NURS 6521 Midterm Exam 2026 Update: Advanced Pharmacology Practice Questions with Complete
Solutions and Rationales for Nurse Practitioners Mastering Drug Therapy, Safety, and Prescriptive
Reasoning.
Version 3 – Questions 1–150 (Multiple Choice, Answers +
Explanations)
1. A patient newly started on lisinopril develops a persistent dry cough. What is the mechanism?
A) Histamine release from mast cells
B) Bradykinin accumulation in the airways
C) Direct bronchial smooth muscle constriction
D) Leukotriene overproduction
Correct Answer: B – ACE inhibitors prevent bradykinin breakdown, leading to bradykinin accumulation,
which causes dry cough.
2. Which laboratory value requires immediate action in a patient taking spironolactone?
A) Sodium 135 mEq/L
B) Potassium 5.9 mEq/L
C) Chloride 100 mEq/L
D) Glucose 95 mg/dL
Correct Answer: B – Spironolactone is potassium-sparing; potassium >5.5 mEq/L increases risk of life-
threatening arrhythmias.
3. A patient with major depressive disorder has failed two SSRIs. Which medication should be
considered next?
A) Bupropion
B) Venlafaxine (SNRI)
C) Trazodone
D) Mirtazapine
Correct Answer: B – Venlafaxine (SNRI) is often used after SSRI failure due to dual reuptake inhibition.
,4. A patient on warfarin presents with an INR of 1.1. The patient reports starting a new herb. Which
herb is most likely?
A) Garlic
B) Ginkgo biloba
C) St. John's wort
D) Ginger
Correct Answer: C – St. John's wort induces CYP2C9 and CYP3A4, reducing warfarin levels and INR.
5. A child with otitis media has a penicillin allergy. Which antibiotic is safe?
A) Amoxicillin
B) Cefdinir
C) Doxycycline
D) Cefuroxime
Correct Answer: B – Cefdinir (3rd generation cephalosporin) has low cross-reactivity with penicillin
allergy (≈1%).
6. A patient on metformin reports muscle pain and fatigue. What is the most serious concern?
A) Hypoglycemia
B) Lactic acidosis
C) Vitamin B12 deficiency
D) Weight gain
Correct Answer: B – Lactic acidosis is rare but serious (mortality ~50%); presents with myalgia, malaise,
hyperventilation.
7. Which medication should be avoided in a patient with a history of QT prolongation?
A) Levofloxacin
B) Amoxicillin
C) Doxycycline
D) Trimethoprim-sulfamethoxazole
Correct Answer: A – Fluoroquinolones (levofloxacin, moxifloxacin) prolong QT interval and risk
torsades de pointes.
8. A patient with heart failure and reduced ejection fraction is on carvedilol. What is the primary
benefit?
A) Increased heart rate
,B) Reduced mortality
C) Diuresis
D) Vasoconstriction
Correct Answer: B – Carvedilol (beta-blocker) reduces mortality in HFrEF by decreasing sympathetic
overactivity.
9. A patient on phenytoin develops nystagmus and ataxia. Phenytoin level is 25 mcg/mL. What is
the interpretation?
A) Subtherapeutic
B) Therapeutic
C) Mild toxicity
D) Severe toxicity
Correct Answer: C – Therapeutic range: 10–20 mcg/mL. Levels >20 cause nystagmus, ataxia, dysarthria.
10. Which drug is most appropriate for rapid sequence intubation in a patient with hyperkalemia?
A) Succinylcholine
B) Rocuronium
C) Vecuronium
D) Cisatracurium
Correct Answer: A – Succinylcholine can worsen hyperkalemia in susceptible patients; avoid if K+ >5.5
mEq/L.
11. A patient with gout is started on allopurinol. Which medication may need dose reduction?
A) Azathioprine
B) Lisinopril
C) Metformin
D) Atorvastatin
Correct Answer: A – Allopurinol inhibits xanthine oxidase, which also metabolizes azathioprine; severe
bone marrow suppression risk.
12. Which antidepressant is most sedating and useful for insomnia?
A) Fluoxetine
B) Sertraline
C) Mirtazapine
D) Bupropion
, Correct Answer: C – Mirtazapine (alpha-2 antagonist) causes significant sedation, especially at low
doses (7.5–15 mg).
13. A patient on clopidogrel is scheduled for surgery. Which medication can be used as a bridge?
A) Aspirin
B) Cilostazol
C) No bridge needed (stop clopidogrel 5–7 days prior)
D) Ticagrelor
Correct Answer: C – Clopidogrel is usually stopped 5–7 days pre-op without bridging due to short
duration of effect (5–7 days).
14. A patient with asthma is prescribed timolol eye drops for glaucoma. What is the risk?
A) Increased intraocular pressure
B) Bronchospasm
C) Tachycardia
D) Hypotension
Correct Answer: B – Timolol (non-selective beta-blocker) is absorbed systemically and can cause
bronchospasm in asthmatics.
15. Which antibiotic causes disulfiram-like reaction with alcohol?
A) Penicillin
B) Metronidazole
C) Azithromycin
D) Doxycycline
Correct Answer: B – Metronidazole inhibits aldehyde dehydrogenase, causing nausea, flushing, and
hypotension with alcohol.
16. A patient on levodopa/carbidopa reports dark sweat and urine. What should the nurse advise?
A) Stop the medication immediately
B) This is a harmless side effect
C) Increase fluid intake
D) Check liver function
Correct Answer: B – Levodopa metabolites cause harmless darkening of sweat, urine, and saliva.
