NSG 533 – Advanced Pharmacology Exam 1
Wilkes University | 2026/2027 | Verified Study Guide with Correct
Concepts
Graduate Nursing Program | AANP & ANCC Adult-Gerontology Primary
Care NP Alignment
UNIT 1: FOUNDATIONAL CONCEPTS – PHARMACOKINETICS,
PHARMACODYNAMICS, PHARMACOGENOMICS, DRUG REGULATION
[GUIDELINE YEAR: FDA 2026, CPIC Guidelines 2026, DEA 2026]
Q1: A 62-year-old patient with cirrhosis is prescribed diazepam for anxiety. Which
pharmacokinetic parameter is most significantly altered in this patient, requiring dose
adjustment?
A. Absorption – decreased bioavailability due to portal hypertension
B. Distribution – increased volume of distribution for lipid-soluble drugs
C. Metabolism – reduced Phase I oxidation via CYP450 enzymes
D. Excretion – decreased renal clearance of active metabolites
Correct Answer: C
Clinical Judgment Skill: Analyze Cues – Recognize Pharmacokinetic Alterations
Rationale: [CORRECT] C: Diazepam undergoes extensive hepatic metabolism via
CYP2C19 and CYP3A4 (Phase I oxidation). In cirrhosis, hepatocellular dysfunction
,reduces CYP450 enzyme activity, decreasing metabolic clearance and prolonging
half-life. This necessitates dose reduction (typically 50%) to avoid accumulation and
excessive sedation. A: Absorption is minimally affected in cirrhosis; portal hypertension
may affect first-pass metabolism but not absorption per se. B: Volume of distribution
may increase due to hypoalbuminemia and ascites, but this is not the primary concern
for diazepam. D: Diazepam metabolites are renally excreted, but hepatic metabolism is
the rate-limiting step. CPIC Guideline for CYP2C19 and Diazepam (2026). Wilkes NSG 533
Module 1: Hepatic drug metabolism. Common NP error: Focusing on renal function while
overlooking hepatic impairment in cirrhosis.
Q2: A patient is started on simvastatin 40 mg daily for hyperlipidemia. Three weeks
later, she reports new-onset muscle pain and weakness. Which of the following
concomitant medications is most likely contributing to this adverse effect?
A. Metformin 1000 mg BID
B. Amlodipine 5 mg daily
C. Amiodarone 200 mg daily
D. Levothyroxine 75 mcg daily
Correct Answer: C
Clinical Judgment Skill: Analyze Cues – Recognize Drug Interactions
Rationale: [CORRECT] C: Amiodarone is a potent CYP3A4 inhibitor. Simvastatin is
metabolized by CYP3A4; co-administration with amiodarone significantly increases
simvastatin plasma concentrations, elevating risk of statin-induced myopathy and
rhabdomyolysis. The FDA limits simvastatin to 20 mg daily when co-administered with
amiodarone. A: Metformin has no significant CYP interactions with statins. B:
,Amlodipine is a weak CYP3A4 inhibitor; interaction is less significant than amiodarone.
D: Levothyroxine does not inhibit CYP3A4. FDA Drug Safety Communication (2026).
Wilkes NSG 533 Module 1: CYP450 drug interactions. Common NP error: Failing to review
drug-drug interactions when prescribing statins.
Q3: A 45-year-old patient of Asian descent is started on warfarin for DVT prophylaxis.
Genetic testing reveals CYP2C9*2/*3 and VKORC1 -1639G>A polymorphisms. Which of
the following is the most appropriate initial warfarin dosing strategy?
A. Start at standard 5 mg daily and adjust based on INR
B. Initiate at 2.5 mg daily with close INR monitoring
C. Start at 7.5 mg daily due to rapid metabolism
D. Avoid warfarin entirely; use DOAC instead
Correct Answer: B
Clinical Judgment Skill: Generate Solutions – Pharmacogenomic-Guided Dosing
Rationale: [CORRECT] B: CYP2C9*2/*3 polymorphisms reduce warfarin metabolism
(decreased clearance), and VKORC1 -1639G>A increases sensitivity to warfarin at the
receptor level. Combined, these genetic variants predict decreased dose requirements
(often 2-3 mg daily) and increased bleeding risk with standard dosing. Starting at 2.5
mg with close INR monitoring is recommended. A: Standard 5 mg would likely result in
supratherapeutic INR and bleeding. C: 7.5 mg would be dangerous. D: DOACs are an
option but not mandatory; warfarin can be used safely with genotype-guided dosing.
CPIC Guideline for CYP2C9 and VKORC1 Genotypes and Warfarin Dosing (2026). Wilkes
NSG 533 Module 1: Pharmacogenomics. Common NP error: Using one-size-fits-all
warfarin dosing without considering genetic and ethnic factors.
, Q4: A drug with a narrow therapeutic index (NTI) requires therapeutic drug monitoring.
Which of the following medications is classified as NTI and requires routine level
monitoring?
A. Metformin
B. Atorvastatin
C. Lithium
D. Losartan
Correct Answer: C
Clinical Judgment Skill: Recognize Cues – Narrow Therapeutic Index Drugs
Rationale: [CORRECT] C: Lithium has a narrow therapeutic index (0.6-1.2 mEq/L for
maintenance; toxicity >1.5 mEq/L). Small increases in concentration can cause toxicity
(neurological, renal, thyroid). Routine level monitoring is essential. A: Metformin has a
wide therapeutic index; monitoring is for renal function, not drug levels. B: Atorvastatin
has a wide therapeutic index; monitoring is for efficacy (lipid panel) and adverse effects,
not drug levels. D: Losartan has a wide therapeutic index; no routine level monitoring
required. Wilkes NSG 533 Module 1: Narrow therapeutic index drugs include digoxin,
warfarin, lithium, theophylline, phenytoin, valproate, aminoglycosides. Common NP error:
Assuming all cardiovascular or metabolic drugs require level monitoring.
Q5: Which CYP450 enzyme is responsible for the metabolism of approximately 50% of
clinically used drugs and is the primary pathway for many statins, calcium channel
blockers, and immunosuppressants?
A. CYP1A2
Wilkes University | 2026/2027 | Verified Study Guide with Correct
Concepts
Graduate Nursing Program | AANP & ANCC Adult-Gerontology Primary
Care NP Alignment
UNIT 1: FOUNDATIONAL CONCEPTS – PHARMACOKINETICS,
PHARMACODYNAMICS, PHARMACOGENOMICS, DRUG REGULATION
[GUIDELINE YEAR: FDA 2026, CPIC Guidelines 2026, DEA 2026]
Q1: A 62-year-old patient with cirrhosis is prescribed diazepam for anxiety. Which
pharmacokinetic parameter is most significantly altered in this patient, requiring dose
adjustment?
A. Absorption – decreased bioavailability due to portal hypertension
B. Distribution – increased volume of distribution for lipid-soluble drugs
C. Metabolism – reduced Phase I oxidation via CYP450 enzymes
D. Excretion – decreased renal clearance of active metabolites
Correct Answer: C
Clinical Judgment Skill: Analyze Cues – Recognize Pharmacokinetic Alterations
Rationale: [CORRECT] C: Diazepam undergoes extensive hepatic metabolism via
CYP2C19 and CYP3A4 (Phase I oxidation). In cirrhosis, hepatocellular dysfunction
,reduces CYP450 enzyme activity, decreasing metabolic clearance and prolonging
half-life. This necessitates dose reduction (typically 50%) to avoid accumulation and
excessive sedation. A: Absorption is minimally affected in cirrhosis; portal hypertension
may affect first-pass metabolism but not absorption per se. B: Volume of distribution
may increase due to hypoalbuminemia and ascites, but this is not the primary concern
for diazepam. D: Diazepam metabolites are renally excreted, but hepatic metabolism is
the rate-limiting step. CPIC Guideline for CYP2C19 and Diazepam (2026). Wilkes NSG 533
Module 1: Hepatic drug metabolism. Common NP error: Focusing on renal function while
overlooking hepatic impairment in cirrhosis.
Q2: A patient is started on simvastatin 40 mg daily for hyperlipidemia. Three weeks
later, she reports new-onset muscle pain and weakness. Which of the following
concomitant medications is most likely contributing to this adverse effect?
A. Metformin 1000 mg BID
B. Amlodipine 5 mg daily
C. Amiodarone 200 mg daily
D. Levothyroxine 75 mcg daily
Correct Answer: C
Clinical Judgment Skill: Analyze Cues – Recognize Drug Interactions
Rationale: [CORRECT] C: Amiodarone is a potent CYP3A4 inhibitor. Simvastatin is
metabolized by CYP3A4; co-administration with amiodarone significantly increases
simvastatin plasma concentrations, elevating risk of statin-induced myopathy and
rhabdomyolysis. The FDA limits simvastatin to 20 mg daily when co-administered with
amiodarone. A: Metformin has no significant CYP interactions with statins. B:
,Amlodipine is a weak CYP3A4 inhibitor; interaction is less significant than amiodarone.
D: Levothyroxine does not inhibit CYP3A4. FDA Drug Safety Communication (2026).
Wilkes NSG 533 Module 1: CYP450 drug interactions. Common NP error: Failing to review
drug-drug interactions when prescribing statins.
Q3: A 45-year-old patient of Asian descent is started on warfarin for DVT prophylaxis.
Genetic testing reveals CYP2C9*2/*3 and VKORC1 -1639G>A polymorphisms. Which of
the following is the most appropriate initial warfarin dosing strategy?
A. Start at standard 5 mg daily and adjust based on INR
B. Initiate at 2.5 mg daily with close INR monitoring
C. Start at 7.5 mg daily due to rapid metabolism
D. Avoid warfarin entirely; use DOAC instead
Correct Answer: B
Clinical Judgment Skill: Generate Solutions – Pharmacogenomic-Guided Dosing
Rationale: [CORRECT] B: CYP2C9*2/*3 polymorphisms reduce warfarin metabolism
(decreased clearance), and VKORC1 -1639G>A increases sensitivity to warfarin at the
receptor level. Combined, these genetic variants predict decreased dose requirements
(often 2-3 mg daily) and increased bleeding risk with standard dosing. Starting at 2.5
mg with close INR monitoring is recommended. A: Standard 5 mg would likely result in
supratherapeutic INR and bleeding. C: 7.5 mg would be dangerous. D: DOACs are an
option but not mandatory; warfarin can be used safely with genotype-guided dosing.
CPIC Guideline for CYP2C9 and VKORC1 Genotypes and Warfarin Dosing (2026). Wilkes
NSG 533 Module 1: Pharmacogenomics. Common NP error: Using one-size-fits-all
warfarin dosing without considering genetic and ethnic factors.
, Q4: A drug with a narrow therapeutic index (NTI) requires therapeutic drug monitoring.
Which of the following medications is classified as NTI and requires routine level
monitoring?
A. Metformin
B. Atorvastatin
C. Lithium
D. Losartan
Correct Answer: C
Clinical Judgment Skill: Recognize Cues – Narrow Therapeutic Index Drugs
Rationale: [CORRECT] C: Lithium has a narrow therapeutic index (0.6-1.2 mEq/L for
maintenance; toxicity >1.5 mEq/L). Small increases in concentration can cause toxicity
(neurological, renal, thyroid). Routine level monitoring is essential. A: Metformin has a
wide therapeutic index; monitoring is for renal function, not drug levels. B: Atorvastatin
has a wide therapeutic index; monitoring is for efficacy (lipid panel) and adverse effects,
not drug levels. D: Losartan has a wide therapeutic index; no routine level monitoring
required. Wilkes NSG 533 Module 1: Narrow therapeutic index drugs include digoxin,
warfarin, lithium, theophylline, phenytoin, valproate, aminoglycosides. Common NP error:
Assuming all cardiovascular or metabolic drugs require level monitoring.
Q5: Which CYP450 enzyme is responsible for the metabolism of approximately 50% of
clinically used drugs and is the primary pathway for many statins, calcium channel
blockers, and immunosuppressants?
A. CYP1A2
