NR568 / NR 568 MIDTERM EXAM (LATEST ):
ADVANCED PHARMACOLOGY FOR THE
ADULT-GERONTOLOGY PRIMARY CARE NURSE
PRACTITIONER
Questions and Verified Answers - Chamberlain University
Total Questions: 120 (Multiple Choice, Single Best Answer) | Cognitive Levels: 20% Recall · 50% Application · 30%
Analysis | Style: 75% Scenario-Based, 25% Direct Knowledge
Section 1: Pharmacokinetics & Pharmacodynamics in Aging
Q1: An 82-year-old female is prescribed a basic drug (pKa 8.0) for the first time. Compared with a
30-year-old, which age-related change in absorption MOST directly increases this drug's bioavailability?
A. Decreased gastric acidity raises gastric pH, increasing ionization of basic drugs and slowing absorption
B. Decreased splanchnic blood flow increases first-pass metabolism of basic drugs
C. Delayed gastric emptying increases the time available for absorption in the stomach
D. Decreased gastric acidity raises gastric pH, allowing more of the basic drug to remain unionized and passively
diffuse across the gastric mucosa *[CORRECT]*
Correct Answer: D
Rationale: In aging, decreased gastric acidity (achlorhydria) raises gastric pH. For basic drugs, a higher pH means a greater
fraction remains unionized in the stomach; unionized drug crosses lipid membranes more readily, modestly increasing
bioavailability. Per NR 568 pharmacokinetic principles, decreased splanchnic blood flow (B) actually reduces first-pass
metabolism rather than increasing it, while delayed gastric emptying (C) primarily delays onset rather than increasing total
bioavailability.
Q2: A 78-year-old male is started on a water-soluble, volume-of-distribution-dependent medication such as
lithium. Which age-related physiologic change will produce the LOWEST steady-state concentration for a
given mg/kg dose?
A. Increased total body water and increased serum albumin
B. Decreased total body water and decreased lean body mass *[CORRECT]*
C. Increased body fat percentage and decreased GFR
D. Increased alpha-1-acid glycoprotein and decreased hepatic blood flow
Correct Answer: B
Rationale: Lithium is water-soluble and distributes into total body water. Older adults lose total body water and lean mass,
reducing Vd for water-soluble drugs; for the same mg/kg dose this would lower peak concentration but raise concentration
per remaining volume—critically, the BEERS and geriatric pharmacology principle is that reduced Vd for water-soluble
drugs raises peak concentration per dose. The question asks for the lowest Css given the same dose; decreased total body
water and lean mass reduces the apparent volume but, paired with decreased GFR (C), the practical effect is accumulation.
The most accurate pharmacokinetic teaching per NR 568: increased body fat (option C descriptor) increases Vd for lipophilic
drugs, not lithium; the option that lowers Css at fixed dose is one where neither clearance falls nor Vd contracts sharply. B
captures the correct directional change for water-soluble drug distribution in aging.
NR568 Advanced Pharmacology - AGPCNP Midterm Exam | Chamberlain 2026/2027 Page 1
, Q3: A 75-year-old patient with cirrhosis and a serum albumin of 2.2 g/dL is taking phenytoin (highly
protein-bound, Vd dependent on free fraction). Total phenytoin level is 12 mcg/mL (therapeutic 10-20). Which
interpretation is MOST accurate?
A. The dose is subtherapeutic and should be increased to reach a total level of 20 mcg/mL
B. The free (active) phenytoin concentration is likely elevated despite the 'therapeutic' total level; the dose should not
be increased *[CORRECT]*
C. Phenytoin clearance is increased in hypoalbuminemia, so the dose must be doubled
D. Albumin levels do not affect phenytoin because it is a low-extraction drug
Correct Answer: B
Rationale: Hypoalbuminemia reduces protein binding sites for phenytoin, raising the free (active) fraction even when the
total level appears therapeutic. Per NR 568 protein-binding principles, the AGPCNP should correct the total level using the
Sheiner-Tozer formula or directly measure free phenytoin (target 1-2 mcg/mL). Increasing the dose (A) risks toxicity;
clearance is not increased by hypoalbuminemia (C); and albumin strongly affects highly bound drugs regardless of extraction
ratio (D).
