1
NR 566 Advanced Pharmacology for Care of the
Family Final Exam 2026/2027 | Actual Exam
Questions with Verified Answers | Graded A+
SECTION 1: CARDIOVASCULAR PHARMACOLOGY (25 Questions)
Case Study 1: Heart Failure with Reduced Ejection Fraction (HFrEF)
Scenario: A 68-year-old male with HFrEF (EF 35%) is on lisinopril 20 mg daily and metoprolol
succinate 100 mg daily. He remains symptomatic with NYHA Class II symptoms, dyspnea on
exertion, and occasional lower extremity edema. Blood pressure is 118/72 mmHg, potassium 4.2
mEq/L, creatinine 1.1 mg/dL (eGFR 58).
Q1. According to current ACC/AHA/HFSA heart failure guidelines, which medication should be
added next to optimize his guideline-directed medical therapy (GDMT)?
A. Spironolactone 25 mg daily
B. Furosemide 40 mg daily
C. Digoxin 0.125 mg daily
D. Amlodipine 5 mg daily
Correct Answer: A. [CORRECT]
Rationale: For HFrEF patients already on ACE inhibitor and beta-blocker who remain
symptomatic, addition of a mineralocorticoid receptor antagonist (spironolactone) is Class I
recommendation to reduce mortality and hospitalizations. Current GDMT for HFrEF includes
ACEi/ARB/ARNI + evidence-based beta-blocker + MRA + SGLT2 inhibitor. Furosemide treats
congestion but does not improve mortality. Digoxin is for symptom control in persistent
symptoms. Amlodipine has neutral effects in HF.
Q2. Three months later, the patient is on lisinopril, metoprolol, and spironolactone but reports
persistent fatigue and dyspnea. Blood pressure is 112/68 mmHg, potassium 4.8 mEq/L. Which
modification is most appropriate?
A. Increase spironolactone to 50 mg daily
B. Switch lisinopril to sacubitril/valsartan (ARNI)
C. Add ivabradine
,2
D. Add dapagliflozin
Correct Answer: D. [CORRECT]
Rationale: SGLT2 inhibitors (dapagliflozin, empagliflozin) are now foundational therapy for
HFrEF regardless of diabetes status, reducing CV death and hospitalization. They should be
added to existing GDMT. ARNI substitution is indicated if still symptomatic on ACEi, but
SGLT2 inhibitors have broader indication. Ivabradine is for patients in sinus rhythm with HR
≥70 despite maximized beta-blocker.
Q3. The patient asks about switching from lisinopril to sacubitril/valsartan. What is the required
washout period between discontinuing the ACE inhibitor and starting the ARNI?
A. No washout required; can switch immediately
B. 12 hours
C. 24 hours
D. 36 hours
Correct Answer: D. [CORRECT]
Rationale: A 36-hour washout period is mandatory between ACE inhibitor discontinuation and
ARNI initiation to prevent angioedema risk from overlapping ACE and neprilysin inhibition.
This is a critical safety parameter.
Case Study 2: Resistant Hypertension
Scenario: A 58-year-old African American male with resistant hypertension (BP 158/94 mmHg
on chlorthalidone 25 mg, amlodipine 10 mg, and lisinopril 40 mg). Adherence confirmed, home
BP monitoring technique appropriate. No secondary causes identified. Potassium 3.8 mEq/L,
creatinine 1.2 mg/dL.
Q4. Which medication is most appropriate to add as fourth-line therapy?
A. Clonidine 0.1 mg twice daily
B. Spironolactone 25 mg daily
C. Hydralazine 25 mg three times daily
D. Doxazosin 4 mg daily
Correct Answer: B. [CORRECT]
Rationale: Spironolactone is the most effective fourth-line agent for resistant hypertension based
on the PATHWAY-2 trial, providing superior BP reduction compared to beta-blockers or alpha-
,3
blockers. It antagonizes aldosterone escape common in resistant hypertension. Monitor
potassium and renal function closely.
