WILKES UNIVERSITY · 2026-2027
NSG 533 Exam 2
Study Guide
Advanced Pharmacology — Comprehensive 75-Question Practice
Examination covering anticoagulants, respiratory agents,
gastrointestinal medications, pain management, neurological
agents, psychiatric medications, and anti-infectives with integrated
clinical scenarios
Course: NSG 533 · Advanced Pharmacology Exam 2
Questions: 75 · Sections: 8
Alignment: 2026-2027 Wilkes University Curriculum Standards
,NSG 533 Exam 2 Study Guide | Advanced Pharmacology | Wilkes University 2026-2027 Page 1
Section 1: Anticoagulants, Antiplatelets, and Thrombolytics
(Q1-Q12)
Q1: A 68-year-old patient with atrial fibrillation is started on warfarin
(Coumadin). The nurse practitioner knows that warfarin exerts its
anticoagulant effect by which mechanism?
A. Directly inhibiting thrombin
B. Inhibiting the synthesis of vitamin K-dependent clotting factors II, VII,
IX, X, and proteins C and S [CORRECT]
C. Activating antithrombin III to inactivate factor Xa
D. Irreversibly inhibiting platelet COX-1
Correct Answer: B
Rationale: Warfarin is a vitamin K antagonist that inhibits the hepatic synthesis of vitamin
K-dependent clotting factors (II, VII, IX, X) and the anticoagulant proteins C and S. Its onset
is delayed (2-7 days) because existing circulating clotting factors must be depleted. Direct
thrombin inhibition is the mechanism of dabigatran. Activating antithrombin III describes
heparin and LMWH. COX-1 inhibition is the mechanism of aspirin. Per Wilkes NSG 533
guidelines, understanding warfarin's mechanism is foundational for anticoagulant
management.
Q2: A patient on warfarin therapy has an INR of 5.2 but is not actively
bleeding. What is the most appropriate initial management?
A. Administer intravenous vitamin K immediately and recheck INR in 2 hours
B. Hold the next dose of warfarin and recheck INR in 24-48 hours
[CORRECT]
C. Administer fresh frozen plasma (FFP) and continue current warfarin dose
D. Switch to therapeutic heparin and resume warfarin at a lower dose
Correct Answer: B
Rationale: For asymptomatic elevated INR (5.0-9.0), the recommended approach is to hold
one or two doses of warfarin and monitor the INR. If the INR is only slightly above the
therapeutic range, no vitamin K is needed. IV vitamin K is reserved for significantly elevated
INR (>10) or active bleeding, as it can cause overcorrection and lead to warfarin
resistance. FFP and PCC are reserved for life-threatening bleeding. Heparin bridging is not
indicated for simple INR elevation without thrombosis or bleeding.
Q3: A 55-year-old patient is receiving continuous intravenous unfractionated
heparin for acute deep vein thrombosis. Which laboratory value should the
Aligned with 2026-2027 Wilkes University NSG 533 Curriculum Standards
75 Questions | 8 Sections For Educational Use Only
,NSG 533 Exam 2 Study Guide | Advanced Pharmacology | Wilkes University 2026-2027 Page 2
nurse practitioner monitor to assess therapeutic efficacy?
A. International Normalized Ratio (INR)
B. Activated partial thromboplastin time (aPTT) [CORRECT]
C. Prothrombin time (PT)
D. Platelet count only
Correct Answer: B
Rationale: Unfractionated heparin (UFH) therapy is monitored using the aPTT, with a
therapeutic target of 1.5 to 2.5 times the control value. UFH works by activating
antithrombin III, which inactivates thrombin (factor IIa) and factor Xa. INR is used to
monitor warfarin therapy, not heparin. Prothrombin time reflects the extrinsic pathway and
is also used for warfarin monitoring. Platelet count must also be monitored to detect
heparin-induced thrombocytopenia (HIT), but it does not assess anticoagulant efficacy.
Q4: A hospitalized patient develops heparin-induced thrombocytopenia (HIT)
type II. Which alternative anticoagulant is most appropriate for this patient?