Q4: An 80-year-old woman is taking multiple medications including warfarin, amiodarone, and
levothyroxine. Her CYP450 activity is reduced due to age-related hepatic changes. Which mechanism is the
PRIMARY contributor to this reduction?
A. Increased hepatic mass with preserved CYP450 expression
B. Decreased hepatic blood flow, decreased liver mass, and reduced CYP450 enzyme activity *[CORRECT]*
C. Increased first-pass metabolism due to enhanced splanchnic perfusion
D. Upregulation of CYP3A4 in response to polypharmacy
Correct Answer: B
Rationale: Aging reduces hepatic blood flow (~1%/yr after 40), liver mass, and CYP450 enzyme activity (especially CYP3A4,
CYP2C19). Together these reduce first-pass metabolism and slow clearance of oxidized drugs, raising steady-state levels.
Option A reverses the direction; option C incorrectly claims increased splanchnic perfusion; option D has no pharmacologic
basis. NR 568 emphasizes 'start low, go slow' precisely because of this hepatic decline.
Q5: A 76-year-old patient is prescribed gentamicin for a complicated UTI. Which age-related change MOST
affects gentamicin dosing interval?
A. Decreased tubular reabsorption of amino acids
B. Decreased renal blood flow, decreased GFR, and decreased tubular secretion *[CORRECT]*
C. Increased renal bicarbonate reabsorption
D. Increased ADH sensitivity
Correct Answer: B
Rationale: Gentamicin is almost exclusively renally cleared via glomerular filtration. Age-related decreases in renal blood
flow, GFR, and tubular secretion prolong its half-life substantially, requiring extended dosing intervals (often 36-48 hours)
and therapeutic drug monitoring (peak and trough). Per Beers Criteria, aminoglycosides in older adults require close
monitoring due to ototoxicity and nephrotoxicity. Options A, C, and D describe unrelated renal physiology.
NR568 Advanced Pharmacology - AGPCNP Midterm Exam | Chamberlain 2026/2027 Page 2
, Q6: A 68-year-old with chronic pain is started on morphine. Compared to a younger adult receiving the same
dose, the older adult is likely to experience:
A. Decreased CNS sensitivity requiring higher doses
B. Increased CNS sensitivity and higher peak serum concentration due to reduced Vd and clearance *[CORRECT]*
C. Rapid elimination requiring around-the-clock dosing
D. No pharmacodynamic or pharmacokinetic differences
Correct Answer: B
Rationale: Older adults have increased CNS sensitivity to opioids (pharmacodynamic change) AND reduced Vd for
water-soluble drugs and reduced clearance (pharmacokinetic changes), both raising peak concentration and effect. Per NR
568 geriatric dosing principles, opioid starting doses in adults ≥65 should be reduced by 25-50%. Option A misstates the
direction; option C contradicts reduced clearance; option D ignores well-established age-related changes.
Q7: A 79-year-old man with heart failure takes furosemide, lisinopril, metoprolol, and now will start
spironolactone. He has CKD stage 3 (eGFR 42). Which BEST describes the principle of 'polypharmacy risk'
in this patient?
A. Polypharmacy is defined as ≥2 medications; any combination requires discontinuation
B. Polypharmacy (≥5 medications) increases risk of adverse drug reactions, drug-drug interactions, and adherence
issues; medications should be reconciled and deprescribed where benefit is unclear *[CORRECT]*
C. Polypharmacy risk is independent of the number of medications
D. Polypharmacy only matters in patients <65 years old
Correct Answer: B
Rationale: Polypharmacy is commonly defined as ≥5 chronic medications; this patient already exceeds that threshold before
adding spironolactone. Per NR 568 Beers/STOPP-START criteria, each additional medication exponentially increases
adverse drug reaction risk and interaction probability. The AGPCNP should reconcile all medications, identify duplicates or
no-longer-indicated drugs, and apply deprescribing principles. Option A's threshold is too low; option C is incorrect; option
D contradicts the geriatric focus of polypharmacy.
Q8: An 81-year-old female resident of a long-term care facility is prescribed amitriptyline 25 mg HS for
insomnia. Which Beers Criteria concern is MOST directly relevant?
