NURSING LICENSURE
NU 578 Exam 4 — 2026/2027 Official Exam
A+
Complete Blueprint Coverage
A+ 5 100%
QUESTIONS VERIFIED CORE DOMAINS COVERED RATIONALES INCLUDED
CATEGORIES
1. Endocrine and Metabolic Pharmacotherapeutics
2. Central Nervous System and Psychopharmacology
3. Antimicrobial Therapy and Infectious Disease
4. Cardiovascular and Antithrombotic Agents
5. Special Populations and Complex Clinical Decisions
STUVIAACTUALEXAM
,1. Endocrine and Metabolic Pharmacotherapeutics
Q1
A 54-year-old patient with type 2 diabetes has an A1C of 8.4 % despite maximum metformin and lifestyle
measures. The nurse practitioner considers adding an agent that also promotes weight loss and has
cardiovascular benefit. Which class best matches this therapeutic goal?
A. GLP-1 receptor agonist such as semaglutide or liraglutide.
B. Sulfonylurea such as glipizide for rapid A1C reduction only.
C. Thiazolidinedione such as pioglitazone despite fluid-retention risk.
D. Meglitinide for post-prandial control without weight or CV benefit.
Correct Answer: A
Rationale:
GLP-1 receptor agonists lower A1C, promote weight loss, and have proven cardiovascular risk reduction in high-risk patients.
Sulfonylureas and meglitinides can cause weight gain and lack CV benefit; TZDs may cause fluid retention.
Q2
A patient with hypothyroidism has been stable on levothyroxine 100 mcg daily. Recent TSH is 8.2 mIU/L
(elevated) with free T4 at the low end of normal. The patient reports taking the tablet with morning coffee and
calcium supplements. What is the most appropriate next step?
A. Immediately double the levothyroxine dose and recheck in one week.
B. Counsel on separating levothyroxine from food, coffee, and calcium by at least 4 hours and recheck TSH in 6–8
weeks before changing the dose.
C. Switch to desiccated thyroid extract without addressing absorption issues.
D. Add liothyronine (T3) at a high dose while continuing the same levothyroxine timing.
Correct Answer: B
Rationale:
Absorption of levothyroxine is markedly reduced by food, coffee, and divalent cations. Optimizing administration often
normalizes TSH without a dose increase. Premature large dose changes risk over-replacement.
Q3
A 62-year-old with longstanding type 2 diabetes and eGFR of 28 mL/min is on metformin 1000 mg BID. The
patient is scheduled for a contrast-enhanced CT. Which action regarding metformin is evidence-based?
A. Continue metformin without interruption because eGFR > 15 allows unrestricted use.
B. Increase the metformin dose temporarily to protect against contrast nephropathy.
C. Hold metformin at the time of or prior to contrast and restart only after renal function is re-evaluated and stable.
D. Replace metformin with a sulfonylurea for 24 hours only and then resume the original dose.
Correct Answer: C
Rationale:
In patients with reduced eGFR, metformin is held around iodinated contrast exposure to minimize the rare risk of lactic
acidosis if acute kidney injury occurs. Restarting requires confirmation of stable renal function.
, Q4
A patient with adrenal insufficiency is on chronic hydrocortisone replacement. The patient develops acute
gastroenteritis with vomiting and is unable to keep oral medication down. What is the priority teaching or action?
A. Advise skipping doses until oral intake resumes to avoid excess steroid exposure.
B. Double the next oral dose once vomiting stops and continue the regular schedule.
C. Switch permanently to dexamethasone because it has a longer half-life.
D. Instruct on the use of emergency injectable glucocorticoid and seek urgent care for parenteral steroid coverage.
Correct Answer: D
Rationale:
Patients with adrenal insufficiency require stress-dose or parenteral glucocorticoid when oral intake is impossible. Missing
replacement during illness risks adrenal crisis; simply doubling later oral doses may be insufficient if absorption remains
impaired.
Q5
A 48-year-old woman with new-onset atrial fibrillation and a BMI of 38 is found to have an elevated TSH and low
free T4. Which statement best guides initial thyroid hormone replacement?
A. Start low and titrate carefully because over-replacement can precipitate or worsen tachyarrhythmias, especially in
older or cardiac patients.
B. Begin at a full replacement dose based on ideal body weight to correct the deficit rapidly.
C. Use T3 monotherapy exclusively because it has a shorter half-life and is safer in arrhythmia.
D. Withhold all thyroid hormone until the atrial fibrillation is permanently ablated.
Correct Answer: A
Rationale:
In patients with cardiac disease or arrhythmia risk, levothyroxine is started at a reduced dose and titrated slowly to avoid
precipitating ischemia or worsening tachyarrhythmia. Full initial replacement is reserved for young, healthy patients.
Q6
A patient with type 2 diabetes on empagliflozin presents with nausea, abdominal pain, and a normal blood
glucose of 142 mg/dL. The anion gap is elevated and serum ketones are positive. Which diagnosis must be
considered?
A. Simple gastroenteritis unrelated to the diabetes medication.
B. Euglycemic diabetic ketoacidosis associated with SGLT2 inhibitor use.
C. Hyperosmolar hyperglycemic state because the glucose is not low.
D. Lactic acidosis from concurrent metformin until proven otherwise.
Correct Answer: B
Rationale:
SGLT2 inhibitors can precipitate euglycemic DKA, in which ketoacidosis occurs with only modestly elevated or near-normal
glucose. Recognition is critical so that insulin, fluids, and temporary drug cessation can be instituted.
