NSG 533: Advanced Pharmacology Exam 1 | Wilkes University 2026-2027 75 Questions
NSG 533 / NSG533: Advanced Pharmacology
Exam 1 (Latest ) - Wilkes University
Questions and Verified Answers with Rationales | 100% Correct | Grade A
Section 1: Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics
(Q1-Q15)
Q1: A patient is prescribed an oral medication that undergoes extensive first-pass
metabolism. Which statement best describes the clinical implication of the first-pass effect?
A. The drug has increased bioavailability because hepatic enzymes enhance its active form
B. A significant portion of the oral dose is metabolized by the liver before reaching systemic
circulation, reducing bioavailability [CORRECT]
C. The drug is primarily excreted unchanged by the kidneys, requiring dose adjustment in renal
impairment
D. The drug crosses the blood-brain barrier more efficiently due to hepatic biotransformation
Correct Answer: B
Rationale: The first-pass effect occurs when orally administered drugs are absorbed through the GI tract and
carried by the portal vein directly to the liver, where they undergo significant metabolism before reaching
systemic circulation. This reduces the bioavailability (fraction of the dose that reaches circulation) of the drug.
Drugs with high first-pass metabolism (e.g., morphine, verapamil, propranolol) may require higher oral doses
or alternative routes. Option A is incorrect because first-pass metabolism reduces, not increases, bioavailability.
Option C describes renal excretion, not hepatic metabolism. Option D is unrelated to first-pass metabolism.
Q2: A patient with advanced liver cirrhosis is prescribed a medication that is highly
protein-bound (98%). Which pharmacokinetic change is most likely to occur in this patient?
A. Increased free drug fraction due to decreased albumin production, increasing the risk of
drug toxicity [CORRECT]
B. Decreased free drug fraction due to increased plasma protein synthesis in response to liver
injury
C. No change in drug distribution because protein binding is unaffected by liver disease
D. Increased volume of distribution due to enhanced tissue binding of the drug
Correct Answer: A
Rationale: In advanced liver cirrhosis, hepatic synthesis of albumin (the primary plasma protein that binds
acidic drugs) is significantly reduced. With less albumin available, the free (unbound) fraction of highly
protein-bound drugs increases. The free drug is pharmacologically active, so this increases the risk of drug
toxicity at standard doses. Dose reduction may be necessary. Option B is incorrect because liver disease
decreases protein synthesis. Option C is false because protein binding is directly affected. Option D is less
relevant; the primary concern is increased free drug concentration.
Q3: A 78-year-old patient is prescribed a renally cleared medication. Which
pharmacokinetic consideration is most important for this patient?
A. Increased first-pass metabolism requiring higher oral doses
B. Decreased GFR associated with aging, which may require dose reduction to prevent drug
accumulation and toxicity [CORRECT]
C. Enhanced protein binding due to increased albumin production in the elderly
Page 1
,NSG 533: Advanced Pharmacology Exam 1 | Wilkes University 2026-2027 75 Questions
D. Faster hepatic Phase II conjugation reactions increasing drug metabolism
Correct Answer: B
Rationale: Aging is associated with a progressive decline in glomerular filtration rate (GFR), which reduces
renal clearance of drugs eliminated primarily by the kidneys. Without dose adjustment, renally cleared drugs
accumulate in elderly patients, increasing the risk of toxicity. This is one of the most important
pharmacokinetic considerations in geriatric pharmacotherapy. Option A describes hepatic changes, not renal.
Option C is incorrect because albumin production actually decreases with age. Option D is incorrect because
hepatic metabolism generally slows with aging.
Q4: A patient is prescribed a medication metabolized primarily by CYP3A4. Which
combination would most likely increase the plasma concentration of this drug?
