NURS 5334 ADVANCED PHARM EXAM 200 ACTUAL
QUESTIONS AND CORRECT ANSWERS WITH RATIONALE
LATEST 2026 ALREADY GRADED A+
This comprehensive 200-question guide covers the full spectrum of advanced
pharmacology for nurse practitioners. It addresses pharmacokinetics
(absorption, distribution, metabolism, excretion), pharmacodynamics
(receptor interactions, dose-response relationships), autonomic pharmacology
(adrenergic and cholinergic agents), cardiovascular drugs (antihypertensives,
antiarrhythmics, anticoagulants), CNS medications (antidepressants,
antipsychotics, anticonvulsants), endocrine therapies (diabetes, thyroid), anti-
infectives, pain management, and special populations (pregnancy,
renal/hepatic impairment, geriatrics). Each question is designed to test clinical
reasoning and prescribing safety, with rationales grounded in evidence-based
practice.
1. A patient with end-stage renal disease (eGFR <15 mL/min) is prescribed a
medication that is 70% renally excreted. The nurse practitioner should anticipate:
A) Increasing the dose by 50%
B) Decreasing the dosing frequency
C) Changing to a prodrug
D) Adding a diuretic to enhance excretion
Correct Answer: B
Rationale: Reduced renal clearance leads to drug accumulation. Decreasing
frequency maintains therapeutic levels without toxicity. Increasing dose would
worsen toxicity. Prodrug conversion may be impaired in renal failure .
2. Which cytochrome P450 enzyme is most commonly involved in clinically
significant drug-drug interactions?
A) CYP1A2
B) CYP2D6
C) CYP3A4
D) CYP2C9
Correct Answer: C
Rationale: CYP3A4 metabolizes approximately 50% of marketed drugs, including
statins, calcium channel blockers, and benzodiazepines. It is highly susceptible to
inhibition (by grapefruit juice, ketoconazole) and induction (by rifampin,
carbamazepine) .
,3. A drug with high first-pass effect is given orally. The NP understands that:
A) The drug will have increased bioavailability
B) The drug must be given via a non-oral route to avoid extensive hepatic
metabolism
C) Gastric pH will alter absorption significantly
D) Protein binding will be decreased
Correct Answer: B
Rationale: High first-pass effect means the liver metabolizes much of the drug
before it reaches systemic circulation. IV, IM, or sublingual routes bypass portal
circulation .
4. A patient develops tolerance to morphine. This is most likely due to:
A) Increased renal excretion
B) Downregulation of opioid receptors
C) Upregulation of P-glycoprotein in the gut
D) Decreased liver blood flow
Correct Answer: B
Rationale: Chronic opioid use leads to receptor desensitization and
downregulation, requiring higher doses for the same effect. Tolerance is
pharmacodynamic, not pharmacokinetic .
5. Which medication exhibits nonlinear (zero-order) pharmacokinetics at
therapeutic doses?
A) Lisinopril
B) Phenytoin
C) Metformin
D) Amoxicillin
Correct Answer: B
Rationale: Phenytoin saturates hepatic enzymes at therapeutic levels, leading to
disproportionate increases in serum concentration with dose adjustments. Others
exhibit first-order kinetics .
6. A patient takes warfarin. Starting rifampin (a potent CYP inducer) will likely:
A) Increase INR and bleeding risk
B) Decrease INR and reduce anticoagulant effect
C) Have no effect on INR
D) Cause warfarin toxicity
Correct Answer: B
,Rationale: Rifampin induces CYP2C9 (warfarin metabolism), lowering warfarin
levels and INR. Dose adjustment upward may be needed .
7. The half-life of Drug X is 24 hours. Approximately how long to reach steady
state?
A) 24 hours
B) 48 hours
C) 5 days
D) 10 days
Correct Answer: C
Rationale: Steady state is reached in 4-5 half-lives. 24 hours × 5 = 120 hours = 5
days .
8. Atropine (anticholinergic) would be contraindicated in:
A) Sinus bradycardia
B) Organophosphate poisoning
C) Narrow-angle glaucoma
D) Preoperative use to reduce secretions
Correct Answer: C
Rationale: Atropine dilates pupils (mydriasis) and can precipitate acute angle-
closure glaucoma by blocking aqueous outflow .
9. A patient on levodopa/carbidopa for Parkinson's disease reports "wearing-off"
effects. Best next step:
A) Increase levodopa dose only
B) Add entacapone (COMT inhibitor)
C) Stop carbidopa
D) Switch to benztropine
Correct Answer: B
Rationale: Entacapone increases levodopa half-life, reducing "off" time. Carbidopa
is already present; do not stop it. Benztropine is for drug-induced EPS .
10. Which antidepressant is most dangerous in overdose due to cardiotoxicity?
A) Fluoxetine (SSRI)
B) Bupropion
C) Venlafaxine
D) Amitriptyline (tricyclic)
Correct Answer: D
Rationale: TCAs block sodium channels, causing widened QRS, arrhythmias, and
seizures. SSRIs are safer in overdose .
, 11. The mechanism of action of donepezil in Alzheimer's disease is:
A) NMDA receptor antagonist
B) Acetylcholinesterase inhibitor
C) Dopamine agonist
D) MAO-B inhibitor
Correct Answer: B
Rationale: Donepezil increases ACh in synaptic cleft. Memantine is NMDA
antagonist; selegiline is MAO-B inhibitor .
12. A patient with generalized anxiety disorder is started on buspirone. The NP
should counsel:
A) "You will feel relief within 24 hours"
B) "This is habit-forming like benzodiazepines"
C) "Take it on an empty stomach"
D) "It may take 2-4 weeks for full effect"
Correct Answer: D
Rationale: Buspirone has delayed onset, no abuse potential, no cross-tolerance with
benzodiazepines .
13. Which antipsychotic is most likely to cause agranulocytosis?
A) Risperidone
B) Clozapine
C) Quetiapine
D) Aripiprazole
Correct Answer: B
Rationale: Clozapine requires regular ANC monitoring due to 0.5-2% risk of
agranulocytosis .
14. A patient on lithium for bipolar disorder develops polyuria and polydipsia.
Most likely cause:
A) Diabetes mellitus
B) Syndrome of inappropriate antidiuretic hormone (SIADH)
C) Nephrogenic diabetes insipidus
D) Hyperparathyroidism
Correct Answer: C
Rationale: Lithium impairs ADH action in collecting ducts, causing inability to
concentrate urine .
QUESTIONS AND CORRECT ANSWERS WITH RATIONALE
LATEST 2026 ALREADY GRADED A+
This comprehensive 200-question guide covers the full spectrum of advanced
pharmacology for nurse practitioners. It addresses pharmacokinetics
(absorption, distribution, metabolism, excretion), pharmacodynamics
(receptor interactions, dose-response relationships), autonomic pharmacology
(adrenergic and cholinergic agents), cardiovascular drugs (antihypertensives,
antiarrhythmics, anticoagulants), CNS medications (antidepressants,
antipsychotics, anticonvulsants), endocrine therapies (diabetes, thyroid), anti-
infectives, pain management, and special populations (pregnancy,
renal/hepatic impairment, geriatrics). Each question is designed to test clinical
reasoning and prescribing safety, with rationales grounded in evidence-based
practice.
1. A patient with end-stage renal disease (eGFR <15 mL/min) is prescribed a
medication that is 70% renally excreted. The nurse practitioner should anticipate:
A) Increasing the dose by 50%
B) Decreasing the dosing frequency
C) Changing to a prodrug
D) Adding a diuretic to enhance excretion
Correct Answer: B
Rationale: Reduced renal clearance leads to drug accumulation. Decreasing
frequency maintains therapeutic levels without toxicity. Increasing dose would
worsen toxicity. Prodrug conversion may be impaired in renal failure .
2. Which cytochrome P450 enzyme is most commonly involved in clinically
significant drug-drug interactions?
A) CYP1A2
B) CYP2D6
C) CYP3A4
D) CYP2C9
Correct Answer: C
Rationale: CYP3A4 metabolizes approximately 50% of marketed drugs, including
statins, calcium channel blockers, and benzodiazepines. It is highly susceptible to
inhibition (by grapefruit juice, ketoconazole) and induction (by rifampin,
carbamazepine) .
,3. A drug with high first-pass effect is given orally. The NP understands that:
A) The drug will have increased bioavailability
B) The drug must be given via a non-oral route to avoid extensive hepatic
metabolism
C) Gastric pH will alter absorption significantly
D) Protein binding will be decreased
Correct Answer: B
Rationale: High first-pass effect means the liver metabolizes much of the drug
before it reaches systemic circulation. IV, IM, or sublingual routes bypass portal
circulation .
4. A patient develops tolerance to morphine. This is most likely due to:
A) Increased renal excretion
B) Downregulation of opioid receptors
C) Upregulation of P-glycoprotein in the gut
D) Decreased liver blood flow
Correct Answer: B
Rationale: Chronic opioid use leads to receptor desensitization and
downregulation, requiring higher doses for the same effect. Tolerance is
pharmacodynamic, not pharmacokinetic .
5. Which medication exhibits nonlinear (zero-order) pharmacokinetics at
therapeutic doses?
A) Lisinopril
B) Phenytoin
C) Metformin
D) Amoxicillin
Correct Answer: B
Rationale: Phenytoin saturates hepatic enzymes at therapeutic levels, leading to
disproportionate increases in serum concentration with dose adjustments. Others
exhibit first-order kinetics .
6. A patient takes warfarin. Starting rifampin (a potent CYP inducer) will likely:
A) Increase INR and bleeding risk
B) Decrease INR and reduce anticoagulant effect
C) Have no effect on INR
D) Cause warfarin toxicity
Correct Answer: B
,Rationale: Rifampin induces CYP2C9 (warfarin metabolism), lowering warfarin
levels and INR. Dose adjustment upward may be needed .
7. The half-life of Drug X is 24 hours. Approximately how long to reach steady
state?
A) 24 hours
B) 48 hours
C) 5 days
D) 10 days
Correct Answer: C
Rationale: Steady state is reached in 4-5 half-lives. 24 hours × 5 = 120 hours = 5
days .
8. Atropine (anticholinergic) would be contraindicated in:
A) Sinus bradycardia
B) Organophosphate poisoning
C) Narrow-angle glaucoma
D) Preoperative use to reduce secretions
Correct Answer: C
Rationale: Atropine dilates pupils (mydriasis) and can precipitate acute angle-
closure glaucoma by blocking aqueous outflow .
9. A patient on levodopa/carbidopa for Parkinson's disease reports "wearing-off"
effects. Best next step:
A) Increase levodopa dose only
B) Add entacapone (COMT inhibitor)
C) Stop carbidopa
D) Switch to benztropine
Correct Answer: B
Rationale: Entacapone increases levodopa half-life, reducing "off" time. Carbidopa
is already present; do not stop it. Benztropine is for drug-induced EPS .
10. Which antidepressant is most dangerous in overdose due to cardiotoxicity?
A) Fluoxetine (SSRI)
B) Bupropion
C) Venlafaxine
D) Amitriptyline (tricyclic)
Correct Answer: D
Rationale: TCAs block sodium channels, causing widened QRS, arrhythmias, and
seizures. SSRIs are safer in overdose .
, 11. The mechanism of action of donepezil in Alzheimer's disease is:
A) NMDA receptor antagonist
B) Acetylcholinesterase inhibitor
C) Dopamine agonist
D) MAO-B inhibitor
Correct Answer: B
Rationale: Donepezil increases ACh in synaptic cleft. Memantine is NMDA
antagonist; selegiline is MAO-B inhibitor .
12. A patient with generalized anxiety disorder is started on buspirone. The NP
should counsel:
A) "You will feel relief within 24 hours"
B) "This is habit-forming like benzodiazepines"
C) "Take it on an empty stomach"
D) "It may take 2-4 weeks for full effect"
Correct Answer: D
Rationale: Buspirone has delayed onset, no abuse potential, no cross-tolerance with
benzodiazepines .
13. Which antipsychotic is most likely to cause agranulocytosis?
A) Risperidone
B) Clozapine
C) Quetiapine
D) Aripiprazole
Correct Answer: B
Rationale: Clozapine requires regular ANC monitoring due to 0.5-2% risk of
agranulocytosis .
14. A patient on lithium for bipolar disorder develops polyuria and polydipsia.
Most likely cause:
A) Diabetes mellitus
B) Syndrome of inappropriate antidiuretic hormone (SIADH)
C) Nephrogenic diabetes insipidus
D) Hyperparathyroidism
Correct Answer: C
Rationale: Lithium impairs ADH action in collecting ducts, causing inability to
concentrate urine .
