Weight loss, night pain, IV drug use, history of malignancy, neurologic deficit, recent infection, age >50 with new onset

B.Mild aching pain with activity

C.Pain improved with rest

D.Pain with prolonged sitting

Explanation: Red flags warranting urgent imaging in low back pain: cancer history, unexplained weight loss, night pain, neurologic deficit (saddle anesthesia, bowel/bladder dysfunction, progressive motor weakness suggesting cauda equina), IV drug use, recent infection or fever, immunosuppression, trauma history, age >50 with new onset, and failure of conservative management >4-6 weeks. Without red flags, imaging in the first 4-6 weeks is not recommended (low yield, may identify incidental findings).

9A 40-year-old presents to your ED with chest pain, diaphoresis, and ECG showing 3-mm ST elevation in V1-V4. Troponin is rising. The cath lab is being activated. What additional management is needed before transfer to cath lab?

A.Aspirin 325 mg, second antiplatelet (ticagrelor 180 mg or prasugrel 60 mg), heparin, statin, beta-blocker if no contraindication

B.Hold all medications until after PCI

C.TPA only

D.IV calcium channel blocker

Explanation: STEMI pre-cath therapy: dual antiplatelet (aspirin 325 mg chewed plus P2Y12 inhibitor — ticagrelor 180 mg or prasugrel 60 mg; clopidogrel 600 mg if others contraindicated), anticoagulation (unfractionated heparin or bivalirudin), high-intensity statin (atorvastatin 80 mg), beta-blocker if hemodynamically stable and no signs of HF. Door-to-balloon time <=90 minutes. Sublingual nitroglycerin if no RV involvement and SBP >90.

10A 35-year-old with major depressive disorder failed sertraline (full dose 200 mg x 8 weeks). She has no suicidal ideation. What is the most appropriate next step?

A.Increase sertraline to 300 mg

B.Switch to a different SSRI or SNRI; or augment with bupropion or atypical antipsychotic (aripiprazole)

C.Add a benzodiazepine

D.Stop all medications

Explanation: Treatment-resistant depression (failure of one adequate SSRI trial): options include switching to a different SSRI/SNRI (escitalopram, duloxetine, venlafaxine), augmenting with bupropion, mirtazapine, or atypical antipsychotic (aripiprazole 2-15 mg or quetiapine XR 150-300 mg are FDA-approved for adjunctive use in MDD). Ketamine/esketamine (Spravato) is FDA-approved for TRD. ECT is highly effective for severe TRD.

About the COMLEX Level 3 Exam

COMLEX-USA Level 3 is the final examination in the three-level NBOME osteopathic licensure sequence. Through 2026 it is a 2-day computer-based exam consisting of up to 420 single-best-answer multiple-choice questions plus 26 Clinical Decision-Making (CDM) cases with 2-4 items each (extended multiple-choice or short constructed-response). The exam assesses readiness for independent osteopathic medical practice across general medicine, with osteopathic principles and OMM integrated throughout. Effective January 2027, NBOME transitions Level 3 to a 1-day, 8-hour single-session format.

Questions

420 scored questions

Time Limit

2-day CBT (~14 hours) through 2026; 1-day 8-hour format starting January 2027

Passing Score

350 (3-digit standard score; range 9-999, mean 500)

Exam Fee

$910 (NBOME 2025-2026) (National Board of Osteopathic Medical Examiners (NBOME) / Pearson VUE)

COMLEX Level 3 Exam Content Outline

~35%

Patient Management & Treatment Planning

Pharmacotherapy selection, dosing, monitoring, and adverse-event recognition across organ systems. Stepwise escalation per ACC/AHA HF GDMT (ARNI/BB/MRA/SGLT2i), ADA 2026 diabetes (metformin + SGLT2i/GLP-1 RA), GOLD COPD (LABA + LAMA, ICS for exacerbator phenotype), GINA asthma (ICS-formoterol), IDSA pneumonia (CAP severity by CURB-65/PSI), USPSTF chronic disease prevention. Surgical indications and post-op care. OMT prescription integrated with biomedical management — lymphatic technique for pneumonia, rib raising for post-op ileus, soft-tissue/MFR for low back pain.

~20%

Diagnosis & Differential Diagnosis

Differential generation by clinical presentation. High-acuity recognition — ACS (STEMI, NSTEMI, unstable angina), sepsis (qSOFA + lactate >=2), stroke (NIHSS, last-known-well, tPA <=4.5 h, thrombectomy <=24 h LVO), anaphylaxis (IM epinephrine), ectopic pregnancy, DKA, hypertensive emergency vs urgency, status epilepticus, PE (Wells, PERC, age-adjusted D-dimer). Pre-test probability and likelihood ratios for test selection. Bayesian reasoning when ruling in vs ruling out.