A. Rifampin and phenytoin
B. Grapefruit juice and ketoconazole [CORRECT]
C. St. John's Wort and carbamazepine
D. Phenobarbital and smoking
Correct Answer: B
Rationale: CYP3A4 inhibitors (grapefruit juice, ketoconazole, erythromycin, ritonavir) block the CYP3A4
enzyme, reducing the metabolism of CYP3A4 substrates and increasing their plasma concentrations. This
increases the risk of drug toxicity. Options A, C, and D all list CYP3A4 inducers, which increase CYP3A4 activity,
decrease drug levels, and potentially reduce therapeutic efficacy. Understanding CYP interactions is essential
for safe prescribing.
Q5: A patient is a CYP2D6 poor metabolizer. The prescriber orders codeine for pain
management. What is the expected clinical outcome?
A. Enhanced analgesia due to increased morphine production from codeine conversion
B. Reduced analgesic effect because codeine requires CYP2D6 to convert to its active
metabolite morphine [CORRECT]
C. No effect on analgesia because codeine acts directly on opioid receptors without metabolism
D. Increased risk of codeine toxicity due to rapid metabolism and accumulation of active
metabolites
Correct Answer: B
Rationale: Codeine is a prodrug that requires CYP2D6-mediated O-demethylation to convert to its active
analgesic metabolite, morphine. CYP2D6 poor metabolizers have reduced or absent CYP2D6 enzyme activity,
resulting in inadequate conversion of codeine to morphine and therefore reduced analgesic effect. This is a
prime example of pharmacogenomics guiding prescribing; alternative analgesics should be selected for poor
metabolizers. Option A describes an ultra-rapid metabolizer. Option C is incorrect; codeine requires
metabolism. Option D also describes ultra-rapid metabolizers who produce excessive morphine.
Q6: A patient requires clopidogrel after placement of a cardiac stent. Genetic testing reveals
the patient is a CYP2C19 poor metabolizer. Which prescribing decision is most appropriate?
A. Continue clopidogrel at a higher dose to overcome the metabolic deficiency
B. Switch to an alternative antiplatelet agent such as ticagrelor that does not require
CYP2C19 activation [CORRECT]
C. Discontinue all antiplatelet therapy due to the genetic risk
D. Add omeprazole to enhance clopidogrel absorption and compensate for the metabolic defect
Correct Answer: B
Rationale: Clopidogrel is a prodrug that requires CYP2C19 activation to its active metabolite. CYP2C19 poor
metabolizers have significantly reduced active metabolite formation, leading to decreased antiplatelet effect
and increased risk of cardiovascular events (stent thrombosis). The appropriate action is to switch to an
alternative antiplatelet agent such as ticagrelor or prasugrel that does not depend on CYP2C19 for activation.
Option A is not evidence-based. Option C is dangerous; antiplatelet therapy is essential post-stent. Option D is
Page 2
, NSG 533: Advanced Pharmacology Exam 1 | Wilkes University 2026-2027 75 Questions
incorrect; omeprazole is a CYP2C19 inhibitor that would further reduce clopidogrel activation.
Q7: A prescriber is evaluating a new medication with a narrow therapeutic index. Which
characteristic best defines this type of drug?
A. The drug has a wide margin between the effective dose and the toxic dose
B. The difference between the minimum effective concentration and the minimum toxic
concentration is small, requiring careful monitoring [CORRECT]
C. The drug is effective at very low doses with minimal side effects at any dose
D. The drug has high bioavailability and consistent absorption across all patients
Correct Answer: B
Rationale: A narrow therapeutic index (TI) means the difference between the effective dose and the toxic dose is
small. Drugs with narrow TI (digoxin, lithium, warfarin, phenytoin, vancomycin, gentamicin) require
therapeutic drug monitoring to maintain serum levels within the therapeutic range and avoid toxicity. Small
changes in dose or pharmacokinetics (drug interactions, organ dysfunction) can push levels from therapeutic to
toxic. Option A describes a wide TI. Options C and D do not define therapeutic index.
Q8: A pregnant patient requires a new medication. The prescriber notes the drug is
Pregnancy Category X. Which action is most appropriate?
