NURS 6521 Advanced Pharmacology Midterm
Examination Study Guide | 2026/2027
Application-Based Practice Questions
DOMAIN 1: FOUNDATIONAL PK/PD & PHARMACOGENOMICS (8 Q)
Q 1 (Calculation)
A 45-year-old woman (weight 70 kg, height 165 cm) with pyelonephritis is prescribed IV
tobramycin. Serum creatinine is 1.4 mg/dL. Calculate her estimated CrCl
(Cockcroft-Gault) and determine the primary implication.
A. Need for a loading dose
B. Dosing interval must be extended
C. Duration of therapy
D. Switch to oral therapy
Correct Answer: B
Rationale: CrCl = [(140−45) × 70] / (72 × 1.4) ≈ 66 mL/min (mild renal impairment).
Tobramycin is renally eliminated with a narrow therapeutic index; reduced CrCl
mandates longer intervals (e.g., q36-48 h) to avoid nephro-/ototoxicity. Loading dose is
based on Vd, not CrCl.
Patient Education: “Blood levels will be checked to keep the drug safe for your kidneys.”
,Monitoring: Serum tobramycin peak/trough at steady state (after 3–5 doses) and SCr
q48 h.
Q 2 (SATA)
Which factors significantly increase the half-life of a renally-excreted, water-soluble
drug? (Select all)
A. Age > 80 y with CrCl 35 mL/min
B. Dehydration (temp ↓ renal perfusion)
C. Co-administration of a CYP3A4 inducer
D. Heart failure (EF 30 %) reducing renal blood flow
E. High-fat meal at the same time
Correct Answers: A, B, D
Rationale: Reduced GRF (A), prerenal azotemia (B, D) slow elimination. C increases
metabolism → shorter t½. E may delay absorption but not elimination.
Patient Education: “Stay hydrated and weigh yourself daily; report sudden weight gain or
decreased urine.”
Monitoring: SCr and BUN q48 h until stable.
Q 3 (Scenario)
A CYP2C19 poor metabolizer post-PCI is prescribed clopidogrel 75 mg daily. The
APRN’s best action is:
,A. Increase to 150 mg daily
B. Switch to prasugrel 10 mg daily
C. Add aspirin 325 mg
D. Continue current dose; monitor INR
Correct Answer: B
Rationale: CPIC 2026: poor metabolizers have ↓ active metabolite → ↑ stent thrombosis.
Use prasugrel or ticagrelor instead. Higher clopidogrel dose does not overcome genetic
defect.
Patient Education: “This newer medication works better with your genetic makeup.”
Monitoring: Platelet function assay or VerifyNow PRU at 2–4 weeks; watch for bleeding.
Q 4 (Mechanism)
A drug has a therapeutic index of 2. This primarily implies:
A. Wide safety margin
B. Dose must be titrated carefully with narrow margin between therapeutic and toxic
levels
C. Loading dose is unnecessary
D. Protein-binding interactions are irrelevant
Correct Answer: B
, Rationale: TI = LD50/ED50 or TC50/EC50; TI ≤ 2 indicates narrow therapeutic window
(e.g., digoxin, lithium).
Patient Education: “Take the exact dose at the exact time; do not double-up if missed.”
Monitoring: Drug levels, ECG or clinical toxicity signs per protocol.
Q 5 (Pharmacogenomics)
Before starting carbamazepine in an Asian patient, which test is most important to
reduce serious dermatologic risk?
A. HLA-B*1502 genotyping
B. CYP3A5 genotype
C. INR level
D. G6PD activity
Correct Answer: A
Rationale: HLA-B*1502 strongly predicts Stevens-Johnson syndrome/toxic epidermal
necrolysis in Asians. If positive, avoid carbamazepine (FDA boxed warning 2026).
Patient Education: “A simple cheek swab can prevent a severe skin reaction.”
Monitoring: If negative, still observe for rash during first 8 weeks.
Q 6 (Drug Interaction)
A patient on warfarin (INR 2.5) starts TMP-SMX for UTI. Expected interaction?
