NR 546 MIDTERM EXAM
Actual Exam Questions and Correct Detailed Answers | A Grade
Chamberlain University • Advanced Pharmacology • 100 Questions
Cognitive Distribution: 25% Recall | 55% Application | 20% Analysis
Section 1: Advanced Pharmacokinetics and Pharmacodynamics (Absorption,
Distribution, Metabolism, Excretion, Receptors, & Dose-Response)
Q1: A drug administered intravenously has which bioavailability compared with the same drug given
orally?
A. 0% IV vs 100% oral
B. 100% IV vs variable oral [CORRECT]
C. 50% IV vs 100% oral
D. 100% IV vs 100% oral
Correct Answer: B
Rationale: Intravenous administration bypasses gastrointestinal absorption and first-pass hepatic metabolism, yielding
100% bioavailability. Oral bioavailability is variable and reduced by gut metabolism (CYP3A4), efflux transporters
(P-gp), hepatic first-pass effect, GI pH, and formulation. This IV-vs-oral difference is the foundation of route conversion
calculations in prescriptive practice.
Q2: The primary organ responsible for first-pass metabolism after oral administration is the:
A. Kidney
B. Liver [CORRECT]
C. Small intestine
D. Stomach
Correct Answer: B
Rationale: The liver performs the bulk of first-pass metabolism through portal circulation before drug reaches systemic
circulation. Intestinal CYP3A4 (enterocyte) contributes significantly for some drugs (e.g., midazolam, tacrolimus) but
hepatic clearance is dominant. The kidney and stomach contribute minimally to first-pass metabolism.
Q3: A 70 kg patient receives a 500 mg loading dose of a drug with a volume of distribution (Vd) of 0.6
L/kg. What is the expected peak plasma concentration?
A. 5.9 mg/L
B. 11.9 mg/L [CORRECT]
C. 1.2 mg/L
D. 8.3 mg/L
Correct Answer: B
Rationale: Total Vd = 0.6 L/kg x 70 kg = 42 L. Cp = Dose / Vd = 500 mg / 42 L = 11.9 mg/L. Loading dose calculations
are essential for drugs with long half-lives (e.g., amiodarone, digoxin, phenytoin) when rapid therapeutic levels are
needed before steady state is reached.
Q4: A patient stabilized on warfarin (highly albumin-bound) is started on
sulfamethoxazole/trimethoprim. The advanced practice nurse anticipates:
A. Decreased warfarin effect
, B. Transient increase in free warfarin with elevated INR and bleeding risk [CORRECT]
C. No change in INR
D. Need to increase warfarin dose
Correct Answer: B
Rationale: Sulfamethoxazole displaces warfarin from albumin, transiently increasing the free (active) fraction. It also
inhibits CYP2C9, reducing S-warfarin clearance and producing a sustained INR rise. The combination of protein-binding
displacement and CYP inhibition can precipitate serious bleeding; close INR monitoring and warfarin dose reduction are
required.
Q5: Which reaction is a Phase II metabolic conjugation process?
A. Oxidation
B. Reduction
C. Hydrolysis
D. Glucuronidation [CORRECT]
Correct Answer: D
Rationale: Phase II reactions are conjugation processes that add a polar moiety to facilitate renal/biliary excretion; they
include glucuronidation (UGT), sulfation (SULT), acetylation (NAT), methylation, and glutathione conjugation. Phase I
reactions (CYP450-mediated oxidation, reduction, hydrolysis) expose or add a functional group. Lamotrigine, lorazepam,
and morphine rely heavily on glucuronidation.
Q6: A patient has a calculated creatinine clearance (CrCl) of 25 mL/min. Which drug most urgently
requires dose adjustment?
