lOMoARcPSD| 63525276
NR565 – Advanced Pharmacology
Midterm Exam Practice Questions
100 Application-Level Clinical Scenario Questions | Weeks 1–4 | With Full Answer Key & Rationales
Instructions: Select the single BEST answer for each question. Questions are written at the
application level to mirror the clinical scenario format of the actual exam. Review rationales in the
Answer Key after completing each section.
■ Week 1: Foundations (Q1–25)
■ Week 2: Cardiovascular (Q26–55)
■ Week 3: Pain (Q56–75)
■ Week 4: MSK/Rheumatology (Q76–100)
WEEK 1: Foundations in Pharmacology
Questions 1–25 | Chapters 1–10
1. A 72-year-old woman with newly diagnosed hypertension is prescribed hydrochlorothiazide. Her
daughter asks why the NP did not prescribe the same blood pressure medication her father
takes. Which response by the NP best demonstrates application of drug selection principles?
A. "Your mother's insurance formulary only covers this medication."
B. "Drug selection is individualized based on indication, comorbidities, safety profile, and patient
factors."
C. "This is the newest medication on the market and is the most effective."
D. "Your father's medication is a controlled substance not appropriate for your mother."
2. A prescriber writes for 'QD' on a prescription. The pharmacy calls to clarify because this
abbreviation is on the 'do not use' list. What should the prescription read instead?
A. "q1d"
B. "every day" or "daily"
C. "quaque die"
D. "QID"
3. A patient is prescribed a drug with high first-pass metabolism. Which route of administration
would best circumvent this effect and deliver the drug directly to systemic circulation?
A. Oral
B. Rectal
C. Sublingual
D. Enteral via NG tube
4. A patient with hypoalbuminemia is started on phenytoin, a highly protein-bound drug. Which
pharmacokinetic concern is MOST relevant?
, lOMoARcPSD| 63525276
A. Decreased volume of distribution
B. Increased free (active) drug fraction leading to potential toxicity
C. Faster renal excretion of the drug
D. Decreased drug absorption from the GI tract
5. A patient is started on rifampin for tuberculosis and also takes warfarin. Two weeks later, her
INR has dropped significantly. What is the most likely explanation?
A. Rifampin inhibits CYP2C9, decreasing warfarin metabolism
B. Rifampin induces CYP enzymes, increasing warfarin metabolism and decreasing its levels
C. Rifampin displaces warfarin from plasma proteins
D. Rifampin improves renal excretion of warfarin
6. A 28-year-old pregnant woman at 10 weeks gestation asks whether she can take ibuprofen for
back pain. What is the NP's BEST response?
A. "Ibuprofen is safe throughout pregnancy at low doses."
B. "Ibuprofen is Category C and can be used in the first trimester only."
C. "Ibuprofen should be avoided during pregnancy; acetaminophen is the preferred analgesic."D.
"Ibuprofen is only contraindicated in the second trimester."
7. A 68-year-old male patient is prescribed diazepam for anxiety by his previous provider.
According to the Beers Criteria, what is the PRIMARY concern with this medication in older
adults?
A. Diazepam has no efficacy in patients over 65
B. Benzodiazepines increase fall and fracture risk and cause cognitive impairment in older adults
C. Diazepam causes hyperkalemia in elderly patients
D. Benzodiazepines are not absorbed well in elderly patients
8. A drug has a half-life of 6 hours. Approximately how long will it take to reach steady-state
plasma concentration with regular dosing?
A. 6 hours
B. 12 hours
C. 24–30 hours
D. 48 hours
9. A patient with liver cirrhosis is prescribed prednisone. The NP is concerned about drug
metabolism. Which alternative glucocorticoid would be MOST appropriate for this patient?
A. Prednisone — no change needed
B. Prednisolone, because it does not require hepatic conversion
C. Dexamethasone, because it bypasses the liver entirely
D. Hydrocortisone, because it has no first-pass effect
10. A patient is an ultra-rapid CYP2D6 metabolizer and is prescribed codeine for post-operative
pain. What is the GREATEST safety concern?
A. Codeine will have no analgesic effect
B. The patient will develop opioid tolerance faster than normal
, lOMoARcPSD| 63525276
C. Rapid conversion of codeine to morphine may cause opioid toxicity or overdoseD. The patient will
experience prolonged sedation due to slow elimination
11. A nurse practitioner is educating a patient on a new prescription. Which teaching method best
ensures the patient understands the medication instructions?
A. Providing a printed medication information sheet
B. Using the teach-back method to ask the patient to explain the instructions in their own words
C. Asking the patient if they have any questions at the end of the visitD. Showing the patient a video
about the medication
12. A patient of Mediterranean ancestry presents for a new prescription. Which pharmacogenomic
consideration is MOST important before prescribing dapsone?
A. Test for CYP2D6 polymorphism
B. Screen for G6PD deficiency
C. Check HLA-B*5701 status
D. Test for TPMT variants
13. A 3-week-old neonate develops gray skin discoloration, abdominal distension, and
cardiovascular collapse after receiving chloramphenicol. What is the underlying mechanism?
A. Immature renal tubular secretion leads to drug accumulation
B. Immature glucuronidation (Phase II metabolism) results in toxic drug accumulation
C. Neonatal CYP3A4 deficiency prevents drug oxidation
D. Increased GI absorption in neonates leads to toxicity
14. A patient asks why their antibiotic dose must be reduced since their kidney function has
declined. What is the BEST explanation?
A. Renally-cleared drugs accumulate in renal impairment, increasing toxicity risk
B. The kidneys produce enzymes that activate the antibiotic
C. Poor kidney function causes faster drug metabolism in the liver
D. Reduced kidney function decreases drug absorption from the GI tract
15. A patient taking warfarin begins drinking large amounts of grapefruit juice daily. What is the
expected effect on warfarin levels?
A. Decreased warfarin levels due to increased metabolism
B. Increased warfarin levels due to CYP3A4 inhibition by grapefruit juice
C. No change; warfarin is not metabolized by CYP3A4
D. Decreased warfarin levels due to reduced absorption
16. An NP prescribes isotretinoin for a 19-year-old woman with severe acne. What is the MOST
critical prescribing safety measure?
A. Monitor LFTs monthly
B. Enroll in iPLEDGE program, confirm two forms of contraception, and monthly negative pregnancy
test
C. Prescribe the lowest effective dose with weekly follow-up
D. Avoid prescribing with tetracyclines due to drug interaction
NR565 – Advanced Pharmacology
Midterm Exam Practice Questions
100 Application-Level Clinical Scenario Questions | Weeks 1–4 | With Full Answer Key & Rationales
Instructions: Select the single BEST answer for each question. Questions are written at the
application level to mirror the clinical scenario format of the actual exam. Review rationales in the
Answer Key after completing each section.
■ Week 1: Foundations (Q1–25)
■ Week 2: Cardiovascular (Q26–55)
■ Week 3: Pain (Q56–75)
■ Week 4: MSK/Rheumatology (Q76–100)
WEEK 1: Foundations in Pharmacology
Questions 1–25 | Chapters 1–10
1. A 72-year-old woman with newly diagnosed hypertension is prescribed hydrochlorothiazide. Her
daughter asks why the NP did not prescribe the same blood pressure medication her father
takes. Which response by the NP best demonstrates application of drug selection principles?
A. "Your mother's insurance formulary only covers this medication."
B. "Drug selection is individualized based on indication, comorbidities, safety profile, and patient
factors."
C. "This is the newest medication on the market and is the most effective."
D. "Your father's medication is a controlled substance not appropriate for your mother."
2. A prescriber writes for 'QD' on a prescription. The pharmacy calls to clarify because this
abbreviation is on the 'do not use' list. What should the prescription read instead?
A. "q1d"
B. "every day" or "daily"
C. "quaque die"
D. "QID"
3. A patient is prescribed a drug with high first-pass metabolism. Which route of administration
would best circumvent this effect and deliver the drug directly to systemic circulation?
A. Oral
B. Rectal
C. Sublingual
D. Enteral via NG tube
4. A patient with hypoalbuminemia is started on phenytoin, a highly protein-bound drug. Which
pharmacokinetic concern is MOST relevant?
, lOMoARcPSD| 63525276
A. Decreased volume of distribution
B. Increased free (active) drug fraction leading to potential toxicity
C. Faster renal excretion of the drug
D. Decreased drug absorption from the GI tract
5. A patient is started on rifampin for tuberculosis and also takes warfarin. Two weeks later, her
INR has dropped significantly. What is the most likely explanation?
A. Rifampin inhibits CYP2C9, decreasing warfarin metabolism
B. Rifampin induces CYP enzymes, increasing warfarin metabolism and decreasing its levels
C. Rifampin displaces warfarin from plasma proteins
D. Rifampin improves renal excretion of warfarin
6. A 28-year-old pregnant woman at 10 weeks gestation asks whether she can take ibuprofen for
back pain. What is the NP's BEST response?
A. "Ibuprofen is safe throughout pregnancy at low doses."
B. "Ibuprofen is Category C and can be used in the first trimester only."
C. "Ibuprofen should be avoided during pregnancy; acetaminophen is the preferred analgesic."D.
"Ibuprofen is only contraindicated in the second trimester."
7. A 68-year-old male patient is prescribed diazepam for anxiety by his previous provider.
According to the Beers Criteria, what is the PRIMARY concern with this medication in older
adults?
A. Diazepam has no efficacy in patients over 65
B. Benzodiazepines increase fall and fracture risk and cause cognitive impairment in older adults
C. Diazepam causes hyperkalemia in elderly patients
D. Benzodiazepines are not absorbed well in elderly patients
8. A drug has a half-life of 6 hours. Approximately how long will it take to reach steady-state
plasma concentration with regular dosing?
A. 6 hours
B. 12 hours
C. 24–30 hours
D. 48 hours
9. A patient with liver cirrhosis is prescribed prednisone. The NP is concerned about drug
metabolism. Which alternative glucocorticoid would be MOST appropriate for this patient?
A. Prednisone — no change needed
B. Prednisolone, because it does not require hepatic conversion
C. Dexamethasone, because it bypasses the liver entirely
D. Hydrocortisone, because it has no first-pass effect
10. A patient is an ultra-rapid CYP2D6 metabolizer and is prescribed codeine for post-operative
pain. What is the GREATEST safety concern?
A. Codeine will have no analgesic effect
B. The patient will develop opioid tolerance faster than normal
, lOMoARcPSD| 63525276
C. Rapid conversion of codeine to morphine may cause opioid toxicity or overdoseD. The patient will
experience prolonged sedation due to slow elimination
11. A nurse practitioner is educating a patient on a new prescription. Which teaching method best
ensures the patient understands the medication instructions?
A. Providing a printed medication information sheet
B. Using the teach-back method to ask the patient to explain the instructions in their own words
C. Asking the patient if they have any questions at the end of the visitD. Showing the patient a video
about the medication
12. A patient of Mediterranean ancestry presents for a new prescription. Which pharmacogenomic
consideration is MOST important before prescribing dapsone?
A. Test for CYP2D6 polymorphism
B. Screen for G6PD deficiency
C. Check HLA-B*5701 status
D. Test for TPMT variants
13. A 3-week-old neonate develops gray skin discoloration, abdominal distension, and
cardiovascular collapse after receiving chloramphenicol. What is the underlying mechanism?
A. Immature renal tubular secretion leads to drug accumulation
B. Immature glucuronidation (Phase II metabolism) results in toxic drug accumulation
C. Neonatal CYP3A4 deficiency prevents drug oxidation
D. Increased GI absorption in neonates leads to toxicity
14. A patient asks why their antibiotic dose must be reduced since their kidney function has
declined. What is the BEST explanation?
A. Renally-cleared drugs accumulate in renal impairment, increasing toxicity risk
B. The kidneys produce enzymes that activate the antibiotic
C. Poor kidney function causes faster drug metabolism in the liver
D. Reduced kidney function decreases drug absorption from the GI tract
15. A patient taking warfarin begins drinking large amounts of grapefruit juice daily. What is the
expected effect on warfarin levels?
A. Decreased warfarin levels due to increased metabolism
B. Increased warfarin levels due to CYP3A4 inhibition by grapefruit juice
C. No change; warfarin is not metabolized by CYP3A4
D. Decreased warfarin levels due to reduced absorption
16. An NP prescribes isotretinoin for a 19-year-old woman with severe acne. What is the MOST
critical prescribing safety measure?
A. Monitor LFTs monthly
B. Enroll in iPLEDGE program, confirm two forms of contraception, and monthly negative pregnancy
test
C. Prescribe the lowest effective dose with weekly follow-up
D. Avoid prescribing with tetracyclines due to drug interaction
