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NSG 531 Advanced Pharmacology — Exam 2
Institution : Rush University College of Nursing
Exam Specifications: 60 Questions | 90 Minutes | Passing Score: 78% (47/60 correct) Question
Distribution: 45 Multiple Choice | 10 Clinical Scenarios | 5 Select All That Apply
DOMAIN I: CARDIOVASCULAR PHARMACOLOGY (Questions 1–12)
Question 1
A 68-year-old male with HFrEF (LVEF 35%) is on metoprolol succinate 50 mg daily, lisinopril 10
mg daily, and furosemide 40 mg daily. Which medication, when added to his regimen, has been
shown to reduce both mortality and heart failure hospitalizations?
A. Digoxin
B. Spironolactone
C. Hydralazine/isosorbide dinitrate
D. Diltiazem
Correct Answer: B
Rationale: Mineralocorticoid receptor antagonists (MRAs) such as spironolactone and
eplerenone reduce mortality and HF hospitalizations in patients with HFrEF (LVEF ≤40%) based
on the RALES and EMPHASIS-HF trials. Digoxin (A) reduces hospitalizations but has no mortality
benefit. Hydralazine/ISDN (C) provides mortality benefit primarily in self-identified Black
patients (A-HeFT trial). Non-dihydropyridine calcium channel blockers such as diltiazem (D) are
contraindicated in HFrEF due to negative inotropic effects.
Question 2
A 55-year-old Black male with newly diagnosed hypertension (BP 158/96 mmHg) and no
comorbidities is started on monotherapy. According to ACC/AHA guidelines, which
antihypertensive class is preferred as initial therapy?
A. ACE inhibitor
B. Angiotensin receptor blocker
,2
C. Calcium channel blocker
D. Beta-blocker
Correct Answer: C
Rationale: Black patients tend to have lower plasma renin levels and respond less well to ACE
inhibitors and ARBs as monotherapy. ACC/AHA guidelines recommend thiazide diuretics or
dihydropyridine calcium channel blockers (such as amlodipine) as preferred initial therapy in
Black patients without compelling indications for other classes. Beta-blockers (D) are not first-
line for uncomplicated hypertension.
Question 3
A 62-year-old female with hypertension and Type 2 diabetes mellitus (eGFR 45 mL/min/1.73m²,
albuminuria 250 mg/g) is being started on lisinopril. Which adverse effect requires the most
vigilant monitoring?
A. Hypokalemia
B. Angioedema
C. Hyperkalemia
D. Dry cough
Correct Answer: C
Rationale: In patients with CKD (eGFR <60) and diabetes, ACE inhibitors reduce proteinuria and
slow CKD progression but significantly increase the risk of hyperkalemia due to decreased
aldosterone. Baseline and periodic monitoring of serum potassium and creatinine is essential.
While dry cough (D) and angioedema (B) are known adverse effects, hyperkalemia (C) is the
most dangerous and requires proactive monitoring. Hypokalemia (A) is associated with
diuretics, not ACE inhibitors.
Question 4
A 70-year-old male with atrial fibrillation (CHADS₂-VASc score 4) is started on apixaban 5 mg
twice daily. Which statement accurately describes an advantage of apixaban over warfarin?
A. Apixaban requires routine INR monitoring
B. Apixaban has a higher risk of major bleeding
C. Apixaban has fewer drug-drug interactions with CYP450 enzymes
D. Apixaban is reversed with vitamin K administration
, 3
Correct Answer: C
Rationale: Apixaban, a direct factor Xa inhibitor, has predictable pharmacokinetics and does not
require routine coagulation monitoring (A is incorrect). The ARISTOTLE trial demonstrated that
apixaban has a lower risk of major bleeding compared to warfarin, particularly intracranial
hemorrhage (B is incorrect). Apixaban is metabolized primarily via CYP3A4 but has fewer
clinically significant drug interactions than warfarin, which is metabolized by multiple CYP
enzymes and affected by vitamin K intake. Apixaban is reversed with andexanet alfa, not vitamin
K (D is incorrect).
Question 5
A 58-year-old male with HFrEF (LVEF 30%) on guideline-directed medical therapy remains
symptomatic (NYHA Class III). His cardiologist considers switching his ACE inhibitor to
sacubitril/valsartan (Entresto). What is the primary mechanism by which this medication
improves outcomes compared to ACE inhibitor alone?
A. Selective angiotensin II receptor blockade
B. Neprilysin inhibition combined with ARB
C. Direct renin inhibition
D. Aldosterone receptor antagonism
Correct Answer: B
Rationale: Sacubitril/valsartan is an angiotensin receptor-neprilysin inhibitor (ARNi). Sacubitril
inhibits neprilysin, which degrades natriuretic peptides (ANP, BNP), thereby promoting
vasodilation, natriuresis, and inhibition of fibrosis. Valsartan provides AT₁ receptor blockade. The
PARADIGM-HF trial demonstrated superiority over enalapril in reducing cardiovascular death
and HF hospitalization. A 36-hour washout period is required when switching from ACE inhibitor
to ARNi to avoid angioedema risk from combined ACE and neprilysin inhibition.
Question 6
A 45-year-old female with mechanical mitral valve replacement requires anticoagulation. Which
agent and target INR are most appropriate?
