BCACP Certification Exam Prep 2026 Updated
Practice Questions Comprehensive Ambulatory Care
Pharmacy Review Detailed Explanations, Verified
Answers, Success Workbook
Key Clinical Topics
• Diabetes mellitus (Type 1 and 2)
• Hypertension
• Dyslipidemia
• Heart Failure
• Anticoagulation Management
• COPD/Asthma
• Chronic Kidney Disease (CKD)
• Mental Health Conditions
• Pain Management
• Immunizations
• Medication Therapy Management (MTM)
• Transitions of Care
• Health Literacy and Cultural Competence
Question 1
A 58-year-old patient with type 2 diabetes (HbA1c 8.2%, eGFR 45 mL/min/1.73
m²) is currently on metformin 1000 mg twice daily. According to the 2025 ADA
Standards of Care, which is the most appropriate next step?
A) Add glipizide 5 mg daily
B) Add empagliflozin 10 mg daily
,C) Increase metformin to 2000 mg twice daily
D) Add sitagliptin 100 mg daily
Answer: B) Add empagliflozin 10 mg daily
Rationale: Per ADA guidelines, for patients with type 2 diabetes and CKD (eGFR
≥20 mL/min/1.73 m²), an SGLT2 inhibitor with proven cardiovascular or kidney
benefits (empagliflozin, dapagliflozin, or canagliflozin) is recommended to reduce
progression of CKD and cardiovascular events. Glipizide (A) is not preferred due
to hypoglycemia risk. Metformin should be reduced (not increased, C) when eGFR
<45 mL/min/1.73 m². Sitagliptin (D) does not offer the same renal and
cardiovascular benefits.
Question 2
Which of the following is the preferred first-line agent for hypertension in a patient
with diabetes and albuminuria (UACR 350 mg/g)?
A) Amlodipine 5 mg daily
B) Lisinopril 10 mg daily
C) Hydrochlorothiazide 25 mg daily
D) Metoprolol succinate 50 mg daily
Answer: B) Lisinopril 10 mg daily
Rationale: Per ADA and KDIGO guidelines, ACE inhibitors (like lisinopril) or
ARBs are first-line for hypertension in patients with diabetes and albuminuria
(UACR ≥300 mg/g) due to proven renal protection benefits. They reduce
progression of diabetic kidney disease and cardiovascular events. Amlodipine (A),
HCTZ (C), and metoprolol (D) do not provide the same renal protective effects.
Question 3
A 55-year-old patient with type 2 diabetes and hypertension is on metformin and
lisinopril. A1C is 8.5% and BP is 140/88 mmHg. Which intervention is most
appropriate?
A) Increase metformin dose
B) Add a sulfonylurea
,C) Add an ACE inhibitor
D) Add a GLP-1 receptor agonist
Answer: D) Add a GLP-1 receptor agonist
Rationale: GLP-1 receptor agonists improve glycemic control and promote weight
loss, with cardiovascular benefit, especially in patients with hypertension and
elevated A1C. Sulfonylureas (B) carry hypoglycemia risk and weight gain. The
patient is already on an ACE inhibitor (lisinopril) (C). Metformin dose should be
optimized before adding agents, but adding a GLP-1 RA is preferred given the
cardiovascular benefits.
Question 4
Which of the following is a contraindication to metformin use?
A) eGFR 50 mL/min/1.73 m²
B) eGFR 20 mL/min/1.73 m²
C) HbA1c 7.5%
D) Body mass index 32 kg/m²
Answer: B) eGFR 20 mL/min/1.73 m²
Rationale: Metformin is contraindicated in patients with eGFR <30 mL/min/1.73
m² due to the risk of lactic acidosis. At eGFR 30-45, dose reduction is
recommended. eGFR 50 (A) is acceptable with dose adjustment consideration.
HbA1c 7.5% (C) and BMI 32 (D) are not contraindications to metformin.
Question 5
A patient with type 2 diabetes is prescribed insulin glargine. The nurse practitioner
asks the pharmacist to recommend a starting dose. What is the recommended
starting dose of basal insulin in a patient with an A1C >8%?
A) 5 units daily
B) 10 units daily (or 0.1-0.2 units/kg)
C) 20 units daily
D) 0.5 units/kg daily
Answer: B) 10 units daily (or 0.1-0.2 units/kg)
, Rationale: The recommended starting dose of basal insulin in insulin-naïve
patients with type 2 diabetes is 10 units daily or 0.1-0.2 units/kg daily. Lower
doses (5 units, A) may be insufficient for patients with A1C >8%. Higher doses (C,
D) increase the risk of hypoglycemia.
Question 6
A 62-year-old patient with type 2 diabetes is on metformin and glipizide and has
an A1C of 9.0%. Which of the following is the most appropriate next step?
A) Add a DPP-4 inhibitor
B) Add a TZD
C) Add a GLP-1 receptor agonist
D) Add insulin
Answer: C) Add a GLP-1 receptor agonist
Rationale: GLP-1 receptor agonists are preferred as add-on therapy to metformin
when A1C is above target, particularly in patients with cardiovascular risk factors.