A. Administer the drug at a reduced dose to minimize fetal exposure
B. The drug is contraindicated in pregnancy because animal or human studies have
demonstrated fetal risk that clearly outweighs any potential benefit [CORRECT]
C. Administer the drug only during the first trimester when organogenesis is complete
D. The drug is safe in pregnancy because no animal studies have shown fetal harm
Correct Answer: B
Rationale: Pregnancy Category X drugs are contraindicated in pregnancy. Studies in animals or humans have
demonstrated positive evidence of fetal risk, and the risk clearly outweighs any potential benefit. Examples
include statins, isotretinoin, and warfarin. These drugs must not be used in pregnant women or women who
may become pregnant. Option A is incorrect; there is no safe dose. Option C is incorrect; the first trimester is
the most vulnerable period. Option D describes Category A, not Category X.
Q9: A drug demonstrates high potency but low efficacy compared to a reference drug in the
same class. Which statement best describes this drug's dose-response relationship?
A. The drug requires a higher dose to achieve the same effect as the reference drug and cannot
reach the same maximum effect
B. The drug produces its effect at a lower dose than the reference drug but cannot achieve
the same maximum response [CORRECT]
C. The drug requires a lower dose and achieves a greater maximum effect than the reference
drug
D. The drug has the same dose-response curve as the reference drug with identical clinical
outcomes
Correct Answer: B
Rationale: Potency refers to the dose required to produce a given effect (position on the dose-response curve),
while efficacy refers to the maximum effect achievable (ceiling of the curve). A drug with high potency but low
efficacy produces a response at lower doses than the reference drug but cannot achieve the same maximum
therapeutic effect regardless of dose. This is the pharmacodynamic profile of a partial agonist. Option A
describes low potency, low efficacy. Option C describes high potency, high efficacy (a full agonist more potent
than the reference). Option D is incorrect; the curves would differ.
Q10: A patient with a known HLA-B*5701 allele presents for treatment of HIV infection.
Which medication is contraindicated, and why?
Page 3
NSG 533 / NSG533: Advanced Pharmacology
Exam 1 (Latest ) - Wilkes University
Questions and Verified Answers with Rationales | 100% Correct | Grade A
Section 1: Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics
(Q1-Q15)
Q1: A patient is prescribed an oral medication that undergoes extensive first-pass
metabolism. Which statement best describes the clinical implication of the first-pass effect?
A. The drug has increased bioavailability because hepatic enzymes enhance its active form
B. A significant portion of the oral dose is metabolized by the liver before reaching systemic
circulation, reducing bioavailability [CORRECT]
C. The drug is primarily excreted unchanged by the kidneys, requiring dose adjustment in renal
impairment
D. The drug crosses the blood-brain barrier more efficiently due to hepatic biotransformation
Correct Answer: B
Rationale: The first-pass effect occurs when orally administered drugs are absorbed through the GI tract and
carried by the portal vein directly to the liver, where they undergo significant metabolism before reaching
systemic circulation. This reduces the bioavailability (fraction of the dose that reaches circulation) of the drug.
Drugs with high first-pass metabolism (e.g., morphine, verapamil, propranolol) may require higher oral doses
or alternative routes. Option A is incorrect because first-pass metabolism reduces, not increases, bioavailability.
Option C describes renal excretion, not hepatic metabolism. Option D is unrelated to first-pass metabolism.
Q2: A patient with advanced liver cirrhosis is prescribed a medication that is highly
protein-bound (98%). Which pharmacokinetic change is most likely to occur in this patient?
A. Increased free drug fraction due to decreased albumin production, increasing the risk of
drug toxicity [CORRECT]
B. Decreased free drug fraction due to increased plasma protein synthesis in response to liver
injury
C. No change in drug distribution because protein binding is unaffected by liver disease
D. Increased volume of distribution due to enhanced tissue binding of the drug
Correct Answer: A
Rationale: In advanced liver cirrhosis, hepatic synthesis of albumin (the primary plasma protein that binds
acidic drugs) is significantly reduced. With less albumin available, the free (unbound) fraction of highly
protein-bound drugs increases. The free drug is pharmacologically active, so this increases the risk of drug
toxicity at standard doses. Dose reduction may be necessary. Option B is incorrect because liver disease
decreases protein synthesis. Option C is false because protein binding is directly affected. Option D is less
relevant; the primary concern is increased free drug concentration.
Q3: A 78-year-old patient is prescribed a renally cleared medication. Which
pharmacokinetic consideration is most important for this patient?
A. Increased first-pass metabolism requiring higher oral doses
B. Decreased GFR associated with aging, which may require dose reduction to prevent drug
accumulation and toxicity [CORRECT]
C. Enhanced protein binding due to increased albumin production in the elderly
Page 1
,NSG 533: Advanced Pharmacology Exam 1 | Wilkes University 2026-2027 75 Questions
D. Faster hepatic Phase II conjugation reactions increasing drug metabolism
Correct Answer: B
Rationale: Aging is associated with a progressive decline in glomerular filtration rate (GFR), which reduces
renal clearance of drugs eliminated primarily by the kidneys. Without dose adjustment, renally cleared drugs
accumulate in elderly patients, increasing the risk of toxicity. This is one of the most important
pharmacokinetic considerations in geriatric pharmacotherapy. Option A describes hepatic changes, not renal.
Option C is incorrect because albumin production actually decreases with age. Option D is incorrect because
hepatic metabolism generally slows with aging.
Q4: A patient is prescribed a medication metabolized primarily by CYP3A4. Which
combination would most likely increase the plasma concentration of this drug?
A. Rifampin and phenytoin
B. Grapefruit juice and ketoconazole [CORRECT]
C. St. John's Wort and carbamazepine
D. Phenobarbital and smoking
Correct Answer: B
Rationale: CYP3A4 inhibitors (grapefruit juice, ketoconazole, erythromycin, ritonavir) block the CYP3A4
enzyme, reducing the metabolism of CYP3A4 substrates and increasing their plasma concentrations. This
increases the risk of drug toxicity. Options A, C, and D all list CYP3A4 inducers, which increase CYP3A4 activity,
decrease drug levels, and potentially reduce therapeutic efficacy. Understanding CYP interactions is essential
for safe prescribing.
Q5: A patient is a CYP2D6 poor metabolizer. The prescriber orders codeine for pain
management. What is the expected clinical outcome?
A. Enhanced analgesia due to increased morphine production from codeine conversion
B. Reduced analgesic effect because codeine requires CYP2D6 to convert to its active
metabolite morphine [CORRECT]
C. No effect on analgesia because codeine acts directly on opioid receptors without metabolism
D. Increased risk of codeine toxicity due to rapid metabolism and accumulation of active
metabolites
Correct Answer: B
Rationale: Codeine is a prodrug that requires CYP2D6-mediated O-demethylation to convert to its active
analgesic metabolite, morphine. CYP2D6 poor metabolizers have reduced or absent CYP2D6 enzyme activity,
resulting in inadequate conversion of codeine to morphine and therefore reduced analgesic effect. This is a
prime example of pharmacogenomics guiding prescribing; alternative analgesics should be selected for poor
metabolizers. Option A describes an ultra-rapid metabolizer. Option C is incorrect; codeine requires
metabolism. Option D also describes ultra-rapid metabolizers who produce excessive morphine.
Q6: A patient requires clopidogrel after placement of a cardiac stent. Genetic testing reveals
the patient is a CYP2C19 poor metabolizer. Which prescribing decision is most appropriate?
