NURS 251 PHARMACOLOGY MODULE 1, 2, 3, 4,
5, 6, 7, 8, 9, 10 EXAM'S NEWEST QUESTIONS
AND ANSWERS () LATEST GRADED
A+…
1. A patient with chronic heart failure is initiated on sacubitril/valsartan. Which mechanism best
explains the drug's therapeutic benefit in reducing mortality?
A. Combined angiotensin receptor blockade and neprilysin inhibition, increasing natriuretic peptides and
decreasing aldosterone release.
B. Selective beta-1 adrenergic antagonism reducing myocardial oxygen demand.
C. Aldosterone receptor antagonism preventing sodium and water retention.
D. Direct vasodilation via nitric oxide release and calcium channel blockade.
Answer: A
Rationale: Sacubitril/valsartan is an ARNI that inhibits neprilysin (increasing natriuretic peptides) and
blocks AT1 receptors, reducing aldosterone and sympathetic activity. This dual action improves
outcomes in heart failure with reduced ejection fraction. Beta-blockade (B) and aldosterone antagonism
(C) are distinct drug classes, while direct vasodilation (D) is not its primary mechanism.
2. A patient receiving vancomycin for a MRSA bloodstream infection develops acute kidney injury.
Which pharmacodynamic principle best explains the increased nephrotoxicity risk when
vancomycin is combined with piperacillin-tazobactam?
A. Synergistic antagonism of renal tubular transporters by both drugs.
B. Additive acute tubular necrosis due to similar mechanisms of proximal tubule injury.
C. Competitive inhibition of vancomycin clearance by piperacillin at organic anion transporters.
D. Enhanced formation of reactive oxygen species in the loop of Henle.
Answer: B
Rationale: Both vancomycin and piperacillin-tazobactam are independently associated with acute kidney
injury, and their combination leads to additive nephrotoxicity, likely through synergistic tubular cell
stress and necrosis. While transporter interactions (C) may contribute, the primary mechanism is
additive cellular injury. Options A and D are not well-supported mechanisms.
3. A patient with severe hypertension and a history of angioedema from lisinopril requires urgent
blood pressure reduction. Which agent is most appropriate?
A. Hydralazine
B. Losartan
C. Aliskiren
D. Enalaprilat
Page 1
,Answer: A
Rationale: Hydralazine is a direct vasodilator that does not affect the renin-angiotensin-aldosterone
system, making it safe in patients with ACE inhibitor-induced angioedema. Losartan (B) and aliskiren
(C) also act on the RAAS and could cross-react. Enalaprilat (D) is an intravenous ACE inhibitor,
contraindicated due to the history of angioedema.
4. A patient on long-term warfarin therapy for a mechanical heart valve presents with an INR of
5.2 and minor epistaxis. Which intervention is recommended per current guidelines?
A. Administer vitamin K 10 mg intravenously and hold warfarin until INR normalizes.
B. Administer fresh frozen plasma (FFP) immediately to reverse anticoagulation.
C. Hold warfarin and administer vitamin K 1-2.5 mg orally.
D. Administer prothrombin complex concentrate (PCC) and vitamin K 10 mg intravenously.
Answer: C
Rationale: For an INR >5 but <9 with minor bleeding, guidelines recommend holding warfarin and
giving low-dose oral vitamin K (1-2.5 mg) to gradually lower the INR. High-dose IV vitamin K (A) may
cause overcorrection and warfarin resistance. FFP (B) and PCC (D) are reserved for life-threatening
bleeding. This approach balances reversal while maintaining anticoagulation for the mechanical valve.
5. A patient with type 2 diabetes inadequately controlled on metformin and glipizide is started on
an SGLT2 inhibitor. Which laboratory parameter requires close monitoring due to the mechanism
of this drug class?
A. Serum potassium
B. Serum creatinine and eGFR
C. Hemoglobin A1c
D. Serum bicarbonate
Answer: B
Rationale: SGLT2 inhibitors reduce glucose reabsorption in the proximal tubule, leading to osmotic
diuresis and a reversible decrease in eGFR, especially upon initiation. Monitoring renal function is
critical to detect acute kidney injury or volume depletion. While serum bicarbonate (D) may be
monitored for euglycemic DKA, renal function monitoring is the priority per prescribing information.
6. A patient with major depressive disorder and comorbid generalized anxiety disorder has failed
trials of sertraline and venlafaxine. Which of the following augmentation strategies is supported by
current evidence for treatment-resistant depression?