Q5. If this patient had a history of gout and chlorthalidone was contraindicated, which thiazide-
like diuretic would be preferred?
A. Hydrochlorothiazide 25 mg daily
B. Indapamide 1.25 mg daily
C. Metolazone 2.5 mg daily
D. Acetazolamide 250 mg daily
Correct Answer: B. [CORRECT]
Rationale: Indapamide is a thiazide-like diuretic with less metabolic impact than chlorthalidone
and may have lower gout risk while maintaining cardiovascular benefits. It has proven outcomes
data in hypertension (HYVET trial in elderly). Metolazone is reserved for severe edema/heart
failure. Acetazolamide is not for hypertension.
Case Study 3: Atrial Fibrillation Anticoagulation
Scenario: A 72-year-old female with non-valvular atrial fibrillation (CHA₂DS₂-VASc score 4) on
apixaban 5 mg twice daily. She is scheduled for elective total knee replacement in 2 weeks.
Q6. What is the appropriate periprocedural management of her apixaban?
A. Continue apixaban through surgery; no interruption needed
B. Stop apixaban 1 day before surgery (last dose morning before procedure)
C. Stop apixaban 3 days before surgery; bridge with enoxaparin
D. Stop apixaban 5 days before surgery; bridge with warfarin
Correct Answer: B. [CORRECT]
Rationale: For apixaban (and rivaroxaban) with standard bleeding risk surgery, discontinuation
24-48 hours prior is recommended based on renal function (CrCl ≥30: stop 1 day prior; CrCl 15-
29: stop 2 days prior). Bridging is generally NOT recommended with DOACs due to rapid
offset/onset and increased bleeding risk. Warfarin requires bridging; DOACs do not.
Q7. The patient develops acute gastrointestinal bleeding while on apixaban. Her hemoglobin
drops from 12 to 8 g/dL. Which reversal agent is appropriate?
A. Vitamin K 10 mg IV
B. Fresh frozen plasma
, 4
C. Andexanet alfa
D. Protamine sulfate
Correct Answer: C. [CORRECT]
Rationale: Andexanet alfa is the FDA-approved specific reversal agent for apixaban and
rivaroxaban. It is a modified recombinant human Factor Xa decoy that binds and sequesters
Factor Xa inhibitors. Vitamin K and FFP work for warfarin. Protamine reverses heparin.
Idarucizumab is for dabigatran.
SATA Question 1: Warfarin vs. DOAC Selection
Q8. In which clinical situations is warfarin preferred over a direct oral anticoagulant (DOAC)?
Select all that apply.
A. Patient with mechanical heart valve (bileaflet aortic valve)
B. Patient with moderate mitral stenosis
C. Patient with creatinine clearance <15 mL/min
D. Patient with recurrent venous thromboembolism on appropriate DOAC therapy
E. Patient with triple-positive antiphospholipid syndrome
F. Patient requiring once-daily dosing for adherence
G. Patient with severe hepatic impairment (Child-Pugh C)
H. Patient with non-valvular atrial fibrillation and age >75
Correct Answers: A, B, C, D, E, G. [CORRECT]
Rationale: Warfarin is mandatory for mechanical valves (RE-ALIGN trial showed harm with
dabigatran) and moderate-severe mitral stenosis (considered "valvular" AF). DOACs are not
approved for CrCl <15 or severe hepatic impairment. Recurrent VTE on DOAC suggests
warfarin may be preferred. Antiphospholipid syndrome, especially triple-positive, has limited
DOAC data with some concerning signals. Once-daily dosing is available with rivaroxaban and
edoxaban (not warfarin-specific). Age >75 is not a warfarin indication—DOACs are preferred in
elderly due to lower ICH risk.
Case Study 4: Dyslipidemia Management
Scenario: A 55-year-old male with ASCVD (prior MI 2 years ago, coronary stent placement).
Current medications: atorvastatin 40 mg, aspirin 81 mg, metoprolol, lisinopril. LDL-C is 98
mg/dL, non-HDL-C 128 mg/dL, triglycerides 185 mg/dL.