NU 578 Exam 4 — 2026/2027 Official Exam Page 3
NU 578 Exam 4 — 2026/2027 Official Exam
A+
Complete Blueprint Coverage
A+ 5 100%
QUESTIONS VERIFIED CORE DOMAINS COVERED RATIONALES INCLUDED
CATEGORIES
1. Endocrine and Metabolic Pharmacotherapeutics
2. Central Nervous System and Psychopharmacology
3. Antimicrobial Therapy and Infectious Disease
4. Cardiovascular and Antithrombotic Agents
5. Special Populations and Complex Clinical Decisions
STUVIAACTUALEXAM
,1. Endocrine and Metabolic Pharmacotherapeutics
Q1
A 54-year-old patient with type 2 diabetes has an A1C of 8.4 % despite maximum metformin and lifestyle
measures. The nurse practitioner considers adding an agent that also promotes weight loss and has
cardiovascular benefit. Which class best matches this therapeutic goal?
A. GLP-1 receptor agonist such as semaglutide or liraglutide.
B. Sulfonylurea such as glipizide for rapid A1C reduction only.
C. Thiazolidinedione such as pioglitazone despite fluid-retention risk.
D. Meglitinide for post-prandial control without weight or CV benefit.
Correct Answer: A
Rationale:
GLP-1 receptor agonists lower A1C, promote weight loss, and have proven cardiovascular risk reduction in high-risk patients.
Sulfonylureas and meglitinides can cause weight gain and lack CV benefit; TZDs may cause fluid retention.
Q2
A patient with hypothyroidism has been stable on levothyroxine 100 mcg daily. Recent TSH is 8.2 mIU/L
(elevated) with free T4 at the low end of normal. The patient reports taking the tablet with morning coffee and
calcium supplements. What is the most appropriate next step?
A. Immediately double the levothyroxine dose and recheck in one week.
B. Counsel on separating levothyroxine from food, coffee, and calcium by at least 4 hours and recheck TSH in 6–8
weeks before changing the dose.
C. Switch to desiccated thyroid extract without addressing absorption issues.
D. Add liothyronine (T3) at a high dose while continuing the same levothyroxine timing.
Correct Answer: B
Rationale:
Absorption of levothyroxine is markedly reduced by food, coffee, and divalent cations. Optimizing administration often
normalizes TSH without a dose increase. Premature large dose changes risk over-replacement.
Q3
A 62-year-old with longstanding type 2 diabetes and eGFR of 28 mL/min is on metformin 1000 mg BID. The
patient is scheduled for a contrast-enhanced CT. Which action regarding metformin is evidence-based?
A. Continue metformin without interruption because eGFR > 15 allows unrestricted use.
B. Increase the metformin dose temporarily to protect against contrast nephropathy.
C. Hold metformin at the time of or prior to contrast and restart only after renal function is re-evaluated and stable.
D. Replace metformin with a sulfonylurea for 24 hours only and then resume the original dose.
Correct Answer: C
Rationale:
In patients with reduced eGFR, metformin is held around iodinated contrast exposure to minimize the rare risk of lactic
acidosis if acute kidney injury occurs. Restarting requires confirmation of stable renal function.
, Q4
A patient with adrenal insufficiency is on chronic hydrocortisone replacement. The patient develops acute
gastroenteritis with vomiting and is unable to keep oral medication down. What is the priority teaching or action?
A. Advise skipping doses until oral intake resumes to avoid excess steroid exposure.
B. Double the next oral dose once vomiting stops and continue the regular schedule.
C. Switch permanently to dexamethasone because it has a longer half-life.
D. Instruct on the use of emergency injectable glucocorticoid and seek urgent care for parenteral steroid coverage.
Correct Answer: D
Rationale:
Patients with adrenal insufficiency require stress-dose or parenteral glucocorticoid when oral intake is impossible. Missing
replacement during illness risks adrenal crisis; simply doubling later oral doses may be insufficient if absorption remains
impaired.
Q5
A 48-year-old woman with new-onset atrial fibrillation and a BMI of 38 is found to have an elevated TSH and low
free T4. Which statement best guides initial thyroid hormone replacement?
A. Start low and titrate carefully because over-replacement can precipitate or worsen tachyarrhythmias, especially in
older or cardiac patients.
B. Begin at a full replacement dose based on ideal body weight to correct the deficit rapidly.
C. Use T3 monotherapy exclusively because it has a shorter half-life and is safer in arrhythmia.
D. Withhold all thyroid hormone until the atrial fibrillation is permanently ablated.
Correct Answer: A
Rationale:
In patients with cardiac disease or arrhythmia risk, levothyroxine is started at a reduced dose and titrated slowly to avoid
precipitating ischemia or worsening tachyarrhythmia. Full initial replacement is reserved for young, healthy patients.
Q6
A patient with type 2 diabetes on empagliflozin presents with nausea, abdominal pain, and a normal blood
glucose of 142 mg/dL. The anion gap is elevated and serum ketones are positive. Which diagnosis must be
considered?
A. Simple gastroenteritis unrelated to the diabetes medication.
B. Euglycemic diabetic ketoacidosis associated with SGLT2 inhibitor use.
C. Hyperosmolar hyperglycemic state because the glucose is not low.
D. Lactic acidosis from concurrent metformin until proven otherwise.
Correct Answer: B
Rationale:
SGLT2 inhibitors can precipitate euglycemic DKA, in which ketoacidosis occurs with only modestly elevated or near-normal
glucose. Recognition is critical so that insulin, fluids, and temporary drug cessation can be instituted.
NU 578 Exam 4 — 2026/2027 Official Exam Page 3