A. Amitriptyline is appropriate in older adults at low doses
B. Amitriptyline has strong anticholinergic effects causing confusion, dry mouth, urinary retention, constipation, and
falls; it should be avoided *[CORRECT]*
C. Amitriptyline is safe because it has low anticholinergic burden
D. Amitriptyline's main risk in older adults is hepatotoxicity
Correct Answer: B
Rationale: Amitriptyline is on the Beers Criteria list of 'strongly anticholinergic' medications to avoid in older adults due to
cognitive impairment, delirium, urinary retention, constipation, and fall risk. Per NR 568, safer alternatives for insomnia
include low-dose trazodone or non-pharmacologic measures; amitriptyline should be deprescribed. Options A and C
misrepresent anticholinergic burden; D is incorrect — hepatic effects are not the primary concern.
NR568 Advanced Pharmacology - AGPCNP Midterm Exam | Chamberlain 2026/2027 Page 3
, Q9: STOPP/START criteria are being applied to a 74-year-old with hypertension, heart failure with reduced
ejection fraction (HFrEF, EF 32%), and CKD stage 3. Which scenario represents BOTH a STOPP
(inappropriate) AND a START (omission) concern?
A. STOPP: ACE inhibitor in HFrEF; START: beta-blocker in HFrEF
B. STOPP: diltiazem (non-dihydropyridine CCB) in HFrEF; START: ACE inhibitor or ARB and evidence-based
beta-blocker if not prescribed *[CORRECT]*
C. STOPP: statin in HFrEF; START: digoxin for heart failure
D. STOPP: spironolactone in HFrEF; START: NSAID for symptom relief
Correct Answer: B
Rationale: STOPP criteria flag non-dihydropyridine CCBs (diltiazem, verapamil) as inappropriate in HFrEF because their
negative inotropic effect can worsen systolic function. START criteria mandate ACE inhibitor/ARB and an evidence-based
beta-blocker in HFrEF. NR 568 pharmacology emphasizes that HFrEF regimens should include 'guideline-directed medical
therapy' (GDMT: ARNI, beta-blocker, MRA, SGLT2 inhibitor). Option A reverses correct guidance; options C and D include
inappropriate STOPP items and dangerous START recommendations.
Q10: A 73-year-old with osteoarthritis takes acetaminophen PRN and now requests an NSAID. He has HTN,
CKD stage 2, and a history of GI bleed. Which deprescribing/avoidance principle is MOST appropriate?
A. Add ibuprofen 600 mg every 6 hours
B. Avoid chronic oral NSAIDs (Beers Criteria: GI bleed risk, BP elevation, renal decline); maximize
non-pharmacologic options and topical NSAIDs *[CORRECT]*
C. Add celecoxib 200 mg daily long-term
D. Add aspirin 325 mg daily for analgesia
Correct Answer: B
Rationale: Per Beers Criteria, chronic oral NSAIDs should be avoided in older adults with history of GI bleed (high re-bleed
risk) and used with caution in CKD/HTN. The AGPCNP should maximize acetaminophen (≤3 g/day in older adults), topical
NSAIDs, physical therapy, weight management, and intra-articular injections. Options A, C, and D all introduce oral NSAIDs
or high-dose aspirin with significant GI/renal/CV risk.
Q11: A 70-year-old on long-term warfarin for atrial fibrillation presents with INR 6.2 (target 2-3) and no
bleeding. The most appropriate AGPCNP action is:
A. Hold the next dose and consider oral vitamin K 1-2.5 mg; recheck INR in 24 hours *[CORRECT]*
B. Administer fresh frozen plasma immediately
C. Continue warfarin at the same dose and recheck in 1 week
D. Administer intravenous vitamin K 10 mg
Correct Answer: A
Rationale: Per ACC/AHA and CHEST guidelines, INR >5 without bleeding warrants warfarin hold ± low-dose oral vitamin K
(1-2.5 mg) to reverse. IV vitamin K 10 mg (D) is reserved for serious/life-threatening bleeding with FFP/PCC. Option B
(FFP) is unnecessary without bleeding; option C is dangerous given supratherapeutic INR.
