University of Texas, Arlington NURS
5334/NURS5334: Quiz 2 and Answers (explained) |
100% correct 2025/26.
1. A patient with a history of heart failure with reduced ejection fraction (HFrEF) is currently on
sacubitril/valsartan, metoprolol succinate, spironolactone, and furosemide. The patient develops
acute decompensated heart failure requiring hospitalization. Which of the following medication
adjustments is most appropriate during the acute phase?
A. Continue sacubitril/valsartan at the same dose and add intravenous nitroglycerin.
B. Hold sacubitril/valsartan and initiate intravenous nitroprusside.
C. Discontinue spironolactone and increase furosemide to 80 mg IV twice daily.
D. Reduce metoprolol succinate dose by 50% and add dobutamine.
Answer: C
Rationale: In acute decompensated HF, loop diuretics are first-line for volume overload. Spironolactone
may be held due to risk of hyperkalemia and limited acute benefit. Sacubitril/valsartan is typically
continued unless hypotension or renal impairment occurs. Nitroprusside is not preferred due to risk of
cyanide toxicity. Dobutamine increases myocardial oxygen demand and is reserved for cardiogenic
shock.
2. A patient with type 2 diabetes and chronic kidney disease stage G3b (eGFR 35 mL/min/1.73m2)
is being started on an SGLT2 inhibitor. Which of the following statements best reflects the current
evidence-based approach?
A. SGLT2 inhibitors are contraindicated when eGFR is below 45 mL/min/1.73m2 due to lack of efficacy and
increased risk of acute kidney injury.
B. Initiate dapagliflozin at 10 mg daily; monitor eGFR and potassium within 2 weeks; continue if eGFR decline
<30% and no hyperkalemia.
C. SGLT2 inhibitors are not recommended in CKD because they increase the risk of urinary tract infections and
euglycemic ketoacidosis.
D. Empagliflozin is preferred over dapagliflozin in CKD due to superior cardiovascular outcomes, but both
require dose adjustment for renal function.
Answer: B
Rationale: Recent trials (DAPA-CKD, CREDENCE) show SGLT2 inhibitors slow CKD progression even
when eGFR is as low as 25 mL/min. Dapagliflozin is approved for CKD with eGFR 25. Monitoring
eGFR and potassium is essential because an initial dip in eGFR is common and usually reversible.
Option A is outdated; C is not a contraindication; D is incorrect because both agents have similar renal
benefits and no dose adjustment is needed for renal function.
Page 1
,3. A patient on warfarin for atrial fibrillation is started on amiodarone for rhythm control. The
INR increases from 2.1 to 4.8 within 5 days. Which mechanism best explains this interaction?
A. Amiodarone displaces warfarin from albumin, increasing free warfarin concentration.
B. Amiodarone inhibits CYP2C9, reducing clearance of S-warfarin.
C. Amiodarone induces CYP3A4, increasing warfarin metabolism initially, followed by inhibition.
D. Amiodarone reduces vitamin K absorption by altering gut flora.
Answer: B
Rationale: Amiodarone is a potent inhibitor of CYP2C9, the primary enzyme that metabolizes S-warfarin
(the more active enantiomer). This inhibition decreases warfarin clearance, leading to a rapid and
significant INR increase. Displacement from albumin (A) is minor; CYP3A4 induction (C) would
decrease INR; vitamin K absorption (D) is not affected.
4. A patient with major depressive disorder has failed adequate trials of two different SSRIs and
one SNRI. The patient is now started on phenelzine. Which dietary instruction is most critical to
prevent a hypertensive crisis?
A. Avoid foods high in tyramine, such as aged cheeses, cured meats, and fermented products.
B. Limit caffeine intake to no more than two cups of coffee per day.
C. Avoid alcohol, especially red wine and beer, due to disulfiram-like reaction.
D. Increase fluid intake to prevent orthostatic hypotension, a common side effect.
Answer: A
Rationale: Phenelzine is a nonselective MAOI that irreversibly inhibits MAO-A and MAO-B. Ingestion of
tyramine-rich foods can cause massive norepinephrine release, leading to hypertensive crisis. Option B
is less critical; C is important but not the most critical; D addresses orthostasis but not hypertensive
crisis.
5. A patient with neuropathic pain (postherpetic neuralgia) is prescribed pregabalin. The patient
has an eGFR of 45 mL/min/1.73m2. Which dosing adjustment is recommended?