NR 566 Advanced Pharmacology for Care of the
Family Final Exam 2026/2027 | Actual Exam
Questions with Verified Answers | Graded A+
SECTION 1: CARDIOVASCULAR PHARMACOLOGY (25 Questions)
Case Study 1: Heart Failure with Reduced Ejection Fraction (HFrEF)
Scenario: A 68-year-old male with HFrEF (EF 35%) is on lisinopril 20 mg daily and metoprolol
succinate 100 mg daily. He remains symptomatic with NYHA Class II symptoms, dyspnea on
exertion, and occasional lower extremity edema. Blood pressure is 118/72 mmHg, potassium 4.2
mEq/L, creatinine 1.1 mg/dL (eGFR 58).
Q1. According to current ACC/AHA/HFSA heart failure guidelines, which medication should be
added next to optimize his guideline-directed medical therapy (GDMT)?
A. Spironolactone 25 mg daily
B. Furosemide 40 mg daily
C. Digoxin 0.125 mg daily
D. Amlodipine 5 mg daily
Correct Answer: A. [CORRECT]
Rationale: For HFrEF patients already on ACE inhibitor and beta-blocker who remain
symptomatic, addition of a mineralocorticoid receptor antagonist (spironolactone) is Class I
recommendation to reduce mortality and hospitalizations. Current GDMT for HFrEF includes
ACEi/ARB/ARNI + evidence-based beta-blocker + MRA + SGLT2 inhibitor. Furosemide treats
congestion but does not improve mortality. Digoxin is for symptom control in persistent
symptoms. Amlodipine has neutral effects in HF.
Q2. Three months later, the patient is on lisinopril, metoprolol, and spironolactone but reports
persistent fatigue and dyspnea. Blood pressure is 112/68 mmHg, potassium 4.8 mEq/L. Which
modification is most appropriate?
A. Increase spironolactone to 50 mg daily
B. Switch lisinopril to sacubitril/valsartan (ARNI)
C. Add ivabradine
,2
D. Add dapagliflozin
Correct Answer: D. [CORRECT]
Rationale: SGLT2 inhibitors (dapagliflozin, empagliflozin) are now foundational therapy for
HFrEF regardless of diabetes status, reducing CV death and hospitalization. They should be
added to existing GDMT. ARNI substitution is indicated if still symptomatic on ACEi, but
SGLT2 inhibitors have broader indication. Ivabradine is for patients in sinus rhythm with HR
≥70 despite maximized beta-blocker.
Q3. The patient asks about switching from lisinopril to sacubitril/valsartan. What is the required
washout period between discontinuing the ACE inhibitor and starting the ARNI?
A. No washout required; can switch immediately
B. 12 hours
C. 24 hours
D. 36 hours
Correct Answer: D. [CORRECT]
Rationale: A 36-hour washout period is mandatory between ACE inhibitor discontinuation and
ARNI initiation to prevent angioedema risk from overlapping ACE and neprilysin inhibition.
This is a critical safety parameter.
Case Study 2: Resistant Hypertension
Scenario: A 58-year-old African American male with resistant hypertension (BP 158/94 mmHg
on chlorthalidone 25 mg, amlodipine 10 mg, and lisinopril 40 mg). Adherence confirmed, home
BP monitoring technique appropriate. No secondary causes identified. Potassium 3.8 mEq/L,
creatinine 1.2 mg/dL.
Q4. Which medication is most appropriate to add as fourth-line therapy?
A. Clonidine 0.1 mg twice daily
B. Spironolactone 25 mg daily
C. Hydralazine 25 mg three times daily
D. Doxazosin 4 mg daily
Correct Answer: B. [CORRECT]
Rationale: Spironolactone is the most effective fourth-line agent for resistant hypertension based
on the PATHWAY-2 trial, providing superior BP reduction compared to beta-blockers or alpha-
,3
blockers. It antagonizes aldosterone escape common in resistant hypertension. Monitor
potassium and renal function closely.