A. Adding bupropion to the existing SSRI regimen.
B. Switching to a monoamine oxidase inhibitor (MAOI) without washout.
C. Augmenting with a typical antipsychotic like haloperidol.
D. Adding buspirone 30 mg daily in divided doses.
Answer: A
Rationale: Bupropion augmentation of SSRIs is an evidence-based strategy for treatment-resistant
depression, particularly when residual symptoms include anergia or sexual dysfunction. MAOIs (B)
require a washout period to avoid serotonin syndrome. Haloperidol (C) is not first-line augmentation;
atypical antipsychotics like aripiprazole are preferred. Buspirone (D) is more effective for anxiety than
depression augmentation.
Page 2
,7. A patient receiving morphine via patient-controlled analgesia (PCA) develops respiratory
depression with a respiratory rate of 6 breaths/min. Which statement accurately describes the
mechanism of action of the reversal agent?
A. Naloxone competitively antagonizes mu-opioid receptors, reversing both analgesia and respiratory
depression.
B. Naloxone non-competitively inhibits opioid binding to kappa receptors, selectively reversing respiratory
effects.
C. Naloxone acts as a partial agonist at mu receptors, displacing morphine and restoring ventilation.
D. Naloxone potentiates GABAergic inhibition in the medullary respiratory center.
Answer: A
Rationale: Naloxone is a competitive antagonist at mu-opioid receptors, reversing all opioid effects
including analgesia and respiratory depression. It does not selectively target respiratory depression (B)
and is not a partial agonist (C). Its action is not via GABA (D). Titration is critical to avoid acute
withdrawal or pain recurrence.
8. A patient with a history of opioid use disorder is prescribed buprenorphine/naloxone for
maintenance therapy. Which pharmacokinetic property of buprenorphine contributes to its lower
abuse liability compared to full agonists?
A. High intrinsic activity at mu receptors with long half-life.
B. High affinity but partial agonism at mu receptors, resulting in a ceiling effect for respiratory depression.
C. Rapid dissociation from mu receptors limiting duration of action.
D. First-pass metabolism to an inactive metabolite reducing bioavailability.
Answer: B
Rationale: Buprenorphine's partial agonism at mu receptors produces a ceiling effect on respiratory
depression and euphoria, reducing abuse potential and overdose risk. Its high affinity (B) prevents
displacement by full agonists. Option A describes a full agonist. Option C is incorrect; buprenorphine
dissociates slowly. Option D is not the primary reason for lower abuse liability.
9. A patient on a cisplatin-based chemotherapy regimen develops severe nausea and vomiting
despite prophylaxis with ondansetron and dexamethasone. Which additional agent would be most
appropriate to add based on the emetic potential of cisplatin?
A. Metoclopramide 10 mg IV every 6 hours.
B. Aprepitant 125 mg orally before chemotherapy, then 80 mg daily for 2 days.
C. Prochlorperazine 10 mg IM every 4 hours as needed.
D. Dronabinol 5 mg orally every 6 hours.
Answer: B
Rationale: Cisplatin is highly emetogenic and requires a three-drug regimen including a neurokinin-1
(NK1) receptor antagonist like aprepitant, a 5-HT3 antagonist, and dexamethasone. Aprepitant targets
the substance P/NK1 pathway, which is critical for delayed emesis. Metoclopramide (A) and
prochlorperazine (C) are less effective for highly emetogenic chemotherapy. Dronabinol (D) is reserved
for breakthrough nausea.
Page 3
, 10. A patient with methicillin-sensitive Staphylococcus aureus (MSSA) osteomyelitis is being
treated with cefazolin. Which statement about the pharmacodynamics of beta-lactam antibiotics is
most relevant to ensuring bactericidal activity?
A. The time that the free drug concentration exceeds the minimum inhibitory concentration (fT>MIC) should be
at least 40-50% of the dosing interval.
B. The peak concentration to MIC ratio (Cmax/MIC) should exceed 10 for optimal killing.
C. The area under the curve to MIC ratio (AUC/MIC) should be at least 400.
D. Post-antibiotic effect (PAE) against gram-positive cocci is prolonged, allowing extended dosing intervals.
Answer: A
Rationale: Beta-lactams exhibit time-dependent killing, and the critical PK/PD parameter is the
percentage of time the free drug concentration remains above the MIC. For cephalosporins, achieving
fT>MIC for at least 40-50% of the dosing interval is associated with bactericidal efficacy. Option B
applies to aminoglycosides, C to fluoroquinolones, and D is not characteristic of beta-lactams against
MSSA.