A. Start at 75 mg twice daily and titrate based on response.
B. Start at 25 mg twice daily and titrate slowly.
C. Start at 150 mg once daily in the evening.
D. Pregabalin is contraindicated in renal impairment; use gabapentin instead.
Answer: B
Rationale: Pregabalin is primarily renally excreted. For CrCl 30-60 mL/min, the recommended starting
dose is 25 mg twice daily, with maximum dose of 150 mg/day. Option A is the dose for normal renal
function; C is not standard; D is false-gabapentin also requires renal adjustment.
6. A patient with community-acquired pneumonia (CAP) is prescribed levofloxacin. The patient
has a history of a severe allergic reaction to penicillin (anaphylaxis). Which statement best
describes the cross-reactivity risk?
A. Levofloxacin is contraindicated due to high cross-reactivity with beta-lactams.
B. Levofloxacin is safe to use as there is no cross-reactivity between fluoroquinolones and penicillins.
C. Levofloxacin should be avoided because fluoroquinolones have a similar side chain to penicillins.
Page 2
,D. Levofloxacin can be used but with a test dose due to possible IgE-mediated cross-reactivity.
Answer: B
Rationale: Fluoroquinolones (levofloxacin) have a completely different chemical structure from
beta-lactams and no known cross-reactivity. They are safe in patients with penicillin allergy. Options A
and C are incorrect; D is unnecessary.
7. A patient with opioid use disorder is initiated on buprenorphine/naloxone for
medication-assisted treatment. The patient reports taking their last dose of heroin 12 hours ago
and is currently in moderate withdrawal (COWS score 15). Which of the following is the most
appropriate next step?
A. Administer the first dose of buprenorphine/naloxone 2 mg/0.5 mg sublingually now.
B. Wait until the patient has a COWS score of at least 20 before initiating buprenorphine.
C. Start methadone 30 mg orally instead of buprenorphine due to the severity of withdrawal.
D. Administer naloxone 0.4 mg intramuscularly to confirm opioid dependence before starting buprenorphine.
Answer: A
Rationale: Buprenorphine can be initiated when the patient is in mild to moderate withdrawal (COWS
5-15) to avoid precipitated withdrawal. A COWS of 15 indicates moderate withdrawal, and starting with
a low dose (2 mg) is appropriate. Waiting for COWS 20 (B) is not necessary; methadone (C) requires
special licensing; naloxone (D) would precipitate withdrawal.
8. A patient with hypertension is prescribed hydrochlorothiazide 25 mg daily. Three months later,
serum potassium is 3.2 mmol/L. Which of the following is the most appropriate management?
A. Add spironolactone 25 mg daily to counteract potassium loss.
B. Switch to chlorthalidone 25 mg daily, which has less effect on potassium.
C. Discontinue hydrochlorothiazide and start amlodipine 5 mg daily.
D. Continue hydrochlorothiazide and start oral potassium chloride 20 mEq daily.
Answer: D
Rationale: Thiazide-induced hypokalemia is common and can be managed by potassium supplementation
or adding a potassium-sparing diuretic. However, spironolactone (A) should be used cautiously as it
may cause hyperkalemia, especially in patients with renal impairment. Chlorthalidone (B) has a similar
or greater potassium-wasting effect. Switching to amlodipine (C) is an option but not the most
appropriate initial management; supplementation is indicated.
9. A patient with asthma is prescribed a long-acting beta-agonist (LABA) in combination with an
inhaled corticosteroid (ICS) for maintenance therapy. Which of the following statements
accurately reflects current FDA safety recommendations?
A. LABA monotherapy is safe for mild persistent asthma when used as needed.
B. LABA should always be used in combination with an ICS; LABA monotherapy is contraindicated in asthma.
C. LABA/ICS combination therapy increases the risk of asthma-related death compared to ICS alone.
D. LABA use is contraindicated in patients with a history of exercise-induced bronchospasm.
Answer: B
Rationale: The FDA requires a boxed warning that LABA monotherapy increases the risk of
asthma-related death; therefore, LABAs must be used only in combination with an ICS for asthma.
Page 3
, Option A is false; C is incorrect because combination therapy does not increase risk compared to ICS
alone; D is false-LABA can be used for exercise-induced symptoms but always with ICS.
10. A patient with rheumatoid arthritis is started on methotrexate 15 mg weekly. Which of the
following monitoring parameters is most important to assess before initiating therapy and
periodically thereafter?
