PHARMACOLOGY FOR NURSING CARE 11TH EDITION
EXAM 2026
Lehne’s | Chapters 1–112 Complete Coverage
Drug Names, Mechanisms, Adverse Effects, Nursing Interventions, and Clinical Decision-Making
Introduction
This comprehensive pharmacology exam review for the 2026 certification cycle provides evidence-based
exam-style questions with verified correct answers and clinical rationales covering all 112 chapters of Lehne’s
Pharmacology for Nursing Care, 11th Edition. Content spans pharmacokinetics, pharmacodynamics, autonomic
and CNS pharmacology, cardiovascular agents, antimicrobials, antineoplastics, endocrine drugs, and all major
drug classes critical to nursing pharmacology mastery and safe medication administration.
Unit I: Introduction to Pharmacology (Chapters 1–5)
Covers drug nomenclature, pharmacokinetics (ADME), pharmacodynamics (dose-response, receptors,
agonists/antagonists), drug regulation, and the CYP450 enzyme system.
1. A patient is prescribed a medication that undergoes extensive first-pass hepatic metabolism. When the
same drug is administered intravenously instead of orally, which effect is expected?
A. Higher risk of hepatotoxicity B. Greater bioavailability and higher plasma drug
levels
C. Delayed onset of action D. Increased drug excretion via the kidneys
Correct Answer: B
Rationale: The first-pass effect refers to the rapid hepatic metabolism of orally administered drugs before they reach
systemic circulation, significantly reducing bioavailability. Drugs given intravenously bypass hepatic first-pass
metabolism, resulting in higher bioavailability and higher plasma drug levels for the same dose. Examples of high first-
pass drugs include morphine, propranolol, lidocaine, nitroglycerin, and verapamil. Hepatotoxicity risk is related to the
drug’s intrinsic hepatotoxic potential, not the route. IV administration has a faster onset, not delayed. Excretion is not
directly affected by first-pass metabolism.
2. A drug has a therapeutic index (TI) of 2. Which statement best describes this drug’s safety profile?
A. The drug has a wide margin of safety B. The drug has a narrow therapeutic window
requiring close monitoring
C. The drug is ineffective at any dose D. The drug has no adverse effects
Correct Answer: B
Rationale: The therapeutic index (TI) is calculated as TD50/ED50 (ratio of the dose producing toxicity in 50% of
patients to the dose producing the desired effect in 50% of patients). A low TI (close to 1) indicates a narrow therapeutic
window, meaning the effective dose is close to the toxic dose, requiring careful monitoring and dose adjustment. Drugs
with narrow TI include digoxin, warfarin, lithium, phenytoin, theophylline, vancomycin, and aminoglycosides. A high
TI (e.g., penicillin, TI >100) indicates a wide margin of safety. All drugs have potential adverse effects regardless of TI.
3. A patient’s medication has a half-life of 6 hours. Approximately how long will it take to reach steady-state
concentration with continuous dosing?
A. 6 hours B. 12 hours
,C. 24–30 hours D. 48–60 hours
Correct Answer: C
Rationale: Steady state is achieved when the rate of drug administration equals the rate of elimination, which occurs
after approximately 4–5 half-lives. For a drug with a 6-hour half-life: 4 × 6 = 24 hours and 5 × 6 = 30 hours. At steady
state, approximately 93.75–96.9% of the final steady-state concentration is reached. A loading dose can achieve
therapeutic levels faster. The half-life also determines the time for drug elimination: after 4–5 half-lives, approximately
94–97% of the drug is eliminated from the body. This principle applies to all drugs following first-order kinetics.
4. A highly protein-bound drug (98% bound to albumin) is administered to a patient with hypoalbuminemia.
What is the expected clinical effect?
A. Decreased therapeutic effect due to less free drug B. Increased free drug concentration with higher
risk of toxicity
C. No change in drug effect D. Increased protein binding at alternative sites
Correct Answer: B
Rationale: Drugs bind to plasma proteins (primarily albumin) in a reversible equilibrium. Only unbound (free) drug is
pharmacologically active. When albumin levels are low (hypoalbuminemia, common in liver disease, malnutrition,
elderly), the same total drug dose results in a higher proportion of free drug, potentially increasing pharmacological
effects and toxicity risk. This is clinically significant for highly protein-bound drugs such as warfarin, phenytoin, and
valproate. Close monitoring and potential dose reduction may be needed. Drug displacement from protein binding sites
by other drugs can also increase free drug levels transiently.
5. A patient is taking carbamazepine and phenytoin, both of which are CYP450 enzyme inducers. A new
medication metabolized by CYP3A4 is added. What effect is expected?