~10-15%

Osteopathic Principles & OMT

OMT for community-acquired pneumonia — lymphatic pump (thoracic, pedal), rib raising, paraspinal inhibition (MOPSE trial, AOA guideline). Low back pain — HVLA, muscle energy, counterstrain, myofascial release (AOA 2016 LBP guideline, JAOA). Post-operative ileus — rib raising, mesenteric lift/release. Pediatric otitis media — Galbreath maneuver (mandibular drainage). Pregnancy — sacroiliac, sacral base, pubic shear treatment for low back/pelvic pain. Geriatric — gentle indirect techniques, lymphatic for CHF/edema. Contraindications by population.

~10%

Data Acquisition (CDM Cases)

CDM cases present a clinical scenario and ask the candidate to select the next appropriate history element, physical exam maneuver, or diagnostic test (extended multiple-choice with multiple correct selections, or short constructed response). Examples: an elderly patient with new-onset AF — what next? (TSH, echo, CHA2DS2-VASc, and DOAC). A 60-year-old with three months of low back pain — what red flags must be elicited? (weight loss, night pain, IV drug use, history of malignancy, neurologic deficit, recent infection).

~10%

Health Promotion, Prevention & Patient Safety

USPSTF — colorectal screening 45-75 (FIT or colonoscopy), mammography 40-74 q2y (2024 update), cervical co-test 30-65 q5y, lung CT 50-80 with 20 pack-year history, statin primary prevention 40-75 with >=7.5% ASCVD risk. ACIP — annual influenza, Tdap, updated COVID-19, Shingrix age 50, PCV15/PCV20 age 65, RSV age 75 (and 60-74 shared decision). Hand-off communication (I-PASS), medication reconciliation at transitions, Beers Criteria in elders, opioid safety (CDC 2022 — start low, MME monitoring, naloxone co-prescribing).

~10%

Ethics, Professionalism & Systems-Based Practice

Informed consent (capacity, voluntariness, disclosure, understanding), surrogate decision-making hierarchy, advance directives (living will, durable POA), POLST/MOLST. End-of-life — palliative vs hospice (prognosis <=6 months). HIPAA minimum-necessary, PHI exceptions. Mandatory reporting — child abuse all states, elder abuse most states, reportable infectious diseases. Conflict of interest, gifts from industry. Billing integrity. Patient safety frameworks — Swiss cheese model, Just Culture, root-cause analysis (RCA), PDSA, FMEA.

How to Pass the COMLEX Level 3 Exam

What You Need to Know

Passing score: 350 (3-digit standard score; range 9-999, mean 500)
Exam length: 420 questions
Time limit: 2-day CBT (~14 hours) through 2026; 1-day 8-hour format starting January 2027
Exam fee: $910 (NBOME 2025-2026)

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

COMLEX Level 3 Study Tips from Top Performers

1Use a CDM simulator before exam day. CDM questions are typed and graded on clinically relevant content — practice typing efficiently (NO copy-paste in the real exam), avoid throwaway items, and stick to evidence-based answers. For 'next diagnostic test' items, list specific tests not vague categories (e.g., 'TSH, free T4, TPO antibodies' not 'thyroid studies'). For 'next management step' items, list specific drug + dose when possible. Partial credit is awarded — list 3-5 high-yield items per blank.

2Drill OMT for inpatient scenarios. The highest-yield Level 3 OMT applications are: lymphatic pump for community-acquired pneumonia (improves length of stay and antibiotic duration per MOPSE), rib raising and mesenteric release for post-operative ileus, OMT for low back pain (AOA 2016 guideline), Galbreath mandibular drainage for otitis media in children, sacroiliac/sacral OMT for pregnancy low back pain, and lymphatic/soft tissue for CHF edema. Know the segmental autonomics — T1-T5 cardiac sympathetic, T2-T7 pulmonary, T5-T9 upper GI.

3Recognize the 6 critical do-not-miss diagnoses. (1) STEMI — door-to-balloon <=90 min, dual antiplatelet, anticoagulation, statin. (2) Sepsis — qSOFA + lactate >=2, 1-hour bundle (cultures before antibiotics, broad-spectrum, lactate, fluids 30 mL/kg). (3) Acute ischemic stroke — NIHSS, tPA window <=4.5 h, thrombectomy <=24 h for LVO. (4) Anaphylaxis — IM epinephrine 0.3 mg lateral thigh. (5) DKA — fluids first, then insulin drip, replace K when <5.2. (6) Hypertensive emergency — target ~25% MAP reduction in 1 hour with IV agent.

4Master de-escalation as much as escalation. Level 3 frequently tests when to STOP a medication — Stop NSAIDs in CKD/HF/ulcer, stop beta-blocker in decompensated HFrEF (continue when stable), stop SGLT2i for euglycemic DKA risk during illness/surgery, stop metformin pre-contrast and pre-op, stop ACE-I/ARB if K >5.5 or Cr rise >30%, taper opioids per CDC 2022 (no abrupt taper), taper benzodiazepines (seizure risk), stop statin only for severe myopathy/rhabdo or pregnancy. Polypharmacy review using Beers Criteria for elders.

5Lock in Pathways and transitions. I-PASS hand-off framework: Illness severity, Patient summary, Action items, Situational awareness/contingency, Synthesis by receiver. Medication reconciliation at every transition (admission, transfer, discharge) — single biggest source of preventable harm. Discharge planning — pending labs noted, follow-up scheduled, red-flag teach-back, prescriptions filled, transportation arranged. Reportable diseases by state vary, but tuberculosis, syphilis, gonorrhea, HIV, meningococcal disease, measles, mumps, rubella, pertussis are virtually universal.

Frequently Asked Questions

What is the COMLEX-USA Level 3 exam?

COMLEX-USA Level 3 is the third and final examination in the COMLEX-USA sequence administered by the National Board of Osteopathic Medical Examiners. Through 2026, it is a 2-day computer-based exam with up to 420 single-best-answer multiple-choice questions and 26 Clinical Decision-Making (CDM) cases delivered at Pearson VUE test centers. Passing Level 3 — along with Levels 1 and 2-CE — is required for unrestricted DO licensure in all 50 US states and the District of Columbia.

When can I take Level 3?

Most candidates take Level 3 during PGY-1 or PGY-2 of an ACGME-accredited residency program. NBOME requires that candidates have passed Level 1 and Level 2-CE, be enrolled in an accredited residency or AOA-recognized internship, and obtain endorsement from their program director. Many programs require Level 3 to be passed before promotion to PGY-3 or graduation.

What are CDM cases on Level 3?

Clinical Decision-Making (CDM) cases present a clinical scenario followed by 2-4 questions focused on data acquisition (which history element, exam maneuver, or test to order next), data interpretation (diagnosis), or management planning. Answer formats include extended multiple-choice (select one or more from a long list) and short constructed-response (typed short answer). CDM cases test the same competencies as MCQs but emphasize active problem-solving rather than recognition.

How much does Level 3 cost in 2026?

The NBOME 2025-2026 registration fee for COMLEX-USA Level 3 is $910 — the highest of the three COMLEX levels. Additional fees may apply for late registration, rescheduling, and certain administrative services. Most residency programs reimburse Level 3 fees; check with your GME office. Confirm current pricing at nbome.org before applying.

What is the passing score for Level 3?

The passing 3-digit standard score for COMLEX-USA Level 3 is 350 on the NBOME scale (range 9-999, mean approximately 520, SD ~85 for first-time test-takers). Level 3 has the lowest passing threshold of the three COMLEX exams because the population taking it is already credentialed (passed Levels 1 and 2-CE) and is functioning as residents. First-attempt pass rates run approximately 96-98% for first-time eligible candidates.

Is Level 3 changing in 2027?

Yes. Effective January 2027, NBOME transitions COMLEX-USA Level 3 to a 1-day, 8-hour single-session exam, replacing the current 2-day, ~14-hour format. The exam will continue to follow the COMLEX-USA Master Blueprint with a similar proportion of MCQs and CDM cases. Candidates testing in 2026 should plan for the current 2-day format. NBOME also reduced Level 1 and Level 2-CE from 352 to 320 items starting in spring 2026.

How should I study for Level 3?

Most residents spend 150-300 hours preparing during PGY-1 or PGY-2. Use a CDM simulator (CDMCases.com, COMQUEST CDM), a question bank (TrueLearn COMBANK, UWorld Step 3), the AOA OMT guideline for low back pain, MOPSE pneumonia OMT data, and a high-yield review of inpatient and outpatient general medicine. Practice CDM short-answer typing (no copy-paste; spelling matters but partial credit is given for clinically relevant answers). Take 1-2 timed full-length practice exams.

Do I need to pass Level 3 to get state DO licensure?

Yes. All 50 US states and the District of Columbia require passing all three COMLEX-USA levels (Level 1, Level 2-CE, and Level 3) — or alternatively all three USMLE Steps — for unrestricted DO licensure. Some DOs take the USMLE in addition, but passing COMLEX alone satisfies state licensure boards. State medical boards may set additional requirements (background check, jurisprudence exam, controlled substance permit).