A. Serum uric acid level to monitor for tumor lysis syndrome.
B. Liver function tests, serum creatinine, and complete blood count.
C. Echocardiogram to assess for cardiotoxicity.
D. Pulmonary function tests to detect interstitial lung disease.
Answer: B
Rationale: Methotrexate is hepatotoxic, nephrotoxic, and myelosuppressive. Baseline and periodic
monitoring of LFTs, renal function, and CBC are essential. Uric acid (A) is relevant for tumor lysis but
not routine. Cardiotoxicity (C) is not typical; pulmonary toxicity (D) is a rare but serious adverse effect,
but routine PFTs are not recommended.
11. A 55-year-old patient with chronic kidney disease (GFR 25 mL/min) and type 2 diabetes is
started on metformin. Which pharmacokinetic parameter is most critically altered in this patient,
and what is the primary concern?
A. Increased volume of distribution leading to toxicity
B. Decreased renal clearance leading to accumulation and risk of lactic acidosis
C. Increased hepatic metabolism leading to reduced efficacy
D. Decreased protein binding leading to increased free drug concentration
Answer: B
Rationale: Metformin is primarily excreted unchanged by the kidneys. In chronic kidney disease with
GFR <30 mL/min, renal clearance is severely reduced, causing accumulation and increased risk of
lactic acidosis. Volume of distribution and protein binding changes are not the primary concerns, and
hepatic metabolism is minimal.
12. A patient with hypertension and hyperlipidemia is being treated with a statin and a thiazide
diuretic. Which drug interaction mechanism is most likely to increase the risk of statin-induced
myopathy?
A. Thiazide-induced hypokalemia reducing statin efficacy
B. Competitive inhibition of OATP1B1-mediated hepatic uptake by thiazides
C. Thiazide-induced volume depletion increasing statin plasma concentration
D. Inhibition of CYP3A4 by thiazides, decreasing statin metabolism
Answer: B
Rationale: Thiazide diuretics can inhibit OATP1B1, a transporter responsible for hepatic uptake of
statins like atorvastatin and simvastatin, leading to increased systemic exposure and myopathy risk.
Hypokalemia does not affect statin efficacy, volume depletion is not a major factor, and thiazides do not
inhibit CYP3A4.
Page 4
5334/NURS5334: Quiz 2 and Answers (explained) |
100% correct 2025/26.
1. A patient with a history of heart failure with reduced ejection fraction (HFrEF) is currently on
sacubitril/valsartan, metoprolol succinate, spironolactone, and furosemide. The patient develops
acute decompensated heart failure requiring hospitalization. Which of the following medication
adjustments is most appropriate during the acute phase?
A. Continue sacubitril/valsartan at the same dose and add intravenous nitroglycerin.
B. Hold sacubitril/valsartan and initiate intravenous nitroprusside.
C. Discontinue spironolactone and increase furosemide to 80 mg IV twice daily.
D. Reduce metoprolol succinate dose by 50% and add dobutamine.
Answer: C
Rationale: In acute decompensated HF, loop diuretics are first-line for volume overload. Spironolactone
may be held due to risk of hyperkalemia and limited acute benefit. Sacubitril/valsartan is typically
continued unless hypotension or renal impairment occurs. Nitroprusside is not preferred due to risk of
cyanide toxicity. Dobutamine increases myocardial oxygen demand and is reserved for cardiogenic
shock.
2. A patient with type 2 diabetes and chronic kidney disease stage G3b (eGFR 35 mL/min/1.73m2)
is being started on an SGLT2 inhibitor. Which of the following statements best reflects the current
evidence-based approach?
A. SGLT2 inhibitors are contraindicated when eGFR is below 45 mL/min/1.73m2 due to lack of efficacy and
increased risk of acute kidney injury.
B. Initiate dapagliflozin at 10 mg daily; monitor eGFR and potassium within 2 weeks; continue if eGFR decline
<30% and no hyperkalemia.
C. SGLT2 inhibitors are not recommended in CKD because they increase the risk of urinary tract infections and
euglycemic ketoacidosis.
D. Empagliflozin is preferred over dapagliflozin in CKD due to superior cardiovascular outcomes, but both
require dose adjustment for renal function.
Answer: B
Rationale: Recent trials (DAPA-CKD, CREDENCE) show SGLT2 inhibitors slow CKD progression even
when eGFR is as low as 25 mL/min. Dapagliflozin is approved for CKD with eGFR 25. Monitoring
eGFR and potassium is essential because an initial dip in eGFR is common and usually reversible.
