1|Page
NR565 ADVANCED PHARMACOLOGY FOR
PRIMARY CARE FINAL ACTUAL EXAM PREP
2026 ALL QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
ALREADY A GRADED WITH EXPERT
FEEDBACK |NEW AND REVISED
1. A 68-year-old male with heart failure with reduced ejection fraction (HFrEF, EF
35%) is on carvedilol 25 mg BID, lisinopril 20 mg daily, and furosemide 40 mg
daily. His blood pressure is 110/70 mmHg, heart rate 68 bpm, and potassium 4.2
mEq/L. According to 2022 AHA/ACC/HFSA guidelines, which medication should
be added to reduce mortality and hospitalizations regardless of diabetes status?
A) Digoxin 0.125 mg daily
B) Dapagliflozin 10 mg daily
C) Spironolactone 12.5 mg daily
D) Hydralazine 75 mg TID
*Rationale: Dapagliflozin (SGLT2 inhibitor) is now guideline-recommended for
HFrEF to reduce cardiovascular death and HF hospitalization regardless of
diabetes status (DAPA-HF trial). MRA (spironolactone) is also indicated but
typically after ACEi/ARNI and beta-blocker; the question asks for the newest
class added based on recent trials.*
2. A 45-year-old female with type 2 diabetes has an A1c of 8.5% on metformin
2000 mg daily and glipizide 10 mg BID. She has established atherosclerotic
cardiovascular disease (ASCVD) and heart failure with preserved ejection fraction
(HFpEF). Which add-on therapy provides the greatest reduction in major adverse
cardiovascular events (MACE) and HF hospitalization?
A) Sitagliptin 100 mg daily
B) Empagliflozin 10 mg daily
C) Pioglitazone 30 mg daily
D) Insulin glargine
*Rationale: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)
,2|Page
reduce MACE, cardiovascular death, and HF hospitalization in patients with
ASCVD and HFpEF. Pioglitazone is contraindicated in HF due to fluid
retention. DPP-4 inhibitors are neutral.*
3. A 72-year-old male with chronic kidney disease stage 4 (eGFR 25 mL/min) and
type 2 diabetes has an A1c of 7.2% on sitagliptin and glimepiride. He reports two
episodes of severe hypoglycemia in the past month. Which medication should be
discontinued immediately?
A) Sitagliptin
B) Glimepiride
C) Metformin
D) Empagliflozin
*Rationale: Sulfonylureas (glimepiride, glipizide, glyburide) cause
hypoglycemia, especially in CKD due to accumulation of active metabolites.
Glimepiride should be reduced or discontinued. Metformin is safe at eGFR 25-
30 with dose adjustment; SGLT2 inhibitors are not recommended at eGFR <25-
30.*
4. A patient with opioid use disorder is maintained on buprenorphine/naloxone 8
mg/2 mg sublingual daily. He requires surgery and postoperative pain
management. What is the recommended approach?
A) Discontinue buprenorphine 72 hours before surgery
B) Continue buprenorphine and add a full mu-opioid agonist (e.g.,
hydromorphone) for breakthrough pain
C) Switch to methadone 30 mg daily
D) Discontinue buprenorphine and use only NSAIDs
Rationale: Continuing buprenorphine provides opioid tolerance and prevents
withdrawal. For acute pain, add a full agonist (hydromorphone, fentanyl) at
higher-than-usual doses. Do not discontinue buprenorphine unless necessary.
5. A 55-year-old male with newly diagnosed hypertension and benign prostatic
hyperplasia (BPH) has a BP of 145/92 mmHg and AUA symptom score of 18.
Which single agent would address both conditions?
A) Tamsulosin 0.4 mg daily
B) Doxazosin 4 mg daily
C) Finasteride 5 mg daily
D) Amlodipine 5 mg daily
*Rationale: Doxazosin (non-selective alpha-1 blocker) treats both hypertension
,3|Page
and BPH. Tamsulosin is uroselective (alpha-1A) and does not significantly lower
BP. Finasteride treats BPH but not hypertension.*
6. A 34-year-old female with epilepsy on valproate 500 mg BID is planning
pregnancy. She is also taking lamotrigine 100 mg BID for mood stabilization.