A. Azithromycin (hepatic metabolism, biliary excretion)
B. Vancomycin (renal elimination, nephrotoxic) [CORRECT]
C. Sertraline (hepatic CYP2D6/2B6)
D. Prednisone (hepatic conversion)
Correct Answer: B
Rationale: Vancomycin is primarily eliminated by glomerular filtration and is directly nephrotoxic; dosing must be
adjusted to CrCl and guided by AUC-based therapeutic monitoring. Azithromycin, sertraline, and prednisone undergo
hepatic metabolism and require minimal renal adjustment. Failing to adjust vancomycin in renal impairment causes
accumulation, nephrotoxicity, and ototoxicity.
Q7: Approximately how many half-lives are required to reach steady-state plasma concentration
during repeated dosing?
A. 1-2
B. 3-4
C. 4-5 [CORRECT]
D. 7-10
Correct Answer: C
Rationale: Steady state is achieved after approximately 4-5 half-lives, when drug accumulation equals elimination. For
drugs with long half-lives (e.g., amiodarone half-life ~45 days, fluoxetine ~1-4 days), a loading dose may be needed to
achieve therapeutic concentrations more rapidly. Conversely, drugs with short half-lives reach steady state within hours.
Q8: Which drug has a narrow therapeutic index and routinely requires therapeutic drug monitoring
(TDM)?
A. Acetaminophen
, B. Lisinopril
C. Phenytoin [CORRECT]
D. Metformin
Correct Answer: C
Rationale: Phenytoin follows Michaelis-Menten (saturable) kinetics within the therapeutic range (10-20 mg/L); small
dose increases can produce disproportionate concentration rises and toxicity. TDM is mandatory. Other narrow-index
drugs requiring TDM include digoxin, vancomycin, aminoglycosides, lithium, and immunosuppressants (tacrolimus,
cyclosporine).
Q9: A drug has a Vd of 50 L and a target therapeutic plasma concentration of 4 mg/L. What loading
dose is required?
A. 100 mg
B. 200 mg [CORRECT]
C. 50 mg
D. 12.5 mg
Correct Answer: B
Rationale: Loading dose = Vd x target Cp = 50 L x 4 mg/L = 200 mg. Loading doses are particularly useful for
antiarrhythmics, antiepileptics, and anti-infectives with long half-lives when rapid effect is critical. The calculation
assumes linear kinetics and does not account for bioavailability or clearance for maintenance dosing.
Q10: A partial agonist is best described as a compound that:
A. Has high efficacy but low affinity
B. Produces maximal response at full receptor occupancy
C. Produces submaximal response even at full receptor occupancy and can antagonize a full agonist
[CORRECT]
D. Cannot block the effect of a full agonist
Correct Answer: C
Rationale: Partial agonists have lower intrinsic activity than full agonists; even at full receptor occupancy, they produce a
submaximal response. In the presence of a full agonist, they act as functional antagonists by competing for receptor
binding (e.g., buprenorphine at mu-opioid receptors, pindolol at beta-receptors, aripiprazole at D2 receptors). This
property is exploited clinically for opioid use disorder and schizophrenia management.
Q11: A patient on metoprolol succinate 50 mg daily for hypertension presents with heart rate 48 bpm,
blood pressure 110/68 mmHg, and dizziness on standing. The best prescriptive action is to:
A. Increase to 100 mg daily
B. Switch to propranolol 20 mg TID
C. Decrease the dose to 25 mg daily and re-evaluate in 1-2 weeks [CORRECT]
D. Add ivabradine 5 mg BID
Correct Answer: C
Rationale: Metoprolol is a beta-1 selective antagonist that produces negative chronotropy and dromotropy; symptomatic
bradycardia warrants dose reduction. Propranolol is non-selective and would worsen bradycardia; ivabradine inhibits the
If current and is inappropriate with concurrent beta-blockade. Re-evaluate HR/BP in 1-2 weeks after dose change.
Q12: Which agent is a potent inducer of CYP3A4 (and also CYP2C9, 2C19, and P-glycoprotein)?