A. INR ↑ (TMP-SMX inhibits CYP2C9 and displaces from protein)
Examination Study Guide | 2026/2027
Application-Based Practice Questions
DOMAIN 1: FOUNDATIONAL PK/PD & PHARMACOGENOMICS (8 Q)
Q 1 (Calculation)
A 45-year-old woman (weight 70 kg, height 165 cm) with pyelonephritis is prescribed IV
tobramycin. Serum creatinine is 1.4 mg/dL. Calculate her estimated CrCl
(Cockcroft-Gault) and determine the primary implication.
A. Need for a loading dose
B. Dosing interval must be extended
C. Duration of therapy
D. Switch to oral therapy
Correct Answer: B
Rationale: CrCl = [(140−45) × 70] / (72 × 1.4) ≈ 66 mL/min (mild renal impairment).
Tobramycin is renally eliminated with a narrow therapeutic index; reduced CrCl
mandates longer intervals (e.g., q36-48 h) to avoid nephro-/ototoxicity. Loading dose is
based on Vd, not CrCl.
Patient Education: “Blood levels will be checked to keep the drug safe for your kidneys.”
,Monitoring: Serum tobramycin peak/trough at steady state (after 3–5 doses) and SCr
q48 h.
Q 2 (SATA)
Which factors significantly increase the half-life of a renally-excreted, water-soluble
drug? (Select all)
A. Age > 80 y with CrCl 35 mL/min
B. Dehydration (temp ↓ renal perfusion)
C. Co-administration of a CYP3A4 inducer
D. Heart failure (EF 30 %) reducing renal blood flow
E. High-fat meal at the same time
Correct Answers: A, B, D
Rationale: Reduced GRF (A), prerenal azotemia (B, D) slow elimination. C increases
metabolism → shorter t½. E may delay absorption but not elimination.
Patient Education: “Stay hydrated and weigh yourself daily; report sudden weight gain or
decreased urine.”
Monitoring: SCr and BUN q48 h until stable.
Q 3 (Scenario)
A CYP2C19 poor metabolizer post-PCI is prescribed clopidogrel 75 mg daily. The
APRN’s best action is:
,A. Increase to 150 mg daily
B. Switch to prasugrel 10 mg daily
C. Add aspirin 325 mg
D. Continue current dose; monitor INR
Correct Answer: B
Rationale: CPIC 2026: poor metabolizers have ↓ active metabolite → ↑ stent thrombosis.
Use prasugrel or ticagrelor instead. Higher clopidogrel dose does not overcome genetic
defect.
Patient Education: “This newer medication works better with your genetic makeup.”
Monitoring: Platelet function assay or VerifyNow PRU at 2–4 weeks; watch for bleeding.
Q 4 (Mechanism)
A drug has a therapeutic index of 2. This primarily implies:
A. Wide safety margin
B. Dose must be titrated carefully with narrow margin between therapeutic and toxic
levels
C. Loading dose is unnecessary
D. Protein-binding interactions are irrelevant
Correct Answer: B
, Rationale: TI = LD50/ED50 or TC50/EC50; TI ≤ 2 indicates narrow therapeutic window
(e.g., digoxin, lithium).
Patient Education: “Take the exact dose at the exact time; do not double-up if missed.”
Monitoring: Drug levels, ECG or clinical toxicity signs per protocol.
Q 5 (Pharmacogenomics)
Before starting carbamazepine in an Asian patient, which test is most important to
reduce serious dermatologic risk?
A. HLA-B*1502 genotyping
B. CYP3A5 genotype
C. INR level
D. G6PD activity
Correct Answer: A
Rationale: HLA-B*1502 strongly predicts Stevens-Johnson syndrome/toxic epidermal
necrolysis in Asians. If positive, avoid carbamazepine (FDA boxed warning 2026).
Patient Education: “A simple cheek swab can prevent a severe skin reaction.”
Monitoring: If negative, still observe for rash during first 8 weeks.
Q 6 (Drug Interaction)
A patient on warfarin (INR 2.5) starts TMP-SMX for UTI. Expected interaction?
A. INR ↑ (TMP-SMX inhibits CYP2C9 and displaces from protein)