A. Enoxaparin (Lovenox)
B. Warfarin (Coumadin)
C. Argatroban or bivalirudin (direct thrombin inhibitors) [CORRECT]
D. Aspirin (high-dose)
Correct Answer: C
Rationale: HIT type II is an immune-mediated adverse reaction to heparin that causes
paradoxical thrombosis and thrombocytopenia. All heparin products (including LMWH)
must be discontinued immediately. Direct thrombin inhibitors such as argatroban or
bivalirudin are the agents of choice because they do not cross-react with HIT antibodies.
Warfarin is contraindicated initially because it can cause venous limb gangrene
(warfarin-induced skin necrosis) by depleting protein C before factor X. Aspirin does not
provide adequate anticoagulation for HIT-associated thrombosis.
Q5: A patient with nonvalvular atrial fibrillation is prescribed apixaban
(Eliquis). The nurse practitioner should counsel the patient about which
important characteristic of this medication?
A. Requires regular INR monitoring to maintain therapeutic levels
B. Has a specific reversal agent (andexanet alfa) available for bleeding
emergencies [CORRECT]
C. Must be taken with food to enhance absorption
D. Is contraindicated in patients with any degree of renal impairment
Correct Answer: B
Aligned with 2026-2027 Wilkes University NSG 533 Curriculum Standards
75 Questions | 8 Sections For Educational Use Only
, NSG 533 Exam 2 Study Guide | Advanced Pharmacology | Wilkes University 2026-2027 Page 3
Rationale: Apixaban is a direct factor Xa inhibitor (DOAC) that does not require routine
coagulation monitoring. Andexanet alfa is the specific reversal agent for factor Xa
inhibitors (apixaban, rivaroxaban, edoxaban). Dabigatran (a direct thrombin inhibitor) has
its own reversal agent, idarucizumab. DOACs do not require INR monitoring, distinguishing
them from warfarin. Apixaban can be taken with or without food. Renal dose adjustment is
needed but it is not contraindicated in all renal impairment, making this the most accurate
counseling point per NSG 533 pharmacology standards.
Q6: A patient is prescribed clopidogrel (Plavix) after placement of a coronary
artery stent. The nurse practitioner understands that clopidogrel requires
activation by which enzyme system?
A. CYP3A4
B. CYP2C19 [CORRECT]
C. CYP2D6
D. CYP1A2
Correct Answer: B
Rationale: Clopidogrel is a prodrug that requires bioactivation by the hepatic cytochrome
P450 enzyme CYP2C19 to its active metabolite. Genetic polymorphisms in CYP2C19 can
result in poor metabolizers who have reduced antiplatelet response, increasing the risk of
thrombotic events. CYP2C19 inhibitors such as omeprazole can also decrease clopidogrel
activation. If a PPI is needed, pantoprazole is preferred because it has less CYP2C19
inhibition. CYP3A4, CYP2D6, and CYP1A2 are not the primary activation pathways for
clopidogrel.
Q7: Which of the following is a contraindication to the use of ticagrelor
(Brilinta) in a patient with acute coronary syndrome?
A. History of peptic ulcer disease
B. Severe hepatic impairment
C. Concurrent use of aspirin 81 mg daily
D. Active bleeding or history of intracranial hemorrhage [CORRECT]
Correct Answer: D
Rationale: Ticagrelor is a reversible P2Y12 receptor antagonist with a black box warning
for bleeding, similar to other antiplatelet agents. Active bleeding or a history of intracranial
hemorrhage is an absolute contraindication. Ticagrelor must be used with low-dose aspirin
(81 mg daily); higher aspirin doses reduce its effectiveness. Unlike clopidogrel, ticagrelor
does not require CYP2C19 activation. A common adverse effect is dyspnea, which occurs in
approximately 10-15% of patients and usually does not require discontinuation. Severe
hepatic impairment is a relative but not absolute contraindication.