A. Increased plasma levels of the new medication B. Decreased plasma levels of the new medication
with potential therapeutic failure
C. No interaction expected D. Increased risk of bleeding
Correct Answer: B
Rationale: CYP450 enzyme inducers increase the synthesis of metabolic enzymes, accelerating the metabolism of
substrate drugs and reducing their plasma levels. This can lead to therapeutic failure if doses are not adjusted. Common
inducers include carbamazepine, phenytoin, barbiturates, rifampin, St. John’s Wort, and cigarette smoke. Conversely,
enzyme inhibitors (amiodarone, cimetidine, fluconazole, erythromycin, grapefruit juice) decrease metabolism,
increasing drug levels and toxicity risk. When starting or stopping inducers/inhibitors, drug levels should be monitored
and doses adjusted accordingly.
6. A patient taking a medication that follows zero-order kinetics requires careful monitoring. Which drug
follows zero-order kinetics at therapeutic doses?
A. Metoprolol B. Phenytoin
C. Amoxicillin D. Lisinopril
Correct Answer: B
Rationale: Most drugs follow first-order kinetics (constant fraction eliminated per unit time). Phenytoin follows zero-
order (Michaelis-Menten) kinetics at therapeutic doses, meaning a constant amount (not fraction) is metabolized per
unit time. Small dose increases can produce disproportionate increases in plasma levels, leading to toxicity. Phenytoin
requires therapeutic drug monitoring (target 10–20 mcg/mL). Other drugs with zero-order kinetics include ethanol and
high-dose aspirin. At low doses, phenytoin actually follows first-order kinetics, converting to zero-order as hepatic
enzymes become saturated.
, Unit II: Basic Principles of Pharmacology (Chapters 6–9)
Covers drug-drug and drug-food interactions, individual variation in drug response (pharmacogenetics, age,
body weight), drug administration in pregnancy/lactation, and renal disease dosing adjustments.
7. A patient taking a monoamine oxidase inhibitor (MAOI) eats aged cheese and drinks Chianti wine. Which
adverse reaction is most likely to occur?
A. Hypoglycemia B. Hypertensive crisis
C. Serotonin syndrome D. Neuroleptic malignant syndrome
Correct Answer: B
Rationale: MAOIs block the enzyme monoamine oxidase, which normally breaks down tyramine in the GI tract. When
MAOIs inhibit this enzyme, ingested tyramine (found in aged cheese, Chianti wine, pickled herring, smoked meats,
avocados, bananas, fava beans, soy sauce) accumulates and displaces norepinephrine from nerve terminals, causing a
hypertensive crisis with potentially fatal intracranial hemorrhage. Patients on MAOIs must follow a tyramine-restricted
diet. Treatment includes phentolamine (an alpha-blocker) or nitroprusside. Serotonin syndrome occurs from combining
MAOIs with serotonergic drugs, not from tyramine.
8. A patient takes grapefruit juice daily and is started on a new medication metabolized by CYP3A4. What
effect is expected?
A. Decreased drug levels B. Increased drug levels with potential toxicity
C. No effect on drug metabolism D. Rapid drug elimination
Correct Answer: B
Rationale: Grapefruit juice inhibits intestinal CYP3A4 enzymes (not hepatic), reducing presystemic metabolism of
CYP3A4 substrates and increasing their bioavailability. This can lead to elevated drug levels and increased risk of
toxicity. Affected drugs include statins (simvastatin, atorvastatin), calcium channel blockers (felodipine, nifedipine),
immunosuppressants (cyclosporine, tacrolimus), and benzodiazepines (midazolam, triazolam). The interaction is most
significant with large quantities of grapefruit juice and can persist for 24–72 hours. Seville oranges (but not regular
oranges) have a similar effect.
9. A patient with a genetic polymorphism causing CYP2D6 poor metabolizer status is prescribed codeine for
pain. What is the expected clinical outcome?
A. Enhanced analgesia B. No analgesic effect because codeine cannot be
converted to morphine
C. Increased risk of codeine toxicity D. Delayed onset of analgesia
Correct Answer: B
Rationale: Codeine is a prodrug that requires conversion to morphine (the active analgesic) by CYP2D6. Poor
metabolizers lack functional CYP2D6 enzymes and cannot convert codeine to morphine, resulting in no analgesic
effect. Ultra-rapid metabolizers convert codeine too rapidly, producing excessive morphine levels and risk of respiratory
depression and death (contraindicated in ultra-rapid metabolizers and breastfeeding mothers). CYP2D6 testing can
guide opioid prescribing. Other CYP2D6 substrates include tramadol, tamoxifen, and some antidepressants (paroxetine,
fluoxetine are also CYP2D6 inhibitors).