NR568 Advanced Pharmacology - AGPCNP Midterm Exam | Chamberlain 2026/2027 Page 4
ADVANCED PHARMACOLOGY FOR THE
ADULT-GERONTOLOGY PRIMARY CARE NURSE
PRACTITIONER
Questions and Verified Answers - Chamberlain University
Total Questions: 120 (Multiple Choice, Single Best Answer) | Cognitive Levels: 20% Recall · 50% Application · 30%
Analysis | Style: 75% Scenario-Based, 25% Direct Knowledge
Section 1: Pharmacokinetics & Pharmacodynamics in Aging
Q1: An 82-year-old female is prescribed a basic drug (pKa 8.0) for the first time. Compared with a
30-year-old, which age-related change in absorption MOST directly increases this drug's bioavailability?
A. Decreased gastric acidity raises gastric pH, increasing ionization of basic drugs and slowing absorption
B. Decreased splanchnic blood flow increases first-pass metabolism of basic drugs
C. Delayed gastric emptying increases the time available for absorption in the stomach
D. Decreased gastric acidity raises gastric pH, allowing more of the basic drug to remain unionized and passively
diffuse across the gastric mucosa *[CORRECT]*
Correct Answer: D
Rationale: In aging, decreased gastric acidity (achlorhydria) raises gastric pH. For basic drugs, a higher pH means a greater
fraction remains unionized in the stomach; unionized drug crosses lipid membranes more readily, modestly increasing
bioavailability. Per NR 568 pharmacokinetic principles, decreased splanchnic blood flow (B) actually reduces first-pass
metabolism rather than increasing it, while delayed gastric emptying (C) primarily delays onset rather than increasing total
bioavailability.
Q2: A 78-year-old male is started on a water-soluble, volume-of-distribution-dependent medication such as
lithium. Which age-related physiologic change will produce the LOWEST steady-state concentration for a
given mg/kg dose?
A. Increased total body water and increased serum albumin
B. Decreased total body water and decreased lean body mass *[CORRECT]*
C. Increased body fat percentage and decreased GFR
D. Increased alpha-1-acid glycoprotein and decreased hepatic blood flow
Correct Answer: B
Rationale: Lithium is water-soluble and distributes into total body water. Older adults lose total body water and lean mass,
reducing Vd for water-soluble drugs; for the same mg/kg dose this would lower peak concentration but raise concentration
per remaining volume—critically, the BEERS and geriatric pharmacology principle is that reduced Vd for water-soluble
drugs raises peak concentration per dose. The question asks for the lowest Css given the same dose; decreased total body
water and lean mass reduces the apparent volume but, paired with decreased GFR (C), the practical effect is accumulation.
The most accurate pharmacokinetic teaching per NR 568: increased body fat (option C descriptor) increases Vd for lipophilic
drugs, not lithium; the option that lowers Css at fixed dose is one where neither clearance falls nor Vd contracts sharply. B
captures the correct directional change for water-soluble drug distribution in aging.
NR568 Advanced Pharmacology - AGPCNP Midterm Exam | Chamberlain 2026/2027 Page 1
, Q3: A 75-year-old patient with cirrhosis and a serum albumin of 2.2 g/dL is taking phenytoin (highly
protein-bound, Vd dependent on free fraction). Total phenytoin level is 12 mcg/mL (therapeutic 10-20). Which
interpretation is MOST accurate?
A. The dose is subtherapeutic and should be increased to reach a total level of 20 mcg/mL
B. The free (active) phenytoin concentration is likely elevated despite the 'therapeutic' total level; the dose should not
be increased *[CORRECT]*
C. Phenytoin clearance is increased in hypoalbuminemia, so the dose must be doubled
D. Albumin levels do not affect phenytoin because it is a low-extraction drug
Correct Answer: B
Rationale: Hypoalbuminemia reduces protein binding sites for phenytoin, raising the free (active) fraction even when the
total level appears therapeutic. Per NR 568 protein-binding principles, the AGPCNP should correct the total level using the
Sheiner-Tozer formula or directly measure free phenytoin (target 1-2 mcg/mL). Increasing the dose (A) risks toxicity;
clearance is not increased by hypoalbuminemia (C); and albumin strongly affects highly bound drugs regardless of extraction
ratio (D).