A. Apixaban 5 mg BID; no INR monitoring
B. Warfarin; INR goal 2.0–3.0
C. Warfarin; INR goal 2.5–3.5
D. Rivaroxaban 20 mg daily; no INR monitoring
NSG 531 Advanced Pharmacology — Exam 2
Institution : Rush University College of Nursing
Exam Specifications: 60 Questions | 90 Minutes | Passing Score: 78% (47/60 correct) Question
Distribution: 45 Multiple Choice | 10 Clinical Scenarios | 5 Select All That Apply
DOMAIN I: CARDIOVASCULAR PHARMACOLOGY (Questions 1–12)
Question 1
A 68-year-old male with HFrEF (LVEF 35%) is on metoprolol succinate 50 mg daily, lisinopril 10
mg daily, and furosemide 40 mg daily. Which medication, when added to his regimen, has been
shown to reduce both mortality and heart failure hospitalizations?
A. Digoxin
B. Spironolactone
C. Hydralazine/isosorbide dinitrate
D. Diltiazem
Correct Answer: B
Rationale: Mineralocorticoid receptor antagonists (MRAs) such as spironolactone and
eplerenone reduce mortality and HF hospitalizations in patients with HFrEF (LVEF ≤40%) based
on the RALES and EMPHASIS-HF trials. Digoxin (A) reduces hospitalizations but has no mortality
benefit. Hydralazine/ISDN (C) provides mortality benefit primarily in self-identified Black
patients (A-HeFT trial). Non-dihydropyridine calcium channel blockers such as diltiazem (D) are
contraindicated in HFrEF due to negative inotropic effects.
Question 2
A 55-year-old Black male with newly diagnosed hypertension (BP 158/96 mmHg) and no
comorbidities is started on monotherapy. According to ACC/AHA guidelines, which
antihypertensive class is preferred as initial therapy?
A. ACE inhibitor
B. Angiotensin receptor blocker
,2
C. Calcium channel blocker
D. Beta-blocker
Correct Answer: C
Rationale: Black patients tend to have lower plasma renin levels and respond less well to ACE
inhibitors and ARBs as monotherapy. ACC/AHA guidelines recommend thiazide diuretics or
dihydropyridine calcium channel blockers (such as amlodipine) as preferred initial therapy in
Black patients without compelling indications for other classes. Beta-blockers (D) are not first-
line for uncomplicated hypertension.
Question 3
A 62-year-old female with hypertension and Type 2 diabetes mellitus (eGFR 45 mL/min/1.73m²,
albuminuria 250 mg/g) is being started on lisinopril. Which adverse effect requires the most
vigilant monitoring?
A. Hypokalemia
B. Angioedema
C. Hyperkalemia
D. Dry cough
Correct Answer: C
Rationale: In patients with CKD (eGFR <60) and diabetes, ACE inhibitors reduce proteinuria and
slow CKD progression but significantly increase the risk of hyperkalemia due to decreased
aldosterone. Baseline and periodic monitoring of serum potassium and creatinine is essential.
While dry cough (D) and angioedema (B) are known adverse effects, hyperkalemia (C) is the
most dangerous and requires proactive monitoring. Hypokalemia (A) is associated with
diuretics, not ACE inhibitors.
Question 4
A 70-year-old male with atrial fibrillation (CHADS₂-VASc score 4) is started on apixaban 5 mg
twice daily. Which statement accurately describes an advantage of apixaban over warfarin?
A. Apixaban requires routine INR monitoring
B. Apixaban has a higher risk of major bleeding
C. Apixaban has fewer drug-drug interactions with CYP450 enzymes
D. Apixaban is reversed with vitamin K administration
, 3
Correct Answer: C
Rationale: Apixaban, a direct factor Xa inhibitor, has predictable pharmacokinetics and does not
require routine coagulation monitoring (A is incorrect). The ARISTOTLE trial demonstrated that
apixaban has a lower risk of major bleeding compared to warfarin, particularly intracranial
hemorrhage (B is incorrect). Apixaban is metabolized primarily via CYP3A4 but has fewer
clinically significant drug interactions than warfarin, which is metabolized by multiple CYP
enzymes and affected by vitamin K intake. Apixaban is reversed with andexanet alfa, not vitamin
K (D is incorrect).
Question 5
A 58-year-old male with HFrEF (LVEF 30%) on guideline-directed medical therapy remains
symptomatic (NYHA Class III). His cardiologist considers switching his ACE inhibitor to
sacubitril/valsartan (Entresto). What is the primary mechanism by which this medication
improves outcomes compared to ACE inhibitor alone?
A. Selective angiotensin II receptor blockade
B. Neprilysin inhibition combined with ARB
C. Direct renin inhibition
D. Aldosterone receptor antagonism
Correct Answer: B
Rationale: Sacubitril/valsartan is an angiotensin receptor-neprilysin inhibitor (ARNi). Sacubitril
inhibits neprilysin, which degrades natriuretic peptides (ANP, BNP), thereby promoting
vasodilation, natriuresis, and inhibition of fibrosis. Valsartan provides AT₁ receptor blockade. The
PARADIGM-HF trial demonstrated superiority over enalapril in reducing cardiovascular death
and HF hospitalization. A 36-hour washout period is required when switching from ACE inhibitor
to ARNi to avoid angioedema risk from combined ACE and neprilysin inhibition.
Question 6
A 45-year-old female with mechanical mitral valve replacement requires anticoagulation. Which
agent and target INR are most appropriate?
A. Apixaban 5 mg BID; no INR monitoring
B. Warfarin; INR goal 2.0–3.0
C. Warfarin; INR goal 2.5–3.5
D. Rivaroxaban 20 mg daily; no INR monitoring