Solutions and Rationales for Nurse Practitioners Mastering Drug Therapy, Safety, and Prescriptive
Reasoning.
Version 3 – Questions 1–150 (Multiple Choice, Answers +
Explanations)
1. A patient newly started on lisinopril develops a persistent dry cough. What is the mechanism?
A) Histamine release from mast cells
B) Bradykinin accumulation in the airways
C) Direct bronchial smooth muscle constriction
D) Leukotriene overproduction
Correct Answer: B – ACE inhibitors prevent bradykinin breakdown, leading to bradykinin accumulation,
which causes dry cough.
2. Which laboratory value requires immediate action in a patient taking spironolactone?
A) Sodium 135 mEq/L
B) Potassium 5.9 mEq/L
C) Chloride 100 mEq/L
D) Glucose 95 mg/dL
Correct Answer: B – Spironolactone is potassium-sparing; potassium >5.5 mEq/L increases risk of life-
threatening arrhythmias.
3. A patient with major depressive disorder has failed two SSRIs. Which medication should be
considered next?
A) Bupropion
B) Venlafaxine (SNRI)
C) Trazodone
D) Mirtazapine
Correct Answer: B – Venlafaxine (SNRI) is often used after SSRI failure due to dual reuptake inhibition.
,4. A patient on warfarin presents with an INR of 1.1. The patient reports starting a new herb. Which
herb is most likely?
A) Garlic
B) Ginkgo biloba
C) St. John's wort
D) Ginger
Correct Answer: C – St. John's wort induces CYP2C9 and CYP3A4, reducing warfarin levels and INR.
5. A child with otitis media has a penicillin allergy. Which antibiotic is safe?
A) Amoxicillin
B) Cefdinir
C) Doxycycline
D) Cefuroxime
Correct Answer: B – Cefdinir (3rd generation cephalosporin) has low cross-reactivity with penicillin
allergy (≈1%).
6. A patient on metformin reports muscle pain and fatigue. What is the most serious concern?
A) Hypoglycemia
B) Lactic acidosis
C) Vitamin B12 deficiency
D) Weight gain
Correct Answer: B – Lactic acidosis is rare but serious (mortality ~50%); presents with myalgia, malaise,
hyperventilation.
7. Which medication should be avoided in a patient with a history of QT prolongation?
A) Levofloxacin
B) Amoxicillin
C) Doxycycline
D) Trimethoprim-sulfamethoxazole
Correct Answer: A – Fluoroquinolones (levofloxacin, moxifloxacin) prolong QT interval and risk
torsades de pointes.
8. A patient with heart failure and reduced ejection fraction is on carvedilol. What is the primary
benefit?
A) Increased heart rate
,B) Reduced mortality
C) Diuresis
D) Vasoconstriction
Correct Answer: B – Carvedilol (beta-blocker) reduces mortality in HFrEF by decreasing sympathetic
overactivity.
9. A patient on phenytoin develops nystagmus and ataxia. Phenytoin level is 25 mcg/mL. What is
the interpretation?
A) Subtherapeutic
B) Therapeutic
C) Mild toxicity
D) Severe toxicity
Correct Answer: C – Therapeutic range: 10–20 mcg/mL. Levels >20 cause nystagmus, ataxia, dysarthria.
10. Which drug is most appropriate for rapid sequence intubation in a patient with hyperkalemia?
A) Succinylcholine
B) Rocuronium
C) Vecuronium
D) Cisatracurium
Correct Answer: A – Succinylcholine can worsen hyperkalemia in susceptible patients; avoid if K+ >5.5
mEq/L.
11. A patient with gout is started on allopurinol. Which medication may need dose reduction?
A) Azathioprine
B) Lisinopril
C) Metformin
D) Atorvastatin
Correct Answer: A – Allopurinol inhibits xanthine oxidase, which also metabolizes azathioprine; severe
bone marrow suppression risk.
12. Which antidepressant is most sedating and useful for insomnia?
A) Fluoxetine
B) Sertraline
C) Mirtazapine
D) Bupropion
, Correct Answer: C – Mirtazapine (alpha-2 antagonist) causes significant sedation, especially at low
doses (7.5–15 mg).
13. A patient on clopidogrel is scheduled for surgery. Which medication can be used as a bridge?
A) Aspirin
B) Cilostazol
C) No bridge needed (stop clopidogrel 5–7 days prior)
D) Ticagrelor
Correct Answer: C – Clopidogrel is usually stopped 5–7 days pre-op without bridging due to short
duration of effect (5–7 days).
14. A patient with asthma is prescribed timolol eye drops for glaucoma. What is the risk?
A) Increased intraocular pressure
B) Bronchospasm
C) Tachycardia
D) Hypotension
Correct Answer: B – Timolol (non-selective beta-blocker) is absorbed systemically and can cause
bronchospasm in asthmatics.
15. Which antibiotic causes disulfiram-like reaction with alcohol?
A) Penicillin
B) Metronidazole
C) Azithromycin
D) Doxycycline
Correct Answer: B – Metronidazole inhibits aldehyde dehydrogenase, causing nausea, flushing, and
hypotension with alcohol.
16. A patient on levodopa/carbidopa reports dark sweat and urine. What should the nurse advise?
A) Stop the medication immediately
B) This is a harmless side effect
C) Increase fluid intake
D) Check liver function
Correct Answer: B – Levodopa metabolites cause harmless darkening of sweat, urine, and saliva.
