, NR 565 Advanced Pharmacology Exam
V2 (2026/2027) Questions with Answers
& Detailed Rationales
Question 1
A 58-year-old patient with type 2 diabetes and stage 4 chronic
kidney disease with an eGFR of 22 mL/min/1.73m2 is evaluated
for glucose-lowering therapy. Which medication is strictly
contraindicated due to the high risk of fatal lactic acidosis?
A) Glipizide
B) Metformin
C) Liraglutide
D) Sitagliptin
Correct Answer: B) Metformin
Rationale: Metformin is contraindicated in patients with severe
renal impairment, generally defined as an eGFR below 30
mL/min/1.73m2, because decreased drug clearance leads to
systemic accumulation and a high risk of life-threatening lactic
acidosis.
Question 2
A patient with chronic heart failure and a reduced ejection
fraction of 35% is started on a new medication regimen. Which
class of diabetes medications is contraindicated in this patient
,because it causes fluid retention and can exacerbate heart
failure?
A) Sodium-glucose cotransporter 2 inhibitors
B) Thiazolidinediones
C) Glucagon-like peptide-1 receptor agonists
D) Dipeptidyl peptidase-4 inhibitors
Correct Answer: B) Thiazolidinediones
Rationale: Thiazolidinediones promote renal sodium
reabsorption and fluid retention, which can expand plasma
volume and precipitate or severely worsen acute decompensated
heart failure in susceptible patients.
Question 3
An APRN is monitoring a patient receiving intravenous
phenytoin for status epilepticus. The patient develops ataxia,
horizontal nystagmus, and lethargy. A serum level reveals
toxicity. What pharmacokinetic property explains why small
dosage adjustments can cause massive spikes in serum levels?
A) First-order linear clearance
B) Capacity-limited zero-order metabolism
C) Extensive first-pass hepatic extraction
D) Rapid renal tubular secretion
Correct Answer: B) Capacity-limited zero-order metabolism
, Rationale: Phenytoin is metabolized by hepatic enzymes that
easily become saturated at therapeutic levels, transitioning the
drug from first-order to zero-order elimination kinetics where
small dose increases cause disproportionately large rises in
serum concentration.
Question 4
A patient with a history of chronic obstructive pulmonary
disease and mild hypertension is prescribed a non-selective beta-
blocker. Which serious adverse respiratory complication is most
likely to occur?
A) Pulmonary alveolar proteinosis
B) Severe bronchospasm
C) Spontaneous pneumothorax
D) Acute respiratory distress syndrome
Correct Answer: B) Severe bronchospasm
Rationale: Non-selective beta-blockers block both beta-1
receptors in the heart and beta-2 receptors in bronchial smooth
muscle, removing sympathetic bronchodilation and precipitating
severe bronchoconstriction in patients with airway disease.
Question 5
A patient with an eGFR of 20 mL/min requires treatment for a
severe gram-negative infection. Which antimicrobial agent
requires strict therapeutic drug monitoring and dosage reduction
due to exclusive renal elimination and nephrotoxicity?
V2 (2026/2027) Questions with Answers
& Detailed Rationales
Question 1
A 58-year-old patient with type 2 diabetes and stage 4 chronic
kidney disease with an eGFR of 22 mL/min/1.73m2 is evaluated
for glucose-lowering therapy. Which medication is strictly
contraindicated due to the high risk of fatal lactic acidosis?
A) Glipizide
B) Metformin
C) Liraglutide
D) Sitagliptin
Correct Answer: B) Metformin
Rationale: Metformin is contraindicated in patients with severe
renal impairment, generally defined as an eGFR below 30
mL/min/1.73m2, because decreased drug clearance leads to
systemic accumulation and a high risk of life-threatening lactic
acidosis.
Question 2
A patient with chronic heart failure and a reduced ejection
fraction of 35% is started on a new medication regimen. Which
class of diabetes medications is contraindicated in this patient
,because it causes fluid retention and can exacerbate heart
failure?
A) Sodium-glucose cotransporter 2 inhibitors
B) Thiazolidinediones
C) Glucagon-like peptide-1 receptor agonists
D) Dipeptidyl peptidase-4 inhibitors
Correct Answer: B) Thiazolidinediones
Rationale: Thiazolidinediones promote renal sodium
reabsorption and fluid retention, which can expand plasma
volume and precipitate or severely worsen acute decompensated
heart failure in susceptible patients.
Question 3
An APRN is monitoring a patient receiving intravenous
phenytoin for status epilepticus. The patient develops ataxia,
horizontal nystagmus, and lethargy. A serum level reveals
toxicity. What pharmacokinetic property explains why small
dosage adjustments can cause massive spikes in serum levels?
A) First-order linear clearance
B) Capacity-limited zero-order metabolism
C) Extensive first-pass hepatic extraction
D) Rapid renal tubular secretion
Correct Answer: B) Capacity-limited zero-order metabolism
, Rationale: Phenytoin is metabolized by hepatic enzymes that
easily become saturated at therapeutic levels, transitioning the
drug from first-order to zero-order elimination kinetics where
small dose increases cause disproportionately large rises in
serum concentration.
Question 4
A patient with a history of chronic obstructive pulmonary
disease and mild hypertension is prescribed a non-selective beta-
blocker. Which serious adverse respiratory complication is most
likely to occur?
A) Pulmonary alveolar proteinosis
B) Severe bronchospasm
C) Spontaneous pneumothorax
D) Acute respiratory distress syndrome
Correct Answer: B) Severe bronchospasm
Rationale: Non-selective beta-blockers block both beta-1
receptors in the heart and beta-2 receptors in bronchial smooth
muscle, removing sympathetic bronchodilation and precipitating
severe bronchoconstriction in patients with airway disease.
Question 5
A patient with an eGFR of 20 mL/min requires treatment for a
severe gram-negative infection. Which antimicrobial agent
requires strict therapeutic drug monitoring and dosage reduction
due to exclusive renal elimination and nephrotoxicity?
