NURS 5334 Antimicrobial Recall Quiz Graduate
Nursing Pharmacology – A+ Level Assessment
Instructions: 50 questions | 60 minutes | Passing: 90% (45/50 correct)
• Multiple Choice: 35 questions (1 point each)
• Clinical Scenario: 10 questions (1 point each)
• Select All That Apply: 5 questions (1 point each – all correct selections required, no
partial credit)
DOMAIN I: CELL WALL SYNTHESIS INHIBITORS (Questions 1–10)
Q1. Which cephalosporin is the only generation with reliable MRSA coverage?
A. Ceftriaxone (3rd generation)
B. Cefepime (4th generation)
C. Ceftaroline (5th generation) ← CORRECT
D. Cefoxitin (2nd generation)
Rationale: Ceftaroline is a 5th-generation cephalosporin with unique anti-MRSA activity via high
affinity for PBP2a. All other cephalosporins (1st–4th gen) lack MRSA coverage. Ceftriaxone
covers gram-negatives and some gram-positives (not MRSA). Cefepime is broad gram-negative
including Pseudomonas. Cefoxitin covers anaerobes (B. fragilis) but not MRSA.
Q2. A patient with a documented severe penicillin allergy (anaphylaxis) requires gram-negative
coverage including Pseudomonas. Which agent is contraindicated due to cross-reactivity?
A. Aztreonam
B. Ceftazidime (3rd gen cephalosporin) ← CORRECT
C. Vancomycin
D. Ciprofloxacin
Rationale: Aztreonam (monobactam) has NO cross-reactivity with penicillin and is safe in
penicillin-allergic patients. Cephalosporins share a beta-lactam ring and have ~10% cross-
reactivity with penicillins; severe allergy warrants avoidance. Vancomycin and fluoroquinolones
have no beta-lactam structure. Ceftazidime is specifically noted here as a cephalosporin.
,Q3. Which statement accurately describes the mechanism of MRSA resistance to beta-lactams?
A. Production of extended-spectrum beta-lactamases (ESBLs)
B. Alteration of porin channels
C. Acquisition of PBP2a (mecA gene) with low affinity for all beta-lactams ← CORRECT
D. Active efflux pumps
Rationale: MRSA expresses PBP2a (penicillin-binding protein 2a), encoded by the mecA gene,
which has extremely low affinity for all beta-lactams. ESBLs are gram-negative resistance
mechanisms (TEM, SHV, CTX-M). Porin loss affects carbapenem resistance in gram-negatives.
Efflux pumps contribute to fluoroquinolone resistance.
Q4. Piperacillin-tazobactam (Zosyn) provides coverage against which of the following
organisms?
A. MRSA
B. VRE
C. Pseudomonas aeruginosa + anaerobes + Enterobacteriaceae ← CORRECT
D. Candida albicans
Rationale: Zosyn = antipseudomonal penicillin + beta-lactamase inhibitor. It covers
Pseudomonas, most anaerobes (including B. fragilis), and Enterobacteriaceae. It does NOT cover
MRSA (needs vancomycin, daptomycin, or ceftaroline) or VRE (needs linezolid or daptomycin). It
has no antifungal activity.
Q5. A patient on vancomycin for MRSA bacteremia has a trough level of 8 mcg/mL drawn
appropriately. What is the appropriate clinical action?
A. Continue current dose—level is therapeutic
B. Decrease dose to avoid toxicity
C. Increase dose to achieve trough 15–20 mcg/mL for serious MRSA infections ← CORRECT
D. Switch to oral vancomycin immediately
Rationale: For serious MRSA infections (bacteremia, endocarditis, pneumonia, meningitis),
vancomycin trough targets are 15–20 mcg/mL per IDSA guidelines. Trough 10–15 mcg/mL is
acceptable for less serious infections. Oral vancomycin has negligible systemic absorption and is
only for C. difficile colitis.
, Q6. Which adverse effect is specifically associated with rapid vancomycin infusion?
A. Nephrotoxicity
B. Red man syndrome (histamine-mediated flushing, pruritus, hypotension) ← CORRECT
C. Ototoxicity
D. Thrombocytopenia
Rationale: Red man syndrome is a rate-dependent histamine release reaction occurring with
rapid infusion (<60 minutes). It is NOT a true allergy. Management: slow infusion to ≥60
minutes, consider antihistamine premedication. Nephrotoxicity and ototoxicity are
concentration/time-dependent, not infusion-rate dependent. Thrombocytopenia is a linezolid
adverse effect.
Q7. Which carbapenem lacks reliable Pseudomonas aeruginosa coverage?
A. Imipenem-cilastatin
B. Meropenem
C. Doripenem
D. Ertapenem ← CORRECT
Rationale: Ertapenem has a narrower spectrum among carbapenems and lacks Pseudomonas
and Enterococcus coverage. It is once-daily dosed (favorable pharmacokinetics). Imipenem,
meropenem, and doripenem all cover Pseudomonas. Ertapenem is useful for community-
acquired intra-abdominal infections and diabetic foot infections where Pseudomonas is less
likely.
Q8. A patient develops C. difficile colitis. Which oral antibiotic is first-line for initial episode?
A. Oral metronidazole
B. IV vancomycin
C. Oral vancomycin ← CORRECT
D. Oral amoxicillin
Rationale: Per IDSA/SHEA 2021 guidelines, oral vancomycin 125 mg QID is first-line for initial C.
difficile episode (fidaxomicin is acceptable alternative). Metronidazole is no longer
recommended as first-line due to inferior efficacy. IV vancomycin does not achieve colonic
luminal concentrations. Oral amoxicillin would worsen C. diff by further disrupting flora.