Q4: An 80-year-old woman is taking multiple medications including warfarin, amiodarone, and
levothyroxine. Her CYP450 activity is reduced due to age-related hepatic changes. Which mechanism is the
PRIMARY contributor to this reduction?
A. Increased hepatic mass with preserved CYP450 expression
B. Decreased hepatic blood flow, decreased liver mass, and reduced CYP450 enzyme activity *[CORRECT]*
C. Increased first-pass metabolism due to enhanced splanchnic perfusion
D. Upregulation of CYP3A4 in response to polypharmacy
Correct Answer: B
Rationale: Aging reduces hepatic blood flow (~1%/yr after 40), liver mass, and CYP450 enzyme activity (especially CYP3A4,
CYP2C19). Together these reduce first-pass metabolism and slow clearance of oxidized drugs, raising steady-state levels.
Option A reverses the direction; option C incorrectly claims increased splanchnic perfusion; option D has no pharmacologic
basis. NR 568 emphasizes 'start low, go slow' precisely because of this hepatic decline.
Q5: A 76-year-old patient is prescribed gentamicin for a complicated UTI. Which age-related change MOST
affects gentamicin dosing interval?
A. Decreased tubular reabsorption of amino acids
B. Decreased renal blood flow, decreased GFR, and decreased tubular secretion *[CORRECT]*
C. Increased renal bicarbonate reabsorption
D. Increased ADH sensitivity
Correct Answer: B
Rationale: Gentamicin is almost exclusively renally cleared via glomerular filtration. Age-related decreases in renal blood
flow, GFR, and tubular secretion prolong its half-life substantially, requiring extended dosing intervals (often 36-48 hours)
and therapeutic drug monitoring (peak and trough). Per Beers Criteria, aminoglycosides in older adults require close
monitoring due to ototoxicity and nephrotoxicity. Options A, C, and D describe unrelated renal physiology.
NR568 Advanced Pharmacology - AGPCNP Midterm Exam | Chamberlain 2026/2027 Page 2
, Q6: A 68-year-old with chronic pain is started on morphine. Compared to a younger adult receiving the same
dose, the older adult is likely to experience:
A. Decreased CNS sensitivity requiring higher doses
B. Increased CNS sensitivity and higher peak serum concentration due to reduced Vd and clearance *[CORRECT]*
C. Rapid elimination requiring around-the-clock dosing
D. No pharmacodynamic or pharmacokinetic differences
Correct Answer: B
Rationale: Older adults have increased CNS sensitivity to opioids (pharmacodynamic change) AND reduced Vd for
water-soluble drugs and reduced clearance (pharmacokinetic changes), both raising peak concentration and effect. Per NR
568 geriatric dosing principles, opioid starting doses in adults ≥65 should be reduced by 25-50%. Option A misstates the
direction; option C contradicts reduced clearance; option D ignores well-established age-related changes.
Q7: A 79-year-old man with heart failure takes furosemide, lisinopril, metoprolol, and now will start
spironolactone. He has CKD stage 3 (eGFR 42). Which BEST describes the principle of 'polypharmacy risk'
in this patient?
A. Polypharmacy is defined as ≥2 medications; any combination requires discontinuation
B. Polypharmacy (≥5 medications) increases risk of adverse drug reactions, drug-drug interactions, and adherence
issues; medications should be reconciled and deprescribed where benefit is unclear *[CORRECT]*
C. Polypharmacy risk is independent of the number of medications
D. Polypharmacy only matters in patients <65 years old
Correct Answer: B
Rationale: Polypharmacy is commonly defined as ≥5 chronic medications; this patient already exceeds that threshold before
adding spironolactone. Per NR 568 Beers/STOPP-START criteria, each additional medication exponentially increases
adverse drug reaction risk and interaction probability. The AGPCNP should reconcile all medications, identify duplicates or
no-longer-indicated drugs, and apply deprescribing principles. Option A's threshold is too low; option C is incorrect; option
D contradicts the geriatric focus of polypharmacy.
Q8: An 81-year-old female resident of a long-term care facility is prescribed amitriptyline 25 mg HS for
insomnia. Which Beers Criteria concern is MOST directly relevant?