A. Ketoconazole
B. Grapefruit juice
Actual Exam Questions and Correct Detailed Answers | A Grade
Chamberlain University • Advanced Pharmacology • 100 Questions
Cognitive Distribution: 25% Recall | 55% Application | 20% Analysis
Section 1: Advanced Pharmacokinetics and Pharmacodynamics (Absorption,
Distribution, Metabolism, Excretion, Receptors, & Dose-Response)
Q1: A drug administered intravenously has which bioavailability compared with the same drug given
orally?
A. 0% IV vs 100% oral
B. 100% IV vs variable oral [CORRECT]
C. 50% IV vs 100% oral
D. 100% IV vs 100% oral
Correct Answer: B
Rationale: Intravenous administration bypasses gastrointestinal absorption and first-pass hepatic metabolism, yielding
100% bioavailability. Oral bioavailability is variable and reduced by gut metabolism (CYP3A4), efflux transporters
(P-gp), hepatic first-pass effect, GI pH, and formulation. This IV-vs-oral difference is the foundation of route conversion
calculations in prescriptive practice.
Q2: The primary organ responsible for first-pass metabolism after oral administration is the:
A. Kidney
B. Liver [CORRECT]
C. Small intestine
D. Stomach
Correct Answer: B
Rationale: The liver performs the bulk of first-pass metabolism through portal circulation before drug reaches systemic
circulation. Intestinal CYP3A4 (enterocyte) contributes significantly for some drugs (e.g., midazolam, tacrolimus) but
hepatic clearance is dominant. The kidney and stomach contribute minimally to first-pass metabolism.
Q3: A 70 kg patient receives a 500 mg loading dose of a drug with a volume of distribution (Vd) of 0.6
L/kg. What is the expected peak plasma concentration?
A. 5.9 mg/L
B. 11.9 mg/L [CORRECT]
C. 1.2 mg/L
D. 8.3 mg/L
Correct Answer: B
Rationale: Total Vd = 0.6 L/kg x 70 kg = 42 L. Cp = Dose / Vd = 500 mg / 42 L = 11.9 mg/L. Loading dose calculations
are essential for drugs with long half-lives (e.g., amiodarone, digoxin, phenytoin) when rapid therapeutic levels are
needed before steady state is reached.
Q4: A patient stabilized on warfarin (highly albumin-bound) is started on
sulfamethoxazole/trimethoprim. The advanced practice nurse anticipates:
A. Decreased warfarin effect
, B. Transient increase in free warfarin with elevated INR and bleeding risk [CORRECT]
C. No change in INR
D. Need to increase warfarin dose
Correct Answer: B
Rationale: Sulfamethoxazole displaces warfarin from albumin, transiently increasing the free (active) fraction. It also
inhibits CYP2C9, reducing S-warfarin clearance and producing a sustained INR rise. The combination of protein-binding
displacement and CYP inhibition can precipitate serious bleeding; close INR monitoring and warfarin dose reduction are
required.
Q5: Which reaction is a Phase II metabolic conjugation process?
A. Oxidation
B. Reduction
C. Hydrolysis
D. Glucuronidation [CORRECT]
Correct Answer: D
Rationale: Phase II reactions are conjugation processes that add a polar moiety to facilitate renal/biliary excretion; they
include glucuronidation (UGT), sulfation (SULT), acetylation (NAT), methylation, and glutathione conjugation. Phase I
reactions (CYP450-mediated oxidation, reduction, hydrolysis) expose or add a functional group. Lamotrigine, lorazepam,
and morphine rely heavily on glucuronidation.
Q6: A patient has a calculated creatinine clearance (CrCl) of 25 mL/min. Which drug most urgently
requires dose adjustment?
