Wilkes University NSG 533 Final Exam (pdf) | 2026/2027 | Advanced
Pharmacology Q&A | Pharmacology
1. A patient with advanced heart failure has significant peripheral edema and
reduced cardiac output. Which pharmacokinetic process is most likely to be
impaired?
A) Absorption
B) Distribution
C) Metabolism
D) Excretion
Correct Answer: Distribution
Rationale: Reduced cardiac output and peripheral edema decrease blood
flow to the gastrointestinal tract and peripheral tissues, altering the
distribution of drugs (particularly those that are tissue-bound or highly
lipophilic). Absorption may also be impaired, but distribution is most directly
affected by decreased perfusion of drug target sites. Metabolism and
excretion may be affected indirectly through reduced hepatic and renal blood
flow.
2. An 85-year-old patient with chronic kidney disease (CKD) stage 4 has been
prescribed digoxin. The prescriber orders a reduced dose. This adjustment
primarily accounts for which pharmacokinetic change in this patient?
A) Decreased absorption
B) Increased volume of distribution
C) Decreased renal excretion
D) Increased protein binding
Correct Answer: Decreased renal excretion
,Rationale: Digoxin is primarily eliminated by the kidneys via glomerular
filtration. In CKD stage 4 (eGFR 15-29 mL/min), renal excretion is severely
impaired, leading to drug accumulation and toxicity. Dose reduction is
required to prevent toxicity. Protein binding (digoxin is ~25% protein bound)
is minimally affected by CKD.
3. Which CYP450 enzyme is responsible for metabolizing approximately 50%
of all marketed drugs?
A) CYP2D6
B) CYP2C9
C) CYP3A4
D) CYP1A2
Correct Answer: CYP3A4
Rationale: CYP3A4 metabolizes approximately 50% of all marketed drugs,
including statins (simvastatin, atorvastatin), calcium channel blockers,
benzodiazepines, and many others. CYP2D6 metabolizes about 25% of drugs
(including many antidepressants and antipsychotics). CYP2C9 metabolizes
warfarin and some NSAIDs, while CYP1A2 metabolizes caffeine and
theophylline.
4. A patient taking warfarin starts taking amiodarone for atrial fibrillation.
The international normalized ratio (INR) increases from 2.5 to 5.5. This
interaction is most likely due to:
A) Additive anticoagulant effects
B) Inhibition of warfarin metabolism by amiodarone
C) Displacement of warfarin from protein binding sites
D) Increased warfarin absorption
Correct Answer: Inhibition of warfarin metabolism by amiodarone
,Rationale: Amiodarone inhibits CYP2C9 and CYP1A2, which are responsible
for metabolizing warfarin. This leads to increased warfarin levels and
elevated INR. The INR should be monitored closely when amiodarone is
added to warfarin therapy, and the warfarin dose should be adjusted
accordingly.
5. A patient is prescribed codeine for pain after surgery. The patient reports
no pain relief. Genetic testing reveals the patient is a poor metabolizer of
which enzyme?
A) CYP3A4
B) CYP2D6
C) CYP2C9
D) CYP1A2
Correct Answer: CYP2D6
Rationale: Codeine is a prodrug that requires conversion to morphine by
CYP2D6. Poor metabolizers of CYP2D6 do not convert codeine effectively,
resulting in inadequate pain relief. This is a classic example of
pharmacogenomics in clinical practice. CYP2D6 also metabolizes many
antidepressants, antipsychotics, and other opioids.
6. A patient prescribed simvastatin is also taking amlodipine. Which drug
interaction is most concerning?
A) Increased risk of bleeding
B) Increased risk of myopathy due to CYP3A4 inhibition
C) Increased risk of hyperkalemia
D) Decreased effectiveness of simvastatin
, Correct Answer: Increased risk of myopathy due to CYP3A4 inhibition
Rationale: Amlodipine is a calcium channel blocker that inhibits CYP3A4, the
enzyme responsible for metabolizing simvastatin. This can increase
simvastatin levels and the risk of myopathy and rhabdomyolysis. Patients
should be monitored for muscle pain and weakness, and the simvastatin
dose may need to be reduced.
7. A patient with hepatic impairment is prescribed a medication with high
first-pass metabolism. What is the most likely consequence?
A) Decreased bioavailability requiring higher doses
B) Increased bioavailability requiring lower doses
C) No change in drug effect
D) Increased drug excretion
Correct Answer: Increased bioavailability requiring lower doses
Rationale: Drugs with high first-pass metabolism are extensively metabolized
in the liver before reaching systemic circulation. In hepatic impairment, first-
pass metabolism is reduced, leading to increased bioavailability and higher
drug levels. Lower doses may be required to prevent toxicity.
8. Which of the following best describes the therapeutic index of a drug?
A) The ratio of the toxic dose to the therapeutic dose
B) The time required for the drug to reach steady state
C) The percentage of the drug that reaches systemic circulation
D) The volume of fluid required to clear the drug from the body
Correct Answer: The ratio of the toxic dose to the therapeutic dose
Pharmacology Q&A | Pharmacology
1. A patient with advanced heart failure has significant peripheral edema and
reduced cardiac output. Which pharmacokinetic process is most likely to be
impaired?