Option A is outdated; C is not a contraindication; D is incorrect because both agents have similar renal
benefits and no dose adjustment is needed for renal function.
Page 1
,3. A patient on warfarin for atrial fibrillation is started on amiodarone for rhythm control. The
INR increases from 2.1 to 4.8 within 5 days. Which mechanism best explains this interaction?
A. Amiodarone displaces warfarin from albumin, increasing free warfarin concentration.
B. Amiodarone inhibits CYP2C9, reducing clearance of S-warfarin.
C. Amiodarone induces CYP3A4, increasing warfarin metabolism initially, followed by inhibition.
D. Amiodarone reduces vitamin K absorption by altering gut flora.
Answer: B
Rationale: Amiodarone is a potent inhibitor of CYP2C9, the primary enzyme that metabolizes S-warfarin
(the more active enantiomer). This inhibition decreases warfarin clearance, leading to a rapid and
significant INR increase. Displacement from albumin (A) is minor; CYP3A4 induction (C) would
decrease INR; vitamin K absorption (D) is not affected.
4. A patient with major depressive disorder has failed adequate trials of two different SSRIs and
one SNRI. The patient is now started on phenelzine. Which dietary instruction is most critical to
prevent a hypertensive crisis?
A. Avoid foods high in tyramine, such as aged cheeses, cured meats, and fermented products.
B. Limit caffeine intake to no more than two cups of coffee per day.
C. Avoid alcohol, especially red wine and beer, due to disulfiram-like reaction.
D. Increase fluid intake to prevent orthostatic hypotension, a common side effect.
Answer: A
Rationale: Phenelzine is a nonselective MAOI that irreversibly inhibits MAO-A and MAO-B. Ingestion of
tyramine-rich foods can cause massive norepinephrine release, leading to hypertensive crisis. Option B
is less critical; C is important but not the most critical; D addresses orthostasis but not hypertensive
crisis.
5. A patient with neuropathic pain (postherpetic neuralgia) is prescribed pregabalin. The patient
has an eGFR of 45 mL/min/1.73m2. Which dosing adjustment is recommended?
A. Start at 75 mg twice daily and titrate based on response.
B. Start at 25 mg twice daily and titrate slowly.
C. Start at 150 mg once daily in the evening.
D. Pregabalin is contraindicated in renal impairment; use gabapentin instead.
Answer: B
Rationale: Pregabalin is primarily renally excreted. For CrCl 30-60 mL/min, the recommended starting
dose is 25 mg twice daily, with maximum dose of 150 mg/day. Option A is the dose for normal renal
function; C is not standard; D is false-gabapentin also requires renal adjustment.
6. A patient with community-acquired pneumonia (CAP) is prescribed levofloxacin. The patient
has a history of a severe allergic reaction to penicillin (anaphylaxis). Which statement best
describes the cross-reactivity risk?
A. Levofloxacin is contraindicated due to high cross-reactivity with beta-lactams.
B. Levofloxacin is safe to use as there is no cross-reactivity between fluoroquinolones and penicillins.
C. Levofloxacin should be avoided because fluoroquinolones have a similar side chain to penicillins.
Page 2
,D. Levofloxacin can be used but with a test dose due to possible IgE-mediated cross-reactivity.
Answer: B
Rationale: Fluoroquinolones (levofloxacin) have a completely different chemical structure from
beta-lactams and no known cross-reactivity. They are safe in patients with penicillin allergy. Options A
and C are incorrect; D is unnecessary.
7. A patient with opioid use disorder is initiated on buprenorphine/naloxone for
medication-assisted treatment. The patient reports taking their last dose of heroin 12 hours ago
and is currently in moderate withdrawal (COWS score 15). Which of the following is the most
appropriate next step?
A. Administer the first dose of buprenorphine/naloxone 2 mg/0.5 mg sublingually now.
B. Wait until the patient has a COWS score of at least 20 before initiating buprenorphine.
C. Start methadone 30 mg orally instead of buprenorphine due to the severity of withdrawal.
D. Administer naloxone 0.4 mg intramuscularly to confirm opioid dependence before starting buprenorphine.
Answer: A
Rationale: Buprenorphine can be initiated when the patient is in mild to moderate withdrawal (COWS
5-15) to avoid precipitated withdrawal. A COWS of 15 indicates moderate withdrawal, and starting with
a low dose (2 mg) is appropriate. Waiting for COWS 20 (B) is not necessary; methadone (C) requires
special licensing; naloxone (D) would precipitate withdrawal.