10. Which factor contributes to increased drug sensitivity in geriatric patients?
A. Increased hepatic metabolism B. Decreased total body water with increased body
fat proportion
C. Increased plasma protein binding D. Faster renal drug clearance
Correct Answer: B
EXAM 2026
Lehne’s | Chapters 1–112 Complete Coverage
Drug Names, Mechanisms, Adverse Effects, Nursing Interventions, and Clinical Decision-Making
Introduction
This comprehensive pharmacology exam review for the 2026 certification cycle provides evidence-based
exam-style questions with verified correct answers and clinical rationales covering all 112 chapters of Lehne’s
Pharmacology for Nursing Care, 11th Edition. Content spans pharmacokinetics, pharmacodynamics, autonomic
and CNS pharmacology, cardiovascular agents, antimicrobials, antineoplastics, endocrine drugs, and all major
drug classes critical to nursing pharmacology mastery and safe medication administration.
Unit I: Introduction to Pharmacology (Chapters 1–5)
Covers drug nomenclature, pharmacokinetics (ADME), pharmacodynamics (dose-response, receptors,
agonists/antagonists), drug regulation, and the CYP450 enzyme system.
1. A patient is prescribed a medication that undergoes extensive first-pass hepatic metabolism. When the
same drug is administered intravenously instead of orally, which effect is expected?
A. Higher risk of hepatotoxicity B. Greater bioavailability and higher plasma drug
levels
C. Delayed onset of action D. Increased drug excretion via the kidneys
Correct Answer: B
Rationale: The first-pass effect refers to the rapid hepatic metabolism of orally administered drugs before they reach
systemic circulation, significantly reducing bioavailability. Drugs given intravenously bypass hepatic first-pass
metabolism, resulting in higher bioavailability and higher plasma drug levels for the same dose. Examples of high first-
pass drugs include morphine, propranolol, lidocaine, nitroglycerin, and verapamil. Hepatotoxicity risk is related to the
drug’s intrinsic hepatotoxic potential, not the route. IV administration has a faster onset, not delayed. Excretion is not
directly affected by first-pass metabolism.
2. A drug has a therapeutic index (TI) of 2. Which statement best describes this drug’s safety profile?
A. The drug has a wide margin of safety B. The drug has a narrow therapeutic window
requiring close monitoring
C. The drug is ineffective at any dose D. The drug has no adverse effects
Correct Answer: B
Rationale: The therapeutic index (TI) is calculated as TD50/ED50 (ratio of the dose producing toxicity in 50% of
patients to the dose producing the desired effect in 50% of patients). A low TI (close to 1) indicates a narrow therapeutic
window, meaning the effective dose is close to the toxic dose, requiring careful monitoring and dose adjustment. Drugs
with narrow TI include digoxin, warfarin, lithium, phenytoin, theophylline, vancomycin, and aminoglycosides. A high
TI (e.g., penicillin, TI >100) indicates a wide margin of safety. All drugs have potential adverse effects regardless of TI.
3. A patient’s medication has a half-life of 6 hours. Approximately how long will it take to reach steady-state
concentration with continuous dosing?
A. 6 hours B. 12 hours
,C. 24–30 hours D. 48–60 hours
Correct Answer: C
Rationale: Steady state is achieved when the rate of drug administration equals the rate of elimination, which occurs
after approximately 4–5 half-lives. For a drug with a 6-hour half-life: 4 × 6 = 24 hours and 5 × 6 = 30 hours. At steady
state, approximately 93.75–96.9% of the final steady-state concentration is reached. A loading dose can achieve
therapeutic levels faster. The half-life also determines the time for drug elimination: after 4–5 half-lives, approximately
94–97% of the drug is eliminated from the body. This principle applies to all drugs following first-order kinetics.
4. A highly protein-bound drug (98% bound to albumin) is administered to a patient with hypoalbuminemia.
What is the expected clinical effect?
A. Decreased therapeutic effect due to less free drug B. Increased free drug concentration with higher
risk of toxicity
C. No change in drug effect D. Increased protein binding at alternative sites
Correct Answer: B
Rationale: Drugs bind to plasma proteins (primarily albumin) in a reversible equilibrium. Only unbound (free) drug is
pharmacologically active. When albumin levels are low (hypoalbuminemia, common in liver disease, malnutrition,
elderly), the same total drug dose results in a higher proportion of free drug, potentially increasing pharmacological
effects and toxicity risk. This is clinically significant for highly protein-bound drugs such as warfarin, phenytoin, and
valproate. Close monitoring and potential dose reduction may be needed. Drug displacement from protein binding sites
by other drugs can also increase free drug levels transiently.
5. A patient is taking carbamazepine and phenytoin, both of which are CYP450 enzyme inducers. A new
medication metabolized by CYP3A4 is added. What effect is expected?