Nursing Pharmacology – A+ Level Assessment
Instructions: 50 questions | 60 minutes | Passing: 90% (45/50 correct)
• Multiple Choice: 35 questions (1 point each)
• Clinical Scenario: 10 questions (1 point each)
• Select All That Apply: 5 questions (1 point each – all correct selections required, no
partial credit)
DOMAIN I: CELL WALL SYNTHESIS INHIBITORS (Questions 1–10)
Q1. Which cephalosporin is the only generation with reliable MRSA coverage?
A. Ceftriaxone (3rd generation)
B. Cefepime (4th generation)
C. Ceftaroline (5th generation) ← CORRECT
D. Cefoxitin (2nd generation)
Rationale: Ceftaroline is a 5th-generation cephalosporin with unique anti-MRSA activity via high
affinity for PBP2a. All other cephalosporins (1st–4th gen) lack MRSA coverage. Ceftriaxone
covers gram-negatives and some gram-positives (not MRSA). Cefepime is broad gram-negative
including Pseudomonas. Cefoxitin covers anaerobes (B. fragilis) but not MRSA.
Q2. A patient with a documented severe penicillin allergy (anaphylaxis) requires gram-negative
coverage including Pseudomonas. Which agent is contraindicated due to cross-reactivity?
A. Aztreonam
B. Ceftazidime (3rd gen cephalosporin) ← CORRECT
C. Vancomycin
D. Ciprofloxacin
Rationale: Aztreonam (monobactam) has NO cross-reactivity with penicillin and is safe in
penicillin-allergic patients. Cephalosporins share a beta-lactam ring and have ~10% cross-
reactivity with penicillins; severe allergy warrants avoidance. Vancomycin and fluoroquinolones
have no beta-lactam structure. Ceftazidime is specifically noted here as a cephalosporin.
,Q3. Which statement accurately describes the mechanism of MRSA resistance to beta-lactams?
A. Production of extended-spectrum beta-lactamases (ESBLs)
B. Alteration of porin channels
C. Acquisition of PBP2a (mecA gene) with low affinity for all beta-lactams ← CORRECT
D. Active efflux pumps
Rationale: MRSA expresses PBP2a (penicillin-binding protein 2a), encoded by the mecA gene,
which has extremely low affinity for all beta-lactams. ESBLs are gram-negative resistance
mechanisms (TEM, SHV, CTX-M). Porin loss affects carbapenem resistance in gram-negatives.
Efflux pumps contribute to fluoroquinolone resistance.
Q4. Piperacillin-tazobactam (Zosyn) provides coverage against which of the following
organisms?
A. MRSA
B. VRE
C. Pseudomonas aeruginosa + anaerobes + Enterobacteriaceae ← CORRECT
D. Candida albicans
Rationale: Zosyn = antipseudomonal penicillin + beta-lactamase inhibitor. It covers
Pseudomonas, most anaerobes (including B. fragilis), and Enterobacteriaceae. It does NOT cover
MRSA (needs vancomycin, daptomycin, or ceftaroline) or VRE (needs linezolid or daptomycin). It
has no antifungal activity.
Q5. A patient on vancomycin for MRSA bacteremia has a trough level of 8 mcg/mL drawn
appropriately. What is the appropriate clinical action?
A. Continue current dose—level is therapeutic
B. Decrease dose to avoid toxicity
C. Increase dose to achieve trough 15–20 mcg/mL for serious MRSA infections ← CORRECT
D. Switch to oral vancomycin immediately
Rationale: For serious MRSA infections (bacteremia, endocarditis, pneumonia, meningitis),
vancomycin trough targets are 15–20 mcg/mL per IDSA guidelines. Trough 10–15 mcg/mL is
acceptable for less serious infections. Oral vancomycin has negligible systemic absorption and is
only for C. difficile colitis.
, Q6. Which adverse effect is specifically associated with rapid vancomycin infusion?
A. Nephrotoxicity
B. Red man syndrome (histamine-mediated flushing, pruritus, hypotension) ← CORRECT
C. Ototoxicity
D. Thrombocytopenia
Rationale: Red man syndrome is a rate-dependent histamine release reaction occurring with
rapid infusion (<60 minutes). It is NOT a true allergy. Management: slow infusion to ≥60
minutes, consider antihistamine premedication. Nephrotoxicity and ototoxicity are
concentration/time-dependent, not infusion-rate dependent. Thrombocytopenia is a linezolid
adverse effect.
Q7. Which carbapenem lacks reliable Pseudomonas aeruginosa coverage?
A. Imipenem-cilastatin
B. Meropenem
C. Doripenem
D. Ertapenem ← CORRECT
Rationale: Ertapenem has a narrower spectrum among carbapenems and lacks Pseudomonas
and Enterococcus coverage. It is once-daily dosed (favorable pharmacokinetics). Imipenem,
meropenem, and doripenem all cover Pseudomonas. Ertapenem is useful for community-
acquired intra-abdominal infections and diabetic foot infections where Pseudomonas is less
likely.
Q8. A patient develops C. difficile colitis. Which oral antibiotic is first-line for initial episode?
A. Oral metronidazole
B. IV vancomycin
C. Oral vancomycin ← CORRECT
D. Oral amoxicillin
Rationale: Per IDSA/SHEA 2021 guidelines, oral vancomycin 125 mg QID is first-line for initial C.
difficile episode (fidaxomicin is acceptable alternative). Metronidazole is no longer
recommended as first-line due to inferior efficacy. IV vancomycin does not achieve colonic
luminal concentrations. Oral amoxicillin would worsen C. diff by further disrupting flora.