Aligned with 2026-2027 Wilkes University NSG 533 Curriculum Standards
75 Questions | 8 Sections For Educational Use Only
NSG 533 Exam 2
Study Guide
Advanced Pharmacology — Comprehensive 75-Question Practice
Examination covering anticoagulants, respiratory agents,
gastrointestinal medications, pain management, neurological
agents, psychiatric medications, and anti-infectives with integrated
clinical scenarios
Course: NSG 533 · Advanced Pharmacology Exam 2
Questions: 75 · Sections: 8
Alignment: 2026-2027 Wilkes University Curriculum Standards
,NSG 533 Exam 2 Study Guide | Advanced Pharmacology | Wilkes University 2026-2027 Page 1
Section 1: Anticoagulants, Antiplatelets, and Thrombolytics
(Q1-Q12)
Q1: A 68-year-old patient with atrial fibrillation is started on warfarin
(Coumadin). The nurse practitioner knows that warfarin exerts its
anticoagulant effect by which mechanism?
A. Directly inhibiting thrombin
B. Inhibiting the synthesis of vitamin K-dependent clotting factors II, VII,
IX, X, and proteins C and S [CORRECT]
C. Activating antithrombin III to inactivate factor Xa
D. Irreversibly inhibiting platelet COX-1
Correct Answer: B
Rationale: Warfarin is a vitamin K antagonist that inhibits the hepatic synthesis of vitamin
K-dependent clotting factors (II, VII, IX, X) and the anticoagulant proteins C and S. Its onset
is delayed (2-7 days) because existing circulating clotting factors must be depleted. Direct
thrombin inhibition is the mechanism of dabigatran. Activating antithrombin III describes
heparin and LMWH. COX-1 inhibition is the mechanism of aspirin. Per Wilkes NSG 533
guidelines, understanding warfarin's mechanism is foundational for anticoagulant
management.
Q2: A patient on warfarin therapy has an INR of 5.2 but is not actively
bleeding. What is the most appropriate initial management?
A. Administer intravenous vitamin K immediately and recheck INR in 2 hours
B. Hold the next dose of warfarin and recheck INR in 24-48 hours
[CORRECT]
C. Administer fresh frozen plasma (FFP) and continue current warfarin dose
D. Switch to therapeutic heparin and resume warfarin at a lower dose
Correct Answer: B
Rationale: For asymptomatic elevated INR (5.0-9.0), the recommended approach is to hold
one or two doses of warfarin and monitor the INR. If the INR is only slightly above the
therapeutic range, no vitamin K is needed. IV vitamin K is reserved for significantly elevated
INR (>10) or active bleeding, as it can cause overcorrection and lead to warfarin
resistance. FFP and PCC are reserved for life-threatening bleeding. Heparin bridging is not
indicated for simple INR elevation without thrombosis or bleeding.
Q3: A 55-year-old patient is receiving continuous intravenous unfractionated
heparin for acute deep vein thrombosis. Which laboratory value should the
Aligned with 2026-2027 Wilkes University NSG 533 Curriculum Standards
75 Questions | 8 Sections For Educational Use Only
,NSG 533 Exam 2 Study Guide | Advanced Pharmacology | Wilkes University 2026-2027 Page 2
nurse practitioner monitor to assess therapeutic efficacy?
A. International Normalized Ratio (INR)
B. Activated partial thromboplastin time (aPTT) [CORRECT]
C. Prothrombin time (PT)
D. Platelet count only
Correct Answer: B
Rationale: Unfractionated heparin (UFH) therapy is monitored using the aPTT, with a
therapeutic target of 1.5 to 2.5 times the control value. UFH works by activating
antithrombin III, which inactivates thrombin (factor IIa) and factor Xa. INR is used to
monitor warfarin therapy, not heparin. Prothrombin time reflects the extrinsic pathway and
is also used for warfarin monitoring. Platelet count must also be monitored to detect
heparin-induced thrombocytopenia (HIT), but it does not assess anticoagulant efficacy.
Q4: A hospitalized patient develops heparin-induced thrombocytopenia (HIT)
type II. Which alternative anticoagulant is most appropriate for this patient?