What critical change is expected in lamotrigine levels during pregnancy?
A) Lamotrigine levels increase by 50%
B) Lamotrigine levels decrease by 50-70% due to estrogen-induced
glucuronidation
C) No change if valproate is continued
D) Lamotrigine levels become unpredictable
Rationale: Estrogen induces UGT1A4, which metabolizes lamotrigine, leading to
a dramatic drop in levels. Seizure breakthrough risk is high. Monthly level
monitoring and dose adjustment (often doubling or tripling) are required.
7. According to the CDC Clinical Practice Guideline for Prescribing Opioids for
Pain (2022), which statement about urine drug testing (UDT) is correct?
A) UDT is required only at baseline
B) UDT should be performed at baseline and at least annually, with more
frequent testing for high-risk patients
C) UDT is not recommended for patients on stable low-dose opioids
D) UDT should only be performed if aberrant behavior is suspected
Rationale: CDC guidelines recommend baseline UDT to confirm prescribed
medications and detect unprescribed substances, followed by periodic testing (at
least annually) and more frequently for patients at higher risk.
8. A 62-year-old female with chronic obstructive pulmonary disease (COPD),
GOLD Grade 3 (FEV1 45% predicted), with 2 moderate exacerbations in the past
year and blood eosinophils 250 cells/μL. According to GOLD 2024, what is the
preferred initial maintenance therapy?
A) LABA monotherapy
B) LAMA monotherapy
C) ICS/LABA/LAMA triple therapy
D) PRN albuterol only
*Rationale: GOLD Group E (high exacerbation risk) with eosinophils ≥300
cells/μL benefit from ICS. For eosinophils 250 (≥300), triple therapy
(ICS/LABA/LAMA) is preferred. If eosinophils <100, LAMA/LABA is preferred.
This patient meets criteria for triple therapy.*
, 4|Page
9. A patient with generalized anxiety disorder and insomnia is prescribed
trazodone 50 mg at bedtime. He also takes fluoxetine 40 mg daily. Which adverse
effect requires immediate evaluation?
A) Dry mouth
B) Agitation, hyperreflexia, and clonus
C) Constipation
D) Dizziness
Rationale: The combination of trazodone (SARI) and fluoxetine (SSRI)
increases serotonin. Symptoms of serotonin syndrome (agitation, hyperreflexia,
clonus, diaphoresis, hyperthermia) require immediate discontinuation and
supportive care.
10. A 28-year-old pregnant patient at 34 weeks gestation has a history of chronic
hypertension. Her BP is 155/100 mmHg. Which antihypertensive is
contraindicated in the third trimester?
A) Labetalol
B) Nifedipine ER
C) Methyldopa
D) Lisinopril
Rationale: ACE inhibitors (lisinopril) and ARBs are contraindicated throughout
pregnancy, especially in the second and third trimesters, due to risk of fetal renal
agenesis, oligohydramnios, and neonatal death. Labetalol, nifedipine, and
methyldopa are preferred.
11. A 50-year-old male with major depressive disorder has failed adequate trials of
sertraline, escitalopram, and venlafaxine. He has no history of mania. Which
medication is FDA-approved for treatment-resistant depression as an adjunct?
A) Bupropion
B) Aripiprazole
C) Mirtazapine
D) Vortioxetine
Rationale: Aripiprazole (atypical antipsychotic) is FDA-approved as adjunctive
treatment for major depressive disorder in patients with inadequate response to
antidepressants. Brexpiprazole and quetiapine are also approved.
12. A patient with atrial fibrillation on warfarin has an INR of 4.5 without
bleeding. He takes no other medications. What is the appropriate management?