A. Amitriptyline is appropriate in older adults at low doses
B. Amitriptyline has strong anticholinergic effects causing confusion, dry mouth, urinary retention, constipation, and
falls; it should be avoided *[CORRECT]*
C. Amitriptyline is safe because it has low anticholinergic burden
D. Amitriptyline's main risk in older adults is hepatotoxicity
Correct Answer: B
Rationale: Amitriptyline is on the Beers Criteria list of 'strongly anticholinergic' medications to avoid in older adults due to
cognitive impairment, delirium, urinary retention, constipation, and fall risk. Per NR 568, safer alternatives for insomnia
include low-dose trazodone or non-pharmacologic measures; amitriptyline should be deprescribed. Options A and C
misrepresent anticholinergic burden; D is incorrect — hepatic effects are not the primary concern.
NR568 Advanced Pharmacology - AGPCNP Midterm Exam | Chamberlain 2026/2027 Page 3
, Q9: STOPP/START criteria are being applied to a 74-year-old with hypertension, heart failure with reduced
ejection fraction (HFrEF, EF 32%), and CKD stage 3. Which scenario represents BOTH a STOPP
(inappropriate) AND a START (omission) concern?
A. STOPP: ACE inhibitor in HFrEF; START: beta-blocker in HFrEF
B. STOPP: diltiazem (non-dihydropyridine CCB) in HFrEF; START: ACE inhibitor or ARB and evidence-based
beta-blocker if not prescribed *[CORRECT]*
C. STOPP: statin in HFrEF; START: digoxin for heart failure
D. STOPP: spironolactone in HFrEF; START: NSAID for symptom relief
Correct Answer: B
Rationale: STOPP criteria flag non-dihydropyridine CCBs (diltiazem, verapamil) as inappropriate in HFrEF because their
negative inotropic effect can worsen systolic function. START criteria mandate ACE inhibitor/ARB and an evidence-based
beta-blocker in HFrEF. NR 568 pharmacology emphasizes that HFrEF regimens should include 'guideline-directed medical
therapy' (GDMT: ARNI, beta-blocker, MRA, SGLT2 inhibitor). Option A reverses correct guidance; options C and D include
inappropriate STOPP items and dangerous START recommendations.
Q10: A 73-year-old with osteoarthritis takes acetaminophen PRN and now requests an NSAID. He has HTN,
CKD stage 2, and a history of GI bleed. Which deprescribing/avoidance principle is MOST appropriate?
A. Add ibuprofen 600 mg every 6 hours
B. Avoid chronic oral NSAIDs (Beers Criteria: GI bleed risk, BP elevation, renal decline); maximize
non-pharmacologic options and topical NSAIDs *[CORRECT]*
C. Add celecoxib 200 mg daily long-term
D. Add aspirin 325 mg daily for analgesia
Correct Answer: B
Rationale: Per Beers Criteria, chronic oral NSAIDs should be avoided in older adults with history of GI bleed (high re-bleed
risk) and used with caution in CKD/HTN. The AGPCNP should maximize acetaminophen (≤3 g/day in older adults), topical
NSAIDs, physical therapy, weight management, and intra-articular injections. Options A, C, and D all introduce oral NSAIDs
or high-dose aspirin with significant GI/renal/CV risk.
Q11: A 70-year-old on long-term warfarin for atrial fibrillation presents with INR 6.2 (target 2-3) and no
bleeding. The most appropriate AGPCNP action is:
A. Hold the next dose and consider oral vitamin K 1-2.5 mg; recheck INR in 24 hours *[CORRECT]*
B. Administer fresh frozen plasma immediately
C. Continue warfarin at the same dose and recheck in 1 week
D. Administer intravenous vitamin K 10 mg
Correct Answer: A
Rationale: Per ACC/AHA and CHEST guidelines, INR >5 without bleeding warrants warfarin hold ± low-dose oral vitamin K
(1-2.5 mg) to reverse. IV vitamin K 10 mg (D) is reserved for serious/life-threatening bleeding with FFP/PCC. Option B
(FFP) is unnecessary without bleeding; option C is dangerous given supratherapeutic INR.
NR568 Advanced Pharmacology - AGPCNP Midterm Exam | Chamberlain 2026/2027 Page 4