A. Azithromycin (hepatic metabolism, biliary excretion)
B. Vancomycin (renal elimination, nephrotoxic) [CORRECT]
C. Sertraline (hepatic CYP2D6/2B6)
D. Prednisone (hepatic conversion)
Correct Answer: B
Rationale: Vancomycin is primarily eliminated by glomerular filtration and is directly nephrotoxic; dosing must be
adjusted to CrCl and guided by AUC-based therapeutic monitoring. Azithromycin, sertraline, and prednisone undergo
hepatic metabolism and require minimal renal adjustment. Failing to adjust vancomycin in renal impairment causes
accumulation, nephrotoxicity, and ototoxicity.
Q7: Approximately how many half-lives are required to reach steady-state plasma concentration
during repeated dosing?
A. 1-2
B. 3-4
C. 4-5 [CORRECT]
D. 7-10
Correct Answer: C
Rationale: Steady state is achieved after approximately 4-5 half-lives, when drug accumulation equals elimination. For
drugs with long half-lives (e.g., amiodarone half-life ~45 days, fluoxetine ~1-4 days), a loading dose may be needed to
achieve therapeutic concentrations more rapidly. Conversely, drugs with short half-lives reach steady state within hours.
Q8: Which drug has a narrow therapeutic index and routinely requires therapeutic drug monitoring
(TDM)?
A. Acetaminophen
, B. Lisinopril
C. Phenytoin [CORRECT]
D. Metformin
Correct Answer: C
Rationale: Phenytoin follows Michaelis-Menten (saturable) kinetics within the therapeutic range (10-20 mg/L); small
dose increases can produce disproportionate concentration rises and toxicity. TDM is mandatory. Other narrow-index
drugs requiring TDM include digoxin, vancomycin, aminoglycosides, lithium, and immunosuppressants (tacrolimus,
cyclosporine).
Q9: A drug has a Vd of 50 L and a target therapeutic plasma concentration of 4 mg/L. What loading
dose is required?
A. 100 mg
B. 200 mg [CORRECT]
C. 50 mg
D. 12.5 mg
Correct Answer: B
Rationale: Loading dose = Vd x target Cp = 50 L x 4 mg/L = 200 mg. Loading doses are particularly useful for
antiarrhythmics, antiepileptics, and anti-infectives with long half-lives when rapid effect is critical. The calculation
assumes linear kinetics and does not account for bioavailability or clearance for maintenance dosing.
Q10: A partial agonist is best described as a compound that:
A. Has high efficacy but low affinity
B. Produces maximal response at full receptor occupancy
C. Produces submaximal response even at full receptor occupancy and can antagonize a full agonist
[CORRECT]
D. Cannot block the effect of a full agonist
Correct Answer: C
Rationale: Partial agonists have lower intrinsic activity than full agonists; even at full receptor occupancy, they produce a
submaximal response. In the presence of a full agonist, they act as functional antagonists by competing for receptor
binding (e.g., buprenorphine at mu-opioid receptors, pindolol at beta-receptors, aripiprazole at D2 receptors). This
property is exploited clinically for opioid use disorder and schizophrenia management.
Q11: A patient on metoprolol succinate 50 mg daily for hypertension presents with heart rate 48 bpm,
blood pressure 110/68 mmHg, and dizziness on standing. The best prescriptive action is to:
A. Increase to 100 mg daily
B. Switch to propranolol 20 mg TID
C. Decrease the dose to 25 mg daily and re-evaluate in 1-2 weeks [CORRECT]
D. Add ivabradine 5 mg BID
Correct Answer: C
Rationale: Metoprolol is a beta-1 selective antagonist that produces negative chronotropy and dromotropy; symptomatic
bradycardia warrants dose reduction. Propranolol is non-selective and would worsen bradycardia; ivabradine inhibits the
If current and is inappropriate with concurrent beta-blockade. Re-evaluate HR/BP in 1-2 weeks after dose change.
Q12: Which agent is a potent inducer of CYP3A4 (and also CYP2C9, 2C19, and P-glycoprotein)?
A. Ketoconazole
B. Grapefruit juice