A) Administer vitamin K 5 mg orally
NR565 ADVANCED PHARMACOLOGY FOR
PRIMARY CARE FINAL ACTUAL EXAM PREP
2026 ALL QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
ALREADY A GRADED WITH EXPERT
FEEDBACK |NEW AND REVISED
1. A 68-year-old male with heart failure with reduced ejection fraction (HFrEF, EF
35%) is on carvedilol 25 mg BID, lisinopril 20 mg daily, and furosemide 40 mg
daily. His blood pressure is 110/70 mmHg, heart rate 68 bpm, and potassium 4.2
mEq/L. According to 2022 AHA/ACC/HFSA guidelines, which medication should
be added to reduce mortality and hospitalizations regardless of diabetes status?
A) Digoxin 0.125 mg daily
B) Dapagliflozin 10 mg daily
C) Spironolactone 12.5 mg daily
D) Hydralazine 75 mg TID
*Rationale: Dapagliflozin (SGLT2 inhibitor) is now guideline-recommended for
HFrEF to reduce cardiovascular death and HF hospitalization regardless of
diabetes status (DAPA-HF trial). MRA (spironolactone) is also indicated but
typically after ACEi/ARNI and beta-blocker; the question asks for the newest
class added based on recent trials.*
2. A 45-year-old female with type 2 diabetes has an A1c of 8.5% on metformin
2000 mg daily and glipizide 10 mg BID. She has established atherosclerotic
cardiovascular disease (ASCVD) and heart failure with preserved ejection fraction
(HFpEF). Which add-on therapy provides the greatest reduction in major adverse
cardiovascular events (MACE) and HF hospitalization?
A) Sitagliptin 100 mg daily
B) Empagliflozin 10 mg daily
C) Pioglitazone 30 mg daily
D) Insulin glargine
*Rationale: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)
,2|Page
reduce MACE, cardiovascular death, and HF hospitalization in patients with
ASCVD and HFpEF. Pioglitazone is contraindicated in HF due to fluid
retention. DPP-4 inhibitors are neutral.*
3. A 72-year-old male with chronic kidney disease stage 4 (eGFR 25 mL/min) and
type 2 diabetes has an A1c of 7.2% on sitagliptin and glimepiride. He reports two
episodes of severe hypoglycemia in the past month. Which medication should be
discontinued immediately?
A) Sitagliptin
B) Glimepiride
C) Metformin
D) Empagliflozin
*Rationale: Sulfonylureas (glimepiride, glipizide, glyburide) cause
hypoglycemia, especially in CKD due to accumulation of active metabolites.
Glimepiride should be reduced or discontinued. Metformin is safe at eGFR 25-
30 with dose adjustment; SGLT2 inhibitors are not recommended at eGFR <25-
30.*
4. A patient with opioid use disorder is maintained on buprenorphine/naloxone 8
mg/2 mg sublingual daily. He requires surgery and postoperative pain
management. What is the recommended approach?
A) Discontinue buprenorphine 72 hours before surgery
B) Continue buprenorphine and add a full mu-opioid agonist (e.g.,
hydromorphone) for breakthrough pain
C) Switch to methadone 30 mg daily
D) Discontinue buprenorphine and use only NSAIDs
Rationale: Continuing buprenorphine provides opioid tolerance and prevents
withdrawal. For acute pain, add a full agonist (hydromorphone, fentanyl) at
higher-than-usual doses. Do not discontinue buprenorphine unless necessary.
5. A 55-year-old male with newly diagnosed hypertension and benign prostatic
hyperplasia (BPH) has a BP of 145/92 mmHg and AUA symptom score of 18.
Which single agent would address both conditions?
A) Tamsulosin 0.4 mg daily
B) Doxazosin 4 mg daily
C) Finasteride 5 mg daily
D) Amlodipine 5 mg daily
*Rationale: Doxazosin (non-selective alpha-1 blocker) treats both hypertension
,3|Page
and BPH. Tamsulosin is uroselective (alpha-1A) and does not significantly lower
BP. Finasteride treats BPH but not hypertension.*
6. A 34-year-old female with epilepsy on valproate 500 mg BID is planning
pregnancy. She is also taking lamotrigine 100 mg BID for mood stabilization.
What critical change is expected in lamotrigine levels during pregnancy?
A) Lamotrigine levels increase by 50%
B) Lamotrigine levels decrease by 50-70% due to estrogen-induced
glucuronidation
C) No change if valproate is continued
D) Lamotrigine levels become unpredictable
Rationale: Estrogen induces UGT1A4, which metabolizes lamotrigine, leading to
a dramatic drop in levels. Seizure breakthrough risk is high. Monthly level
monitoring and dose adjustment (often doubling or tripling) are required.
7. According to the CDC Clinical Practice Guideline for Prescribing Opioids for
Pain (2022), which statement about urine drug testing (UDT) is correct?
A) UDT is required only at baseline
B) UDT should be performed at baseline and at least annually, with more
frequent testing for high-risk patients
C) UDT is not recommended for patients on stable low-dose opioids
D) UDT should only be performed if aberrant behavior is suspected
Rationale: CDC guidelines recommend baseline UDT to confirm prescribed
medications and detect unprescribed substances, followed by periodic testing (at
least annually) and more frequently for patients at higher risk.
8. A 62-year-old female with chronic obstructive pulmonary disease (COPD),
GOLD Grade 3 (FEV1 45% predicted), with 2 moderate exacerbations in the past
year and blood eosinophils 250 cells/μL. According to GOLD 2024, what is the
preferred initial maintenance therapy?
A) LABA monotherapy
B) LAMA monotherapy
C) ICS/LABA/LAMA triple therapy
D) PRN albuterol only
*Rationale: GOLD Group E (high exacerbation risk) with eosinophils ≥300
cells/μL benefit from ICS. For eosinophils 250 (≥300), triple therapy
(ICS/LABA/LAMA) is preferred. If eosinophils <100, LAMA/LABA is preferred.
This patient meets criteria for triple therapy.*
, 4|Page
9. A patient with generalized anxiety disorder and insomnia is prescribed
trazodone 50 mg at bedtime. He also takes fluoxetine 40 mg daily. Which adverse
effect requires immediate evaluation?
A) Dry mouth
B) Agitation, hyperreflexia, and clonus
C) Constipation
D) Dizziness
Rationale: The combination of trazodone (SARI) and fluoxetine (SSRI)
increases serotonin. Symptoms of serotonin syndrome (agitation, hyperreflexia,
clonus, diaphoresis, hyperthermia) require immediate discontinuation and
supportive care.
10. A 28-year-old pregnant patient at 34 weeks gestation has a history of chronic
hypertension. Her BP is 155/100 mmHg. Which antihypertensive is
contraindicated in the third trimester?
A) Labetalol
B) Nifedipine ER
C) Methyldopa
D) Lisinopril
Rationale: ACE inhibitors (lisinopril) and ARBs are contraindicated throughout
pregnancy, especially in the second and third trimesters, due to risk of fetal renal
agenesis, oligohydramnios, and neonatal death. Labetalol, nifedipine, and
methyldopa are preferred.
11. A 50-year-old male with major depressive disorder has failed adequate trials of
sertraline, escitalopram, and venlafaxine. He has no history of mania. Which
medication is FDA-approved for treatment-resistant depression as an adjunct?
A) Bupropion
B) Aripiprazole
C) Mirtazapine
D) Vortioxetine
Rationale: Aripiprazole (atypical antipsychotic) is FDA-approved as adjunctive
treatment for major depressive disorder in patients with inadequate response to
antidepressants. Brexpiprazole and quetiapine are also approved.
12. A patient with atrial fibrillation on warfarin has an INR of 4.5 without
bleeding. He takes no other medications. What is the appropriate management?
A) Administer vitamin K 5 mg orally