11. A patient with a history of chronic heart failure (NYHA class III) is admitted with acute
decompensation. Current medications include lisinopril, carvedilol, furosemide, and
spironolactone. The provider orders intravenous dobutamine. Which of the following best
describes the mechanism by which dobutamine improves cardiac output in this patient?
A. Selective ²1-adrenergic receptor agonism increasing myocardial contractility
B. Non-selective ²- and ±-adrenergic receptor agonism leading to increased heart rate and vasoconstriction
C. Phosphodiesterase-3 inhibition resulting in increased intracellular cAMP and calcium influx
D. Sensitization of cardiac myofilaments to calcium without increasing intracellular calcium
Answer: A
Rationale: Dobutamine is a synthetic catecholamine that acts as a selective ²1-adrenergic receptor
agonist, producing positive inotropic effects with minimal chronotropic or vasoconstrictive effects at low
doses. Option B describes epinephrine or norepinephrine; option C describes milrinone; option D
describes levosimendan (not available in the US).
12. A patient on warfarin therapy for atrial fibrillation has an INR of 4.8 without bleeding.
According to current guidelines, which of the following is the most appropriate management?
A. Administer 5 mg of oral vitamin K and hold warfarin for 1-2 days, recheck INR in 24 hours
B. Administer 10 mg of intravenous vitamin K and fresh frozen plasma
C. Administer 2.5 mg of oral vitamin K and continue warfarin at a reduced dose
D. Administer 1 mg of oral vitamin K and hold warfarin for 1 day, recheck INR in 24 hours
Answer: D
Rationale: For a patient with INR >4.5 but <10 and no bleeding, guidelines recommend withholding
warfarin and giving a low dose (1-2.5 mg) of oral vitamin K. Option A uses too high a dose; option B is
for major bleeding; option C suggests continuing warfarin which is unsafe.
13. Which of the following pharmacokinetic parameters is most affected by a drug that undergoes
extensive first-pass metabolism in the liver?
Page 4
5, 6, 7, 8, 9, 10 EXAM'S NEWEST QUESTIONS
AND ANSWERS () LATEST GRADED
A+…
1. A patient with chronic heart failure is initiated on sacubitril/valsartan. Which mechanism best
explains the drug's therapeutic benefit in reducing mortality?
A. Combined angiotensin receptor blockade and neprilysin inhibition, increasing natriuretic peptides and
decreasing aldosterone release.
B. Selective beta-1 adrenergic antagonism reducing myocardial oxygen demand.
C. Aldosterone receptor antagonism preventing sodium and water retention.
D. Direct vasodilation via nitric oxide release and calcium channel blockade.
Answer: A
Rationale: Sacubitril/valsartan is an ARNI that inhibits neprilysin (increasing natriuretic peptides) and
blocks AT1 receptors, reducing aldosterone and sympathetic activity. This dual action improves
outcomes in heart failure with reduced ejection fraction. Beta-blockade (B) and aldosterone antagonism
(C) are distinct drug classes, while direct vasodilation (D) is not its primary mechanism.
2. A patient receiving vancomycin for a MRSA bloodstream infection develops acute kidney injury.
Which pharmacodynamic principle best explains the increased nephrotoxicity risk when
vancomycin is combined with piperacillin-tazobactam?
A. Synergistic antagonism of renal tubular transporters by both drugs.
B. Additive acute tubular necrosis due to similar mechanisms of proximal tubule injury.
C. Competitive inhibition of vancomycin clearance by piperacillin at organic anion transporters.
D. Enhanced formation of reactive oxygen species in the loop of Henle.
Answer: B
Rationale: Both vancomycin and piperacillin-tazobactam are independently associated with acute kidney
injury, and their combination leads to additive nephrotoxicity, likely through synergistic tubular cell
stress and necrosis. While transporter interactions (C) may contribute, the primary mechanism is
additive cellular injury. Options A and D are not well-supported mechanisms.
3. A patient with severe hypertension and a history of angioedema from lisinopril requires urgent
blood pressure reduction. Which agent is most appropriate?
A. Hydralazine
B. Losartan
C. Aliskiren
D. Enalaprilat
Page 1
,Answer: A
Rationale: Hydralazine is a direct vasodilator that does not affect the renin-angiotensin-aldosterone
system, making it safe in patients with ACE inhibitor-induced angioedema. Losartan (B) and aliskiren
(C) also act on the RAAS and could cross-react. Enalaprilat (D) is an intravenous ACE inhibitor,
contraindicated due to the history of angioedema.
4. A patient on long-term warfarin therapy for a mechanical heart valve presents with an INR of
5.2 and minor epistaxis. Which intervention is recommended per current guidelines?
A. Administer vitamin K 10 mg intravenously and hold warfarin until INR normalizes.
B. Administer fresh frozen plasma (FFP) immediately to reverse anticoagulation.
C. Hold warfarin and administer vitamin K 1-2.5 mg orally.
D. Administer prothrombin complex concentrate (PCC) and vitamin K 10 mg intravenously.
Answer: C
Rationale: For an INR >5 but <9 with minor bleeding, guidelines recommend holding warfarin and
giving low-dose oral vitamin K (1-2.5 mg) to gradually lower the INR. High-dose IV vitamin K (A) may
cause overcorrection and warfarin resistance. FFP (B) and PCC (D) are reserved for life-threatening
bleeding. This approach balances reversal while maintaining anticoagulation for the mechanical valve.
5. A patient with type 2 diabetes inadequately controlled on metformin and glipizide is started on
an SGLT2 inhibitor. Which laboratory parameter requires close monitoring due to the mechanism
of this drug class?
A. Serum potassium
B. Serum creatinine and eGFR
C. Hemoglobin A1c
D. Serum bicarbonate
Answer: B
Rationale: SGLT2 inhibitors reduce glucose reabsorption in the proximal tubule, leading to osmotic
diuresis and a reversible decrease in eGFR, especially upon initiation. Monitoring renal function is
critical to detect acute kidney injury or volume depletion. While serum bicarbonate (D) may be
monitored for euglycemic DKA, renal function monitoring is the priority per prescribing information.
6. A patient with major depressive disorder and comorbid generalized anxiety disorder has failed
trials of sertraline and venlafaxine. Which of the following augmentation strategies is supported by
current evidence for treatment-resistant depression?
A. Adding bupropion to the existing SSRI regimen.
B. Switching to a monoamine oxidase inhibitor (MAOI) without washout.
C. Augmenting with a typical antipsychotic like haloperidol.
D. Adding buspirone 30 mg daily in divided doses.
Answer: A
Rationale: Bupropion augmentation of SSRIs is an evidence-based strategy for treatment-resistant
depression, particularly when residual symptoms include anergia or sexual dysfunction. MAOIs (B)
require a washout period to avoid serotonin syndrome. Haloperidol (C) is not first-line augmentation;
atypical antipsychotics like aripiprazole are preferred. Buspirone (D) is more effective for anxiety than
depression augmentation.
Page 2
,7. A patient receiving morphine via patient-controlled analgesia (PCA) develops respiratory
depression with a respiratory rate of 6 breaths/min. Which statement accurately describes the
mechanism of action of the reversal agent?
A. Naloxone competitively antagonizes mu-opioid receptors, reversing both analgesia and respiratory
depression.
B. Naloxone non-competitively inhibits opioid binding to kappa receptors, selectively reversing respiratory
effects.
C. Naloxone acts as a partial agonist at mu receptors, displacing morphine and restoring ventilation.
D. Naloxone potentiates GABAergic inhibition in the medullary respiratory center.
Answer: A
Rationale: Naloxone is a competitive antagonist at mu-opioid receptors, reversing all opioid effects
including analgesia and respiratory depression. It does not selectively target respiratory depression (B)
and is not a partial agonist (C). Its action is not via GABA (D). Titration is critical to avoid acute
withdrawal or pain recurrence.
8. A patient with a history of opioid use disorder is prescribed buprenorphine/naloxone for
maintenance therapy. Which pharmacokinetic property of buprenorphine contributes to its lower
abuse liability compared to full agonists?
A. High intrinsic activity at mu receptors with long half-life.
B. High affinity but partial agonism at mu receptors, resulting in a ceiling effect for respiratory depression.
C. Rapid dissociation from mu receptors limiting duration of action.
D. First-pass metabolism to an inactive metabolite reducing bioavailability.
Answer: B
Rationale: Buprenorphine's partial agonism at mu receptors produces a ceiling effect on respiratory
depression and euphoria, reducing abuse potential and overdose risk. Its high affinity (B) prevents
displacement by full agonists. Option A describes a full agonist. Option C is incorrect; buprenorphine
dissociates slowly. Option D is not the primary reason for lower abuse liability.
9. A patient on a cisplatin-based chemotherapy regimen develops severe nausea and vomiting
despite prophylaxis with ondansetron and dexamethasone. Which additional agent would be most
appropriate to add based on the emetic potential of cisplatin?
A. Metoclopramide 10 mg IV every 6 hours.
B. Aprepitant 125 mg orally before chemotherapy, then 80 mg daily for 2 days.
C. Prochlorperazine 10 mg IM every 4 hours as needed.
D. Dronabinol 5 mg orally every 6 hours.
Answer: B
Rationale: Cisplatin is highly emetogenic and requires a three-drug regimen including a neurokinin-1
(NK1) receptor antagonist like aprepitant, a 5-HT3 antagonist, and dexamethasone. Aprepitant targets
the substance P/NK1 pathway, which is critical for delayed emesis. Metoclopramide (A) and
prochlorperazine (C) are less effective for highly emetogenic chemotherapy. Dronabinol (D) is reserved
for breakthrough nausea.
Page 3
, 10. A patient with methicillin-sensitive Staphylococcus aureus (MSSA) osteomyelitis is being
treated with cefazolin. Which statement about the pharmacodynamics of beta-lactam antibiotics is
most relevant to ensuring bactericidal activity?
A. The time that the free drug concentration exceeds the minimum inhibitory concentration (fT>MIC) should be
at least 40-50% of the dosing interval.
B. The peak concentration to MIC ratio (Cmax/MIC) should exceed 10 for optimal killing.
C. The area under the curve to MIC ratio (AUC/MIC) should be at least 400.
D. Post-antibiotic effect (PAE) against gram-positive cocci is prolonged, allowing extended dosing intervals.
Answer: A
Rationale: Beta-lactams exhibit time-dependent killing, and the critical PK/PD parameter is the
percentage of time the free drug concentration remains above the MIC. For cephalosporins, achieving
fT>MIC for at least 40-50% of the dosing interval is associated with bactericidal efficacy. Option B
applies to aminoglycosides, C to fluoroquinolones, and D is not characteristic of beta-lactams against
MSSA.
11. A patient with a history of chronic heart failure (NYHA class III) is admitted with acute
decompensation. Current medications include lisinopril, carvedilol, furosemide, and
spironolactone. The provider orders intravenous dobutamine. Which of the following best
describes the mechanism by which dobutamine improves cardiac output in this patient?
A. Selective ²1-adrenergic receptor agonism increasing myocardial contractility
B. Non-selective ²- and ±-adrenergic receptor agonism leading to increased heart rate and vasoconstriction
C. Phosphodiesterase-3 inhibition resulting in increased intracellular cAMP and calcium influx
D. Sensitization of cardiac myofilaments to calcium without increasing intracellular calcium
Answer: A
Rationale: Dobutamine is a synthetic catecholamine that acts as a selective ²1-adrenergic receptor
agonist, producing positive inotropic effects with minimal chronotropic or vasoconstrictive effects at low
doses. Option B describes epinephrine or norepinephrine; option C describes milrinone; option D
describes levosimendan (not available in the US).
12. A patient on warfarin therapy for atrial fibrillation has an INR of 4.8 without bleeding.
According to current guidelines, which of the following is the most appropriate management?
A. Administer 5 mg of oral vitamin K and hold warfarin for 1-2 days, recheck INR in 24 hours
B. Administer 10 mg of intravenous vitamin K and fresh frozen plasma
C. Administer 2.5 mg of oral vitamin K and continue warfarin at a reduced dose
D. Administer 1 mg of oral vitamin K and hold warfarin for 1 day, recheck INR in 24 hours
Answer: D
Rationale: For a patient with INR >4.5 but <10 and no bleeding, guidelines recommend withholding
warfarin and giving a low dose (1-2.5 mg) of oral vitamin K. Option A uses too high a dose; option B is
for major bleeding; option C suggests continuing warfarin which is unsafe.
13. Which of the following pharmacokinetic parameters is most affected by a drug that undergoes
extensive first-pass metabolism in the liver?
Page 4