A) Absorption
B) Distribution
C) Metabolism
D) Excretion
Correct Answer: Distribution
Rationale: Reduced cardiac output and peripheral edema decrease blood
flow to the gastrointestinal tract and peripheral tissues, altering the
distribution of drugs (particularly those that are tissue-bound or highly
lipophilic). Absorption may also be impaired, but distribution is most directly
affected by decreased perfusion of drug target sites. Metabolism and
excretion may be affected indirectly through reduced hepatic and renal blood
flow.
2. An 85-year-old patient with chronic kidney disease (CKD) stage 4 has been
prescribed digoxin. The prescriber orders a reduced dose. This adjustment
primarily accounts for which pharmacokinetic change in this patient?
A) Decreased absorption
B) Increased volume of distribution
C) Decreased renal excretion
D) Increased protein binding
Correct Answer: Decreased renal excretion
,Rationale: Digoxin is primarily eliminated by the kidneys via glomerular
filtration. In CKD stage 4 (eGFR 15-29 mL/min), renal excretion is severely
impaired, leading to drug accumulation and toxicity. Dose reduction is
required to prevent toxicity. Protein binding (digoxin is ~25% protein bound)
is minimally affected by CKD.
3. Which CYP450 enzyme is responsible for metabolizing approximately 50%
of all marketed drugs?
A) CYP2D6
B) CYP2C9
C) CYP3A4
D) CYP1A2
Correct Answer: CYP3A4
Rationale: CYP3A4 metabolizes approximately 50% of all marketed drugs,
including statins (simvastatin, atorvastatin), calcium channel blockers,
benzodiazepines, and many others. CYP2D6 metabolizes about 25% of drugs
(including many antidepressants and antipsychotics). CYP2C9 metabolizes
warfarin and some NSAIDs, while CYP1A2 metabolizes caffeine and
theophylline.
4. A patient taking warfarin starts taking amiodarone for atrial fibrillation.
The international normalized ratio (INR) increases from 2.5 to 5.5. This
interaction is most likely due to:
A) Additive anticoagulant effects
B) Inhibition of warfarin metabolism by amiodarone
C) Displacement of warfarin from protein binding sites
D) Increased warfarin absorption
Correct Answer: Inhibition of warfarin metabolism by amiodarone
,Rationale: Amiodarone inhibits CYP2C9 and CYP1A2, which are responsible
for metabolizing warfarin. This leads to increased warfarin levels and
elevated INR. The INR should be monitored closely when amiodarone is
added to warfarin therapy, and the warfarin dose should be adjusted
accordingly.
5. A patient is prescribed codeine for pain after surgery. The patient reports
no pain relief. Genetic testing reveals the patient is a poor metabolizer of
which enzyme?
A) CYP3A4
B) CYP2D6
C) CYP2C9
D) CYP1A2
Correct Answer: CYP2D6
Rationale: Codeine is a prodrug that requires conversion to morphine by
CYP2D6. Poor metabolizers of CYP2D6 do not convert codeine effectively,
resulting in inadequate pain relief. This is a classic example of
pharmacogenomics in clinical practice. CYP2D6 also metabolizes many
antidepressants, antipsychotics, and other opioids.
6. A patient prescribed simvastatin is also taking amlodipine. Which drug
interaction is most concerning?
A) Increased risk of bleeding
B) Increased risk of myopathy due to CYP3A4 inhibition
C) Increased risk of hyperkalemia
D) Decreased effectiveness of simvastatin
, Correct Answer: Increased risk of myopathy due to CYP3A4 inhibition
Rationale: Amlodipine is a calcium channel blocker that inhibits CYP3A4, the
enzyme responsible for metabolizing simvastatin. This can increase
simvastatin levels and the risk of myopathy and rhabdomyolysis. Patients
should be monitored for muscle pain and weakness, and the simvastatin
dose may need to be reduced.
7. A patient with hepatic impairment is prescribed a medication with high
first-pass metabolism. What is the most likely consequence?
A) Decreased bioavailability requiring higher doses
B) Increased bioavailability requiring lower doses
C) No change in drug effect
D) Increased drug excretion
Correct Answer: Increased bioavailability requiring lower doses
Rationale: Drugs with high first-pass metabolism are extensively metabolized
in the liver before reaching systemic circulation. In hepatic impairment, first-
pass metabolism is reduced, leading to increased bioavailability and higher
drug levels. Lower doses may be required to prevent toxicity.
8. Which of the following best describes the therapeutic index of a drug?
A) The ratio of the toxic dose to the therapeutic dose
B) The time required for the drug to reach steady state
C) The percentage of the drug that reaches systemic circulation
D) The volume of fluid required to clear the drug from the body
Correct Answer: The ratio of the toxic dose to the therapeutic dose
