NR568 Advanced Pharmacology Weeks 5-8
Final Exam
Instructions:
Select the single best answer for each question.
Section 1: Cardiovascular Pharmacology (Questions 1-30)
1. A 72-year-old male with HFrEF (EF 30%) is on maximally tolerated doses of lisinopril,
carvedilol, and furosemide. He is started on dapagliflozin. What is the primary
mechanism of action for dapagliflozin’s mortality benefit in this patient?
A. Inhibition of the RAAS system.
B. Positive inotropic effect on cardiac myocytes.
C. Reduction in preload and afterload via osmotic diuresis and natriuresis.
D. Blockade of aldosterone receptors.
Rationale: Dapagliflozin, an SGLT2 inhibitor, reduces preload and afterload through
osmotic diuresis, natriuresis, and weight loss. It also improves myocardial energetics, but
the primary hemodynamic effect is the reduction in preload and afterload.
2. Which of the following drug classes is contraindicated in a patient with a history of
angioedema related to lisinopril?
A. Beta-blockers
B. Calcium channel blockers
C. Direct renin inhibitors
D. Thiazide diuretics
Rationale: Direct renin inhibitors (e.g., aliskiren) act on the RAAS pathway and can also
cause angioedema, making them contraindicated in patients with a history of ACE
inhibitor-induced angioedema due to cross-reactivity.
3. A patient is prescribed verapamil for supraventricular tachycardia. The provider should
be most concerned about combining this medication with which of the following?
A. Metoprolol succinate
B. Lisinopril
C. Hydrochlorothiazide
D. Digoxin
, Rationale: Combining a non-dihydropyridine calcium channel blocker like verapamil with
a beta-blocker like metoprolol carries a high risk of severe bradycardia, heart block, and
heart failure exacerbation.
4. A patient with chronic stable angina is prescribed nitroglycerin sublingual for acute
attacks. Patient education should include advising the patient to:
A. Take the medication with a full glass of water.
B. Store the medication in the refrigerator.
C. Swallow the tablet for a slower onset of action.
D. Replace the medication every 3-6 months due to potency loss.
Rationale: Nitroglycerin is volatile and can lose its potency. Patients should replace it every
3-6 months. It should be taken sublingually, not swallowed, and stored in its original dark
container.
5. Which of the following is a characteristic adverse effect of amiodarone that requires
ongoing monitoring?
A. Hyperthyroidism only.
B. Hypothyroidism only.
C. Pulmonary fibrosis and both hyper/hypothyroidism.
D. Acute kidney injury.
Rationale: Amiodarone has a high iodine content and can cause both hypothyroidism and
hyperthyroidism. It also carries a significant risk of pulmonary toxicity, including
pulmonary fibrosis, necessitating baseline and annual pulmonary function tests.
6. A patient with heart failure is prescribed spironolactone. The most important laboratory
value to monitor in the first week of therapy is:
A. Serum calcium.
B. Serum potassium.
C. Serum sodium.
D. BUN and creatinine.
Rationale: Spironolactone is a potassium-sparing diuretic. Hyperkalemia is its most serious
and life-threatening adverse effect, especially when combined with ACE inhibitors, ARBs,
or renal impairment.
7. A patient on warfarin with an INR of 3.8 is started on amiodarone. The NP should
anticipate:
A. No change in warfarin dose.
B. A decrease in the warfarin dose.
C. An increase in the warfarin dose.
D. Discontinuation of warfarin.
Rationale: Amiodarone inhibits the CYP2C9 and CYP3A4 metabolism of warfarin,
significantly increasing its serum concentration and INR. The warfarin dose should be
reduced by 30-50% and the INR closely monitored.
,8. In the treatment of acute decompensated heart failure, intravenous (IV) furosemide is
preferred over oral furosemide because:
A. Oral furosemide has a faster onset.
B. IV furosemide has superior bioavailability and more predictable diuresis.
C. IV furosemide is less likely to cause ototoxicity.
D. Oral furosemide is more expensive.
Rationale: The bioavailability of oral furosemide is variable and lower (approx. 50%) than
IV furosemide, making IV administration the preferred route in acute, decompensated
states for predictable and rapid diuresis.
9. A patient with coronary artery disease is prescribed clopidogrel. Genetic testing reveals
the patient is a CYP2C19 poor metabolizer. Which alternative therapy should be
considered?
A. Aspirin
B. Prasugrel
C. Dipyridamole
D. Cilostazol
Rationale: Clopidogrel is a prodrug that requires CYP2C19 for activation. Poor
metabolizers have significantly reduced antiplatelet effect and higher risk of stent
thrombosis. Prasugrel or ticagrelor is recommended for these patients.
10. A patient reports a cough while taking lisinopril. The provider switches the patient to
losartan. Why might the cough resolve?
A. Losartan has a lower incidence of cough due to not affecting bradykinin breakdown.
B. Losartan is a more potent antihypertensive.
C. Losartan has a longer half-life.
D. Losartan is a diuretic.
Rationale: The cough associated with ACE inhibitors is attributed to the accumulation of
bradykinin. ARBs do not affect bradykinin metabolism, leading to a much lower incidence
of cough.
11. A patient with a history of gout is started on hydrochlorothiazide. The NP should
monitor for:
A. Decreased uric acid levels.
B. Increased uric acid levels leading to a gout flare.
C. No change in uric acid levels.
D. Hyperkalemia.
Rationale: Thiazide diuretics decrease uric acid excretion, leading to hyperuricemia and
potentially precipitating a gout flare in susceptible patients.
12. Which beta-blocker is considered cardioselective (beta-1 selective) at low doses?
A. Propranolol
B. Metoprolol succinate
C. Carvedilol
, D. Labetalol
Rationale: Metoprolol is a beta-1 selective blocker. Propranolol is non-selective, and
carvedilol and labetalol are non-selective with alpha-blocking activity.
13. A patient is prescribed diltiazem for hypertension. Which adverse effect is most
common?
A. Tachycardia
B. Peripheral edema
C. Hyperglycemia
D. Dry cough
Rationale: Peripheral edema is a common dose-dependent adverse effect of non-
dihydropyridine calcium channel blockers like diltiazem and verapamil.
14. A patient is admitted with a hypertensive emergency (systolic BP >220 mmHg). Which
medication is preferred for its rapid onset and ability to be titrated?
A. Oral nifedipine
B. Sublingual clonidine
C. IV sodium nitroprusside
D. IV labetalol
Rationale: IV sodium nitroprusside is a direct-acting vasodilator with a rapid onset and
very short half-life, allowing for precise titration. It is a gold standard for hypertensive
emergencies.
15. A patient on digoxin presents with nausea, vomiting, and visual disturbances. An EKG
shows a "reverse checkmark" ST depression. What is the most likely diagnosis?
A. Acute myocardial infarction
B. Digoxin toxicity
C. Hyperkalemia
D. Pulmonary embolism
Rationale: The combination of GI symptoms, visual disturbances, and classic EKG changes
(reverse checkmark ST depressions) is highly indicative of digoxin toxicity.
16. The antidote for severe digitalis toxicity is:
A. Naloxone
B. Flumazenil
C. Digoxin immune Fab (Digibind)
D. Vitamin K
Rationale: Digoxin immune Fab fragments bind to digoxin, preventing it from binding to
its target receptors, and are the specific antidote for life-threatening toxicity.
17. A patient with hyperlipidemia is prescribed atorvastatin. Baseline and ongoing
monitoring should include:
A. Complete blood count (CBC).
B. Liver function tests (ALT/AST) and creatine kinase (CK).
C. Serum creatinine.
Final Exam
Instructions:
Select the single best answer for each question.
Section 1: Cardiovascular Pharmacology (Questions 1-30)
1. A 72-year-old male with HFrEF (EF 30%) is on maximally tolerated doses of lisinopril,
carvedilol, and furosemide. He is started on dapagliflozin. What is the primary
mechanism of action for dapagliflozin’s mortality benefit in this patient?
A. Inhibition of the RAAS system.
B. Positive inotropic effect on cardiac myocytes.
C. Reduction in preload and afterload via osmotic diuresis and natriuresis.
D. Blockade of aldosterone receptors.
Rationale: Dapagliflozin, an SGLT2 inhibitor, reduces preload and afterload through
osmotic diuresis, natriuresis, and weight loss. It also improves myocardial energetics, but
the primary hemodynamic effect is the reduction in preload and afterload.
2. Which of the following drug classes is contraindicated in a patient with a history of
angioedema related to lisinopril?
A. Beta-blockers
B. Calcium channel blockers
C. Direct renin inhibitors
D. Thiazide diuretics
Rationale: Direct renin inhibitors (e.g., aliskiren) act on the RAAS pathway and can also
cause angioedema, making them contraindicated in patients with a history of ACE
inhibitor-induced angioedema due to cross-reactivity.
3. A patient is prescribed verapamil for supraventricular tachycardia. The provider should
be most concerned about combining this medication with which of the following?
A. Metoprolol succinate
B. Lisinopril
C. Hydrochlorothiazide
D. Digoxin
, Rationale: Combining a non-dihydropyridine calcium channel blocker like verapamil with
a beta-blocker like metoprolol carries a high risk of severe bradycardia, heart block, and
heart failure exacerbation.
4. A patient with chronic stable angina is prescribed nitroglycerin sublingual for acute
attacks. Patient education should include advising the patient to:
A. Take the medication with a full glass of water.
B. Store the medication in the refrigerator.
C. Swallow the tablet for a slower onset of action.
D. Replace the medication every 3-6 months due to potency loss.
Rationale: Nitroglycerin is volatile and can lose its potency. Patients should replace it every
3-6 months. It should be taken sublingually, not swallowed, and stored in its original dark
container.
5. Which of the following is a characteristic adverse effect of amiodarone that requires
ongoing monitoring?
A. Hyperthyroidism only.
B. Hypothyroidism only.
C. Pulmonary fibrosis and both hyper/hypothyroidism.
D. Acute kidney injury.
Rationale: Amiodarone has a high iodine content and can cause both hypothyroidism and
hyperthyroidism. It also carries a significant risk of pulmonary toxicity, including
pulmonary fibrosis, necessitating baseline and annual pulmonary function tests.