8. A patient with hypertension is prescribed hydrochlorothiazide 25 mg daily. Three months later,
serum potassium is 3.2 mmol/L. Which of the following is the most appropriate management?
A. Add spironolactone 25 mg daily to counteract potassium loss.
B. Switch to chlorthalidone 25 mg daily, which has less effect on potassium.
C. Discontinue hydrochlorothiazide and start amlodipine 5 mg daily.
D. Continue hydrochlorothiazide and start oral potassium chloride 20 mEq daily.
Answer: D
Rationale: Thiazide-induced hypokalemia is common and can be managed by potassium supplementation
or adding a potassium-sparing diuretic. However, spironolactone (A) should be used cautiously as it
may cause hyperkalemia, especially in patients with renal impairment. Chlorthalidone (B) has a similar
or greater potassium-wasting effect. Switching to amlodipine (C) is an option but not the most
appropriate initial management; supplementation is indicated.
9. A patient with asthma is prescribed a long-acting beta-agonist (LABA) in combination with an
inhaled corticosteroid (ICS) for maintenance therapy. Which of the following statements
accurately reflects current FDA safety recommendations?
A. LABA monotherapy is safe for mild persistent asthma when used as needed.
B. LABA should always be used in combination with an ICS; LABA monotherapy is contraindicated in asthma.
C. LABA/ICS combination therapy increases the risk of asthma-related death compared to ICS alone.
D. LABA use is contraindicated in patients with a history of exercise-induced bronchospasm.
Answer: B
Rationale: The FDA requires a boxed warning that LABA monotherapy increases the risk of
asthma-related death; therefore, LABAs must be used only in combination with an ICS for asthma.
Page 3
, Option A is false; C is incorrect because combination therapy does not increase risk compared to ICS
alone; D is false-LABA can be used for exercise-induced symptoms but always with ICS.
10. A patient with rheumatoid arthritis is started on methotrexate 15 mg weekly. Which of the
following monitoring parameters is most important to assess before initiating therapy and
periodically thereafter?
A. Serum uric acid level to monitor for tumor lysis syndrome.
B. Liver function tests, serum creatinine, and complete blood count.
C. Echocardiogram to assess for cardiotoxicity.
D. Pulmonary function tests to detect interstitial lung disease.
Answer: B
Rationale: Methotrexate is hepatotoxic, nephrotoxic, and myelosuppressive. Baseline and periodic
monitoring of LFTs, renal function, and CBC are essential. Uric acid (A) is relevant for tumor lysis but
not routine. Cardiotoxicity (C) is not typical; pulmonary toxicity (D) is a rare but serious adverse effect,
but routine PFTs are not recommended.
11. A 55-year-old patient with chronic kidney disease (GFR 25 mL/min) and type 2 diabetes is
started on metformin. Which pharmacokinetic parameter is most critically altered in this patient,
and what is the primary concern?
A. Increased volume of distribution leading to toxicity
B. Decreased renal clearance leading to accumulation and risk of lactic acidosis
C. Increased hepatic metabolism leading to reduced efficacy
D. Decreased protein binding leading to increased free drug concentration
Answer: B
Rationale: Metformin is primarily excreted unchanged by the kidneys. In chronic kidney disease with
GFR <30 mL/min, renal clearance is severely reduced, causing accumulation and increased risk of
lactic acidosis. Volume of distribution and protein binding changes are not the primary concerns, and
hepatic metabolism is minimal.
12. A patient with hypertension and hyperlipidemia is being treated with a statin and a thiazide
diuretic. Which drug interaction mechanism is most likely to increase the risk of statin-induced
myopathy?
A. Thiazide-induced hypokalemia reducing statin efficacy
B. Competitive inhibition of OATP1B1-mediated hepatic uptake by thiazides
C. Thiazide-induced volume depletion increasing statin plasma concentration
D. Inhibition of CYP3A4 by thiazides, decreasing statin metabolism
Answer: B
Rationale: Thiazide diuretics can inhibit OATP1B1, a transporter responsible for hepatic uptake of
statins like atorvastatin and simvastatin, leading to increased systemic exposure and myopathy risk.
Hypokalemia does not affect statin efficacy, volume depletion is not a major factor, and thiazides do not
inhibit CYP3A4.
Page 4