A. Enoxaparin (Lovenox)
B. Warfarin (Coumadin)
C. Argatroban or bivalirudin (direct thrombin inhibitors) [CORRECT]
D. Aspirin (high-dose)
Correct Answer: C
Rationale: HIT type II is an immune-mediated adverse reaction to heparin that causes
paradoxical thrombosis and thrombocytopenia. All heparin products (including LMWH)
must be discontinued immediately. Direct thrombin inhibitors such as argatroban or
bivalirudin are the agents of choice because they do not cross-react with HIT antibodies.
Warfarin is contraindicated initially because it can cause venous limb gangrene
(warfarin-induced skin necrosis) by depleting protein C before factor X. Aspirin does not
provide adequate anticoagulation for HIT-associated thrombosis.
Q5: A patient with nonvalvular atrial fibrillation is prescribed apixaban
(Eliquis). The nurse practitioner should counsel the patient about which
important characteristic of this medication?
A. Requires regular INR monitoring to maintain therapeutic levels
B. Has a specific reversal agent (andexanet alfa) available for bleeding
emergencies [CORRECT]
C. Must be taken with food to enhance absorption
D. Is contraindicated in patients with any degree of renal impairment
Correct Answer: B
Aligned with 2026-2027 Wilkes University NSG 533 Curriculum Standards
75 Questions | 8 Sections For Educational Use Only
, NSG 533 Exam 2 Study Guide | Advanced Pharmacology | Wilkes University 2026-2027 Page 3
Rationale: Apixaban is a direct factor Xa inhibitor (DOAC) that does not require routine
coagulation monitoring. Andexanet alfa is the specific reversal agent for factor Xa
inhibitors (apixaban, rivaroxaban, edoxaban). Dabigatran (a direct thrombin inhibitor) has
its own reversal agent, idarucizumab. DOACs do not require INR monitoring, distinguishing
them from warfarin. Apixaban can be taken with or without food. Renal dose adjustment is
needed but it is not contraindicated in all renal impairment, making this the most accurate
counseling point per NSG 533 pharmacology standards.
Q6: A patient is prescribed clopidogrel (Plavix) after placement of a coronary
artery stent. The nurse practitioner understands that clopidogrel requires
activation by which enzyme system?
A. CYP3A4
B. CYP2C19 [CORRECT]
C. CYP2D6
D. CYP1A2
Correct Answer: B
Rationale: Clopidogrel is a prodrug that requires bioactivation by the hepatic cytochrome
P450 enzyme CYP2C19 to its active metabolite. Genetic polymorphisms in CYP2C19 can
result in poor metabolizers who have reduced antiplatelet response, increasing the risk of
thrombotic events. CYP2C19 inhibitors such as omeprazole can also decrease clopidogrel
activation. If a PPI is needed, pantoprazole is preferred because it has less CYP2C19
inhibition. CYP3A4, CYP2D6, and CYP1A2 are not the primary activation pathways for
clopidogrel.
Q7: Which of the following is a contraindication to the use of ticagrelor
(Brilinta) in a patient with acute coronary syndrome?
A. History of peptic ulcer disease
B. Severe hepatic impairment
C. Concurrent use of aspirin 81 mg daily
D. Active bleeding or history of intracranial hemorrhage [CORRECT]
Correct Answer: D
Rationale: Ticagrelor is a reversible P2Y12 receptor antagonist with a black box warning
for bleeding, similar to other antiplatelet agents. Active bleeding or a history of intracranial
hemorrhage is an absolute contraindication. Ticagrelor must be used with low-dose aspirin
(81 mg daily); higher aspirin doses reduce its effectiveness. Unlike clopidogrel, ticagrelor
does not require CYP2C19 activation. A common adverse effect is dyspnea, which occurs in
approximately 10-15% of patients and usually does not require discontinuation. Severe
hepatic impairment is a relative but not absolute contraindication.
Aligned with 2026-2027 Wilkes University NSG 533 Curriculum Standards
75 Questions | 8 Sections For Educational Use Only