6. A patient with heart failure is prescribed spironolactone. The most important laboratory
value to monitor in the first week of therapy is:
A. Serum calcium.
B. Serum potassium.
C. Serum sodium.
D. BUN and creatinine.
Rationale: Spironolactone is a potassium-sparing diuretic. Hyperkalemia is its most serious
and life-threatening adverse effect, especially when combined with ACE inhibitors, ARBs,
or renal impairment.
7. A patient on warfarin with an INR of 3.8 is started on amiodarone. The NP should
anticipate:
A. No change in warfarin dose.
B. A decrease in the warfarin dose.
C. An increase in the warfarin dose.
D. Discontinuation of warfarin.
Rationale: Amiodarone inhibits the CYP2C9 and CYP3A4 metabolism of warfarin,
significantly increasing its serum concentration and INR. The warfarin dose should be
reduced by 30-50% and the INR closely monitored.
,8. In the treatment of acute decompensated heart failure, intravenous (IV) furosemide is
preferred over oral furosemide because:
A. Oral furosemide has a faster onset.
B. IV furosemide has superior bioavailability and more predictable diuresis.
C. IV furosemide is less likely to cause ototoxicity.
D. Oral furosemide is more expensive.
Rationale: The bioavailability of oral furosemide is variable and lower (approx. 50%) than
IV furosemide, making IV administration the preferred route in acute, decompensated
states for predictable and rapid diuresis.
9. A patient with coronary artery disease is prescribed clopidogrel. Genetic testing reveals
the patient is a CYP2C19 poor metabolizer. Which alternative therapy should be
considered?
A. Aspirin
B. Prasugrel
C. Dipyridamole
D. Cilostazol
Rationale: Clopidogrel is a prodrug that requires CYP2C19 for activation. Poor
metabolizers have significantly reduced antiplatelet effect and higher risk of stent
thrombosis. Prasugrel or ticagrelor is recommended for these patients.
10. A patient reports a cough while taking lisinopril. The provider switches the patient to
losartan. Why might the cough resolve?
A. Losartan has a lower incidence of cough due to not affecting bradykinin breakdown.
B. Losartan is a more potent antihypertensive.
C. Losartan has a longer half-life.
D. Losartan is a diuretic.
Rationale: The cough associated with ACE inhibitors is attributed to the accumulation of
bradykinin. ARBs do not affect bradykinin metabolism, leading to a much lower incidence
of cough.
11. A patient with a history of gout is started on hydrochlorothiazide. The NP should
monitor for:
A. Decreased uric acid levels.
B. Increased uric acid levels leading to a gout flare.
C. No change in uric acid levels.
D. Hyperkalemia.
Rationale: Thiazide diuretics decrease uric acid excretion, leading to hyperuricemia and
potentially precipitating a gout flare in susceptible patients.
12. Which beta-blocker is considered cardioselective (beta-1 selective) at low doses?
A. Propranolol
B. Metoprolol succinate
C. Carvedilol
, D. Labetalol
Rationale: Metoprolol is a beta-1 selective blocker. Propranolol is non-selective, and
carvedilol and labetalol are non-selective with alpha-blocking activity.
13. A patient is prescribed diltiazem for hypertension. Which adverse effect is most
common?
A. Tachycardia
B. Peripheral edema
C. Hyperglycemia
D. Dry cough
Rationale: Peripheral edema is a common dose-dependent adverse effect of non-
dihydropyridine calcium channel blockers like diltiazem and verapamil.
14. A patient is admitted with a hypertensive emergency (systolic BP >220 mmHg). Which
medication is preferred for its rapid onset and ability to be titrated?
A. Oral nifedipine
B. Sublingual clonidine
C. IV sodium nitroprusside
D. IV labetalol
Rationale: IV sodium nitroprusside is a direct-acting vasodilator with a rapid onset and
very short half-life, allowing for precise titration. It is a gold standard for hypertensive
emergencies.
15. A patient on digoxin presents with nausea, vomiting, and visual disturbances. An EKG
shows a "reverse checkmark" ST depression. What is the most likely diagnosis?
A. Acute myocardial infarction
B. Digoxin toxicity
C. Hyperkalemia
D. Pulmonary embolism
Rationale: The combination of GI symptoms, visual disturbances, and classic EKG changes
(reverse checkmark ST depressions) is highly indicative of digoxin toxicity.
16. The antidote for severe digitalis toxicity is:
A. Naloxone
B. Flumazenil
C. Digoxin immune Fab (Digibind)
D. Vitamin K
Rationale: Digoxin immune Fab fragments bind to digoxin, preventing it from binding to
its target receptors, and are the specific antidote for life-threatening toxicity.
17. A patient with hyperlipidemia is prescribed atorvastatin. Baseline and ongoing
monitoring should include:
A. Complete blood count (CBC).
B. Liver function tests (ALT/AST) and creatine kinase (CK).
C. Serum creatinine.