They provide glycemic control, weight loss, and cardiovascular benefit. DPP-4
inhibitors (A) are less potent. TZDs (B) have fluid retention risks. Insulin (D) may
be considered but is not first-line add-on.
Question 7
A patient with type 2 diabetes and CKD (eGFR 35 mL/min/1.73 m²) is on
metformin 1000 mg twice daily. What dose adjustment is required for metformin?
A) No adjustment needed
B) Reduce metformin to 1000 mg daily (50% reduction)
C) Discontinue metformin
D) Increase metformin to 2000 mg daily
Answer: B) Reduce metformin to 1000 mg daily (50% reduction)
Rationale: At eGFR 30-45 mL/min/1.73 m², metformin dose should be reduced by
50%. At eGFR <30, metformin is contraindicated. No adjustment (A) at eGFR 35
is inappropriate. Discontinuation (C) is only required at eGFR <30.
Practice Questions Comprehensive Ambulatory Care
Pharmacy Review Detailed Explanations, Verified
Answers, Success Workbook
Key Clinical Topics
• Diabetes mellitus (Type 1 and 2)
• Hypertension
• Dyslipidemia
• Heart Failure
• Anticoagulation Management
• COPD/Asthma
• Chronic Kidney Disease (CKD)
• Mental Health Conditions
• Pain Management
• Immunizations
• Medication Therapy Management (MTM)
• Transitions of Care
• Health Literacy and Cultural Competence
Question 1
A 58-year-old patient with type 2 diabetes (HbA1c 8.2%, eGFR 45 mL/min/1.73
m²) is currently on metformin 1000 mg twice daily. According to the 2025 ADA
Standards of Care, which is the most appropriate next step?
A) Add glipizide 5 mg daily
B) Add empagliflozin 10 mg daily
,C) Increase metformin to 2000 mg twice daily
D) Add sitagliptin 100 mg daily
Answer: B) Add empagliflozin 10 mg daily
Rationale: Per ADA guidelines, for patients with type 2 diabetes and CKD (eGFR
≥20 mL/min/1.73 m²), an SGLT2 inhibitor with proven cardiovascular or kidney
benefits (empagliflozin, dapagliflozin, or canagliflozin) is recommended to reduce
progression of CKD and cardiovascular events. Glipizide (A) is not preferred due
to hypoglycemia risk. Metformin should be reduced (not increased, C) when eGFR
<45 mL/min/1.73 m². Sitagliptin (D) does not offer the same renal and
cardiovascular benefits.
Question 2
Which of the following is the preferred first-line agent for hypertension in a patient
with diabetes and albuminuria (UACR 350 mg/g)?
A) Amlodipine 5 mg daily
B) Lisinopril 10 mg daily
C) Hydrochlorothiazide 25 mg daily
D) Metoprolol succinate 50 mg daily
Answer: B) Lisinopril 10 mg daily
Rationale: Per ADA and KDIGO guidelines, ACE inhibitors (like lisinopril) or
ARBs are first-line for hypertension in patients with diabetes and albuminuria
(UACR ≥300 mg/g) due to proven renal protection benefits. They reduce
progression of diabetic kidney disease and cardiovascular events. Amlodipine (A),
HCTZ (C), and metoprolol (D) do not provide the same renal protective effects.
Question 3
A 55-year-old patient with type 2 diabetes and hypertension is on metformin and
lisinopril. A1C is 8.5% and BP is 140/88 mmHg. Which intervention is most
appropriate?
A) Increase metformin dose
B) Add a sulfonylurea
,C) Add an ACE inhibitor
D) Add a GLP-1 receptor agonist
Answer: D) Add a GLP-1 receptor agonist
Rationale: GLP-1 receptor agonists improve glycemic control and promote weight
loss, with cardiovascular benefit, especially in patients with hypertension and
elevated A1C. Sulfonylureas (B) carry hypoglycemia risk and weight gain. The
patient is already on an ACE inhibitor (lisinopril) (C). Metformin dose should be
optimized before adding agents, but adding a GLP-1 RA is preferred given the
cardiovascular benefits.
Question 4
Which of the following is a contraindication to metformin use?
A) eGFR 50 mL/min/1.73 m²
B) eGFR 20 mL/min/1.73 m²
C) HbA1c 7.5%
D) Body mass index 32 kg/m²
Answer: B) eGFR 20 mL/min/1.73 m²
Rationale: Metformin is contraindicated in patients with eGFR <30 mL/min/1.73
m² due to the risk of lactic acidosis. At eGFR 30-45, dose reduction is
recommended. eGFR 50 (A) is acceptable with dose adjustment consideration.
HbA1c 7.5% (C) and BMI 32 (D) are not contraindications to metformin.
Question 5
A patient with type 2 diabetes is prescribed insulin glargine. The nurse practitioner
asks the pharmacist to recommend a starting dose. What is the recommended
starting dose of basal insulin in a patient with an A1C >8%?
A) 5 units daily
B) 10 units daily (or 0.1-0.2 units/kg)
C) 20 units daily
D) 0.5 units/kg daily
Answer: B) 10 units daily (or 0.1-0.2 units/kg)
, Rationale: The recommended starting dose of basal insulin in insulin-naïve
patients with type 2 diabetes is 10 units daily or 0.1-0.2 units/kg daily. Lