NR 565 Advanced Pharmacology Actual Final
Exam (2026 Curriculum) – Comprehensive
Review & Verified Guide
Section 1: Cardiovascular & Renal Pharmacology (12 Questions)
Q1: A 58-year-old male presents for hypertension management. BP 158/96 mmHg
(confirmed on two occasions), eGFR 52 mL/min/1.73m² (Stage 3a CKD), serum
creatinine 1.4 mg/dL, and history of gout on allopurinol. No diabetes. Which is the most
appropriate initial antihypertensive therapy?
A. Start hydrochlorothiazide 25 mg daily
B. Start lisinopril 10 mg daily
C. Start amlodipine 5 mg daily
D. Start metoprolol succinate 50 mg daily
Correct Answer: B
Rationale: Primary Justification: Per JNC-8 and KDIGO guidelines, ACE inhibitors (ACEi)
are first-line for hypertension with CKD due to proven reduction in proteinuria and
progression to ESRD. Lisinopril provides renal protection independent of BP lowering.
Risk Mitigation: Monitor serum creatinine and potassium within 1-2 weeks; expect up to
30% creatinine rise which stabilizes. Avoid if bilateral renal artery stenosis. Distractor
Analysis: Hydrochlorothiazide (A) raises uric acid and may precipitate gout flares
,despite allopurinol; less renal protective. Amlodipine (C) is effective but lacks
mortality/morbidity benefits in CKD compared to ACEi. Metoprolol (D) is not first-line for
uncomplicated hypertension and masks hypoglycemia (less relevant here but inferior
for renal outcomes).
Q2: A 67-year-old female with HFrEF (EF 35%), NYHA Class II, already on lisinopril 20 mg
and metoprolol succinate 100 mg, presents with increasing dyspnea on exertion. BP
118/72 mmHg, HR 72 bpm, K⁺ 4.2 mEq/L, creatinine 1.1 mg/dL. What is the next
evidence-based addition?
A. Increase metoprolol to 200 mg daily
B. Add furosemide 40 mg daily
C. Add spironolactone 25 mg daily
D. Add hydralazine-isosorbide dinitrate 37.5/20 mg TID
Correct Answer: C
Rationale: Primary Justification: The PARADIGM-HF and EMPEROR-Reduced trials
support adding an MRA (spironolactone or eplerenone) for HFrEF patients already on
ACEi/ARB and beta-blocker with persistent symptoms or high risk. Spironolactone
reduces mortality and hospitalization. Risk Mitigation: Monitor potassium and renal
function at 1 week, 1 month, then quarterly; risk of hyperkalemia increases with ACEi
combination. Distractor Analysis: Maximizing beta-blocker (A) is reasonable but current
dose is therapeutic; further uptitration limited by BP. Furosemide (B) treats congestion
but doesn't improve mortality in stable outpatients. Hydralazine-nitrate (D) is reserved
for ACEi-intolerant patients or African Americans with persistent symptoms on optimal
therapy (per A-HeFT).
,Q3: A 72-year-old male with atrial fibrillation (CHA₂DS₂-VASc 4) and mechanical mitral
valve replacement (6 months post-op) presents for anticoagulation review. INR 2.8 on
warfarin. He asks about switching to apixaban. What is the appropriate response?
A. Switch to apixaban 5 mg BID, discontinue warfarin
B. Continue warfarin; DOACs are contraindicated with mechanical valves
C. Switch to rivaroxaban 20 mg daily with food
D. Add aspirin 81 mg to current warfarin for better stroke prevention
Correct Answer: B
Rationale: Primary Justification: The RE-ALIGN trial demonstrated increased thrombosis
and bleeding with dabigatran vs. warfarin in mechanical valves; FDA black box warning
extends to all DOACs. Warfarin remains mandatory with target INR 2.5-3.5 for mitral
mechanical valves. Risk Mitigation: Ensure consistent vitamin K intake; monitor INR
every 2-4 weeks once stable; educate on drug interactions (amiodarone, antibiotics).
Distractor Analysis: All DOACs (A, C) are contraindicated—mechanical valves require
warfarin's reliable pharmacokinetics and reversibility. Adding aspirin (D) increases
bleeding without proven stroke benefit in therapeutic INR ranges; consider only for
high-risk coronary disease with caution.
Q4: A 45-year-old female with type 2 diabetes (A1C 7.8%), eGFR 45 mL/min/1.73m², and
UACR 285 mg/g (moderately increased albuminuria) presents for diabetes optimization.
Metformin 1000 mg BID and lifestyle measures for 6 months. BP 138/84 mmHg on no
antihypertensives. What is the most appropriate next step?
A. Add glipizide 5 mg daily
, B. Add empagliflozin 10 mg daily
C. Add sitagliptin 100 mg daily
D. Add insulin glargine 10 units at bedtime
Correct Answer: B
Rationale: Primary Justification: Per ADA 2026 Standards of Care, SGLT2 inhibitors
(empagliflozin, dapagliflozin) are recommended for T2DM with CKD and albuminuria
independent of glycemic control or metformin use. EMPA-REG OUTCOME demonstrated
reduced CKD progression and cardiovascular events. Risk Mitigation: Monitor for genital
mycotic infections, volume depletion; hold during acute illness/surgery; eGFR must be
≥30 for glycemic benefit (cardiovascular/renal benefits persist at lower eGFR).
Distractor Analysis: Glipizide (A) risks hypoglycemia and weight gain without renal
protection. Sitagliptin (C) is weight-neutral but requires dose reduction in renal
impairment and lacks cardiovascular/renal outcome benefits. Insulin (D) is unnecessary
given reasonable A1C and effective oral options available.
Q5: A 62-year-old male with stable angina reports sublingual nitroglycerin 0.4 mg
relieves chest pain in 4-5 minutes, but he experiences severe headaches. He has used
12 tablets in the past week. His current medications include metoprolol 50 mg BID and
amlodipine 5 mg daily. What is the most appropriate intervention?
A. Discontinue nitroglycerin and initiate ranolazine 500 mg BID
B. Reduce nitroglycerin to 0.3 mg and add isosorbide mononitrate 30 mg daily
C. Uptitrate metoprolol to 100 mg BID and continue current nitroglycerin use
D. Add lisinopril 10 mg daily to reduce nitroglycerin requirements
Exam (2026 Curriculum) – Comprehensive
Review & Verified Guide
Section 1: Cardiovascular & Renal Pharmacology (12 Questions)
Q1: A 58-year-old male presents for hypertension management. BP 158/96 mmHg
(confirmed on two occasions), eGFR 52 mL/min/1.73m² (Stage 3a CKD), serum
creatinine 1.4 mg/dL, and history of gout on allopurinol. No diabetes. Which is the most
appropriate initial antihypertensive therapy?
A. Start hydrochlorothiazide 25 mg daily
B. Start lisinopril 10 mg daily
C. Start amlodipine 5 mg daily
D. Start metoprolol succinate 50 mg daily
Correct Answer: B
Rationale: Primary Justification: Per JNC-8 and KDIGO guidelines, ACE inhibitors (ACEi)
are first-line for hypertension with CKD due to proven reduction in proteinuria and
progression to ESRD. Lisinopril provides renal protection independent of BP lowering.
Risk Mitigation: Monitor serum creatinine and potassium within 1-2 weeks; expect up to
30% creatinine rise which stabilizes. Avoid if bilateral renal artery stenosis. Distractor
Analysis: Hydrochlorothiazide (A) raises uric acid and may precipitate gout flares
,despite allopurinol; less renal protective. Amlodipine (C) is effective but lacks
mortality/morbidity benefits in CKD compared to ACEi. Metoprolol (D) is not first-line for
uncomplicated hypertension and masks hypoglycemia (less relevant here but inferior
for renal outcomes).
Q2: A 67-year-old female with HFrEF (EF 35%), NYHA Class II, already on lisinopril 20 mg
and metoprolol succinate 100 mg, presents with increasing dyspnea on exertion. BP
118/72 mmHg, HR 72 bpm, K⁺ 4.2 mEq/L, creatinine 1.1 mg/dL. What is the next
evidence-based addition?
A. Increase metoprolol to 200 mg daily
B. Add furosemide 40 mg daily
C. Add spironolactone 25 mg daily
D. Add hydralazine-isosorbide dinitrate 37.5/20 mg TID
Correct Answer: C
Rationale: Primary Justification: The PARADIGM-HF and EMPEROR-Reduced trials
support adding an MRA (spironolactone or eplerenone) for HFrEF patients already on
ACEi/ARB and beta-blocker with persistent symptoms or high risk. Spironolactone
reduces mortality and hospitalization. Risk Mitigation: Monitor potassium and renal
function at 1 week, 1 month, then quarterly; risk of hyperkalemia increases with ACEi
combination. Distractor Analysis: Maximizing beta-blocker (A) is reasonable but current
dose is therapeutic; further uptitration limited by BP. Furosemide (B) treats congestion
but doesn't improve mortality in stable outpatients. Hydralazine-nitrate (D) is reserved
for ACEi-intolerant patients or African Americans with persistent symptoms on optimal
therapy (per A-HeFT).
,Q3: A 72-year-old male with atrial fibrillation (CHA₂DS₂-VASc 4) and mechanical mitral
valve replacement (6 months post-op) presents for anticoagulation review. INR 2.8 on
warfarin. He asks about switching to apixaban. What is the appropriate response?
A. Switch to apixaban 5 mg BID, discontinue warfarin
B. Continue warfarin; DOACs are contraindicated with mechanical valves
C. Switch to rivaroxaban 20 mg daily with food
D. Add aspirin 81 mg to current warfarin for better stroke prevention
Correct Answer: B
Rationale: Primary Justification: The RE-ALIGN trial demonstrated increased thrombosis
and bleeding with dabigatran vs. warfarin in mechanical valves; FDA black box warning
extends to all DOACs. Warfarin remains mandatory with target INR 2.5-3.5 for mitral
mechanical valves. Risk Mitigation: Ensure consistent vitamin K intake; monitor INR
every 2-4 weeks once stable; educate on drug interactions (amiodarone, antibiotics).
Distractor Analysis: All DOACs (A, C) are contraindicated—mechanical valves require
warfarin's reliable pharmacokinetics and reversibility. Adding aspirin (D) increases
bleeding without proven stroke benefit in therapeutic INR ranges; consider only for
high-risk coronary disease with caution.
Q4: A 45-year-old female with type 2 diabetes (A1C 7.8%), eGFR 45 mL/min/1.73m², and
UACR 285 mg/g (moderately increased albuminuria) presents for diabetes optimization.
Metformin 1000 mg BID and lifestyle measures for 6 months. BP 138/84 mmHg on no
antihypertensives. What is the most appropriate next step?
A. Add glipizide 5 mg daily
, B. Add empagliflozin 10 mg daily
C. Add sitagliptin 100 mg daily
D. Add insulin glargine 10 units at bedtime
Correct Answer: B
Rationale: Primary Justification: Per ADA 2026 Standards of Care, SGLT2 inhibitors
(empagliflozin, dapagliflozin) are recommended for T2DM with CKD and albuminuria
independent of glycemic control or metformin use. EMPA-REG OUTCOME demonstrated
reduced CKD progression and cardiovascular events. Risk Mitigation: Monitor for genital
mycotic infections, volume depletion; hold during acute illness/surgery; eGFR must be
≥30 for glycemic benefit (cardiovascular/renal benefits persist at lower eGFR).
Distractor Analysis: Glipizide (A) risks hypoglycemia and weight gain without renal
protection. Sitagliptin (C) is weight-neutral but requires dose reduction in renal
impairment and lacks cardiovascular/renal outcome benefits. Insulin (D) is unnecessary
given reasonable A1C and effective oral options available.
Q5: A 62-year-old male with stable angina reports sublingual nitroglycerin 0.4 mg
relieves chest pain in 4-5 minutes, but he experiences severe headaches. He has used
12 tablets in the past week. His current medications include metoprolol 50 mg BID and
amlodipine 5 mg daily. What is the most appropriate intervention?
A. Discontinue nitroglycerin and initiate ranolazine 500 mg BID
B. Reduce nitroglycerin to 0.3 mg and add isosorbide mononitrate 30 mg daily
C. Uptitrate metoprolol to 100 mg BID and continue current nitroglycerin use
D. Add lisinopril 10 mg daily to reduce nitroglycerin requirements