A. Continue clopidogrel at a higher dose to overcome the metabolic deficiency
B. Switch to an alternative antiplatelet agent such as ticagrelor that does not require
CYP2C19 activation [CORRECT]
C. Discontinue all antiplatelet therapy due to the genetic risk
D. Add omeprazole to enhance clopidogrel absorption and compensate for the metabolic defect
Correct Answer: B
Rationale: Clopidogrel is a prodrug that requires CYP2C19 activation to its active metabolite. CYP2C19 poor
metabolizers have significantly reduced active metabolite formation, leading to decreased antiplatelet effect
and increased risk of cardiovascular events (stent thrombosis). The appropriate action is to switch to an
alternative antiplatelet agent such as ticagrelor or prasugrel that does not depend on CYP2C19 for activation.
Option A is not evidence-based. Option C is dangerous; antiplatelet therapy is essential post-stent. Option D is
Page 2
, NSG 533: Advanced Pharmacology Exam 1 | Wilkes University 2026-2027 75 Questions
incorrect; omeprazole is a CYP2C19 inhibitor that would further reduce clopidogrel activation.
Q7: A prescriber is evaluating a new medication with a narrow therapeutic index. Which
characteristic best defines this type of drug?
A. The drug has a wide margin between the effective dose and the toxic dose
B. The difference between the minimum effective concentration and the minimum toxic
concentration is small, requiring careful monitoring [CORRECT]
C. The drug is effective at very low doses with minimal side effects at any dose
D. The drug has high bioavailability and consistent absorption across all patients
Correct Answer: B
Rationale: A narrow therapeutic index (TI) means the difference between the effective dose and the toxic dose is
small. Drugs with narrow TI (digoxin, lithium, warfarin, phenytoin, vancomycin, gentamicin) require
therapeutic drug monitoring to maintain serum levels within the therapeutic range and avoid toxicity. Small
changes in dose or pharmacokinetics (drug interactions, organ dysfunction) can push levels from therapeutic to
toxic. Option A describes a wide TI. Options C and D do not define therapeutic index.
Q8: A pregnant patient requires a new medication. The prescriber notes the drug is
Pregnancy Category X. Which action is most appropriate?
A. Administer the drug at a reduced dose to minimize fetal exposure
B. The drug is contraindicated in pregnancy because animal or human studies have
demonstrated fetal risk that clearly outweighs any potential benefit [CORRECT]
C. Administer the drug only during the first trimester when organogenesis is complete
D. The drug is safe in pregnancy because no animal studies have shown fetal harm
Correct Answer: B
Rationale: Pregnancy Category X drugs are contraindicated in pregnancy. Studies in animals or humans have
demonstrated positive evidence of fetal risk, and the risk clearly outweighs any potential benefit. Examples
include statins, isotretinoin, and warfarin. These drugs must not be used in pregnant women or women who
may become pregnant. Option A is incorrect; there is no safe dose. Option C is incorrect; the first trimester is
the most vulnerable period. Option D describes Category A, not Category X.
Q9: A drug demonstrates high potency but low efficacy compared to a reference drug in the
same class. Which statement best describes this drug's dose-response relationship?
A. The drug requires a higher dose to achieve the same effect as the reference drug and cannot
reach the same maximum effect
B. The drug produces its effect at a lower dose than the reference drug but cannot achieve
the same maximum response [CORRECT]
C. The drug requires a lower dose and achieves a greater maximum effect than the reference
drug
D. The drug has the same dose-response curve as the reference drug with identical clinical
outcomes
Correct Answer: B
Rationale: Potency refers to the dose required to produce a given effect (position on the dose-response curve),
while efficacy refers to the maximum effect achievable (ceiling of the curve). A drug with high potency but low
efficacy produces a response at lower doses than the reference drug but cannot achieve the same maximum
therapeutic effect regardless of dose. This is the pharmacodynamic profile of a partial agonist. Option A
describes low potency, low efficacy. Option C describes high potency, high efficacy (a full agonist more potent
than the reference). Option D is incorrect; the curves would differ.
Q10: A patient with a known HLA-B*5701 allele presents for treatment of HIV infection.
Which medication is contraindicated, and why?
Page 3