Q5. If this patient had a history of gout and chlorthalidone was contraindicated, which thiazide-
like diuretic would be preferred?
A. Hydrochlorothiazide 25 mg daily
B. Indapamide 1.25 mg daily
C. Metolazone 2.5 mg daily
D. Acetazolamide 250 mg daily
Correct Answer: B. [CORRECT]
Rationale: Indapamide is a thiazide-like diuretic with less metabolic impact than chlorthalidone
and may have lower gout risk while maintaining cardiovascular benefits. It has proven outcomes
data in hypertension (HYVET trial in elderly). Metolazone is reserved for severe edema/heart
failure. Acetazolamide is not for hypertension.
Case Study 3: Atrial Fibrillation Anticoagulation
Scenario: A 72-year-old female with non-valvular atrial fibrillation (CHA₂DS₂-VASc score 4) on
apixaban 5 mg twice daily. She is scheduled for elective total knee replacement in 2 weeks.
Q6. What is the appropriate periprocedural management of her apixaban?
A. Continue apixaban through surgery; no interruption needed
B. Stop apixaban 1 day before surgery (last dose morning before procedure)
C. Stop apixaban 3 days before surgery; bridge with enoxaparin
D. Stop apixaban 5 days before surgery; bridge with warfarin
Correct Answer: B. [CORRECT]
Rationale: For apixaban (and rivaroxaban) with standard bleeding risk surgery, discontinuation
24-48 hours prior is recommended based on renal function (CrCl ≥30: stop 1 day prior; CrCl 15-
29: stop 2 days prior). Bridging is generally NOT recommended with DOACs due to rapid
offset/onset and increased bleeding risk. Warfarin requires bridging; DOACs do not.
Q7. The patient develops acute gastrointestinal bleeding while on apixaban. Her hemoglobin
drops from 12 to 8 g/dL. Which reversal agent is appropriate?
A. Vitamin K 10 mg IV
B. Fresh frozen plasma
, 4
C. Andexanet alfa
D. Protamine sulfate
Correct Answer: C. [CORRECT]
Rationale: Andexanet alfa is the FDA-approved specific reversal agent for apixaban and
rivaroxaban. It is a modified recombinant human Factor Xa decoy that binds and sequesters
Factor Xa inhibitors. Vitamin K and FFP work for warfarin. Protamine reverses heparin.
Idarucizumab is for dabigatran.
SATA Question 1: Warfarin vs. DOAC Selection
Q8. In which clinical situations is warfarin preferred over a direct oral anticoagulant (DOAC)?
Select all that apply.
A. Patient with mechanical heart valve (bileaflet aortic valve)
B. Patient with moderate mitral stenosis
C. Patient with creatinine clearance <15 mL/min
D. Patient with recurrent venous thromboembolism on appropriate DOAC therapy
E. Patient with triple-positive antiphospholipid syndrome
F. Patient requiring once-daily dosing for adherence
G. Patient with severe hepatic impairment (Child-Pugh C)
H. Patient with non-valvular atrial fibrillation and age >75
Correct Answers: A, B, C, D, E, G. [CORRECT]
Rationale: Warfarin is mandatory for mechanical valves (RE-ALIGN trial showed harm with
dabigatran) and moderate-severe mitral stenosis (considered "valvular" AF). DOACs are not
approved for CrCl <15 or severe hepatic impairment. Recurrent VTE on DOAC suggests
warfarin may be preferred. Antiphospholipid syndrome, especially triple-positive, has limited
DOAC data with some concerning signals. Once-daily dosing is available with rivaroxaban and
edoxaban (not warfarin-specific). Age >75 is not a warfarin indication—DOACs are preferred in
elderly due to lower ICH risk.
Case Study 4: Dyslipidemia Management
Scenario: A 55-year-old male with ASCVD (prior MI 2 years ago, coronary stent placement).
Current medications: atorvastatin 40 mg, aspirin 81 mg, metoprolol, lisinopril. LDL-C is 98
mg/dL, non-HDL-C 128 mg/dL, triglycerides 185 mg/dL.