A. Increased plasma levels of the new medication B. Decreased plasma levels of the new medication
with potential therapeutic failure
C. No interaction expected D. Increased risk of bleeding
Correct Answer: B
Rationale: CYP450 enzyme inducers increase the synthesis of metabolic enzymes, accelerating the metabolism of
substrate drugs and reducing their plasma levels. This can lead to therapeutic failure if doses are not adjusted. Common
inducers include carbamazepine, phenytoin, barbiturates, rifampin, St. John’s Wort, and cigarette smoke. Conversely,
enzyme inhibitors (amiodarone, cimetidine, fluconazole, erythromycin, grapefruit juice) decrease metabolism,
increasing drug levels and toxicity risk. When starting or stopping inducers/inhibitors, drug levels should be monitored
and doses adjusted accordingly.
6. A patient taking a medication that follows zero-order kinetics requires careful monitoring. Which drug
follows zero-order kinetics at therapeutic doses?
A. Metoprolol B. Phenytoin
C. Amoxicillin D. Lisinopril
Correct Answer: B
Rationale: Most drugs follow first-order kinetics (constant fraction eliminated per unit time). Phenytoin follows zero-
order (Michaelis-Menten) kinetics at therapeutic doses, meaning a constant amount (not fraction) is metabolized per
unit time. Small dose increases can produce disproportionate increases in plasma levels, leading to toxicity. Phenytoin
requires therapeutic drug monitoring (target 10–20 mcg/mL). Other drugs with zero-order kinetics include ethanol and
high-dose aspirin. At low doses, phenytoin actually follows first-order kinetics, converting to zero-order as hepatic
enzymes become saturated.
, Unit II: Basic Principles of Pharmacology (Chapters 6–9)
Covers drug-drug and drug-food interactions, individual variation in drug response (pharmacogenetics, age,
body weight), drug administration in pregnancy/lactation, and renal disease dosing adjustments.
7. A patient taking a monoamine oxidase inhibitor (MAOI) eats aged cheese and drinks Chianti wine. Which
adverse reaction is most likely to occur?
A. Hypoglycemia B. Hypertensive crisis
C. Serotonin syndrome D. Neuroleptic malignant syndrome
Correct Answer: B
Rationale: MAOIs block the enzyme monoamine oxidase, which normally breaks down tyramine in the GI tract. When
MAOIs inhibit this enzyme, ingested tyramine (found in aged cheese, Chianti wine, pickled herring, smoked meats,
avocados, bananas, fava beans, soy sauce) accumulates and displaces norepinephrine from nerve terminals, causing a
hypertensive crisis with potentially fatal intracranial hemorrhage. Patients on MAOIs must follow a tyramine-restricted
diet. Treatment includes phentolamine (an alpha-blocker) or nitroprusside. Serotonin syndrome occurs from combining
MAOIs with serotonergic drugs, not from tyramine.
8. A patient takes grapefruit juice daily and is started on a new medication metabolized by CYP3A4. What
effect is expected?
A. Decreased drug levels B. Increased drug levels with potential toxicity
C. No effect on drug metabolism D. Rapid drug elimination
Correct Answer: B
Rationale: Grapefruit juice inhibits intestinal CYP3A4 enzymes (not hepatic), reducing presystemic metabolism of
CYP3A4 substrates and increasing their bioavailability. This can lead to elevated drug levels and increased risk of
toxicity. Affected drugs include statins (simvastatin, atorvastatin), calcium channel blockers (felodipine, nifedipine),
immunosuppressants (cyclosporine, tacrolimus), and benzodiazepines (midazolam, triazolam). The interaction is most
significant with large quantities of grapefruit juice and can persist for 24–72 hours. Seville oranges (but not regular
oranges) have a similar effect.
9. A patient with a genetic polymorphism causing CYP2D6 poor metabolizer status is prescribed codeine for
pain. What is the expected clinical outcome?
A. Enhanced analgesia B. No analgesic effect because codeine cannot be
converted to morphine
C. Increased risk of codeine toxicity D. Delayed onset of analgesia
Correct Answer: B
Rationale: Codeine is a prodrug that requires conversion to morphine (the active analgesic) by CYP2D6. Poor
metabolizers lack functional CYP2D6 enzymes and cannot convert codeine to morphine, resulting in no analgesic
effect. Ultra-rapid metabolizers convert codeine too rapidly, producing excessive morphine levels and risk of respiratory
depression and death (contraindicated in ultra-rapid metabolizers and breastfeeding mothers). CYP2D6 testing can
guide opioid prescribing. Other CYP2D6 substrates include tramadol, tamoxifen, and some antidepressants (paroxetine,
fluoxetine are also CYP2D6 inhibitors).
10. Which factor contributes to increased drug sensitivity in geriatric patients?
A. Increased hepatic metabolism B. Decreased total body water with increased body
fat proportion
C. Increased plasma protein binding D. Faster renal drug clearance
Correct Answer: B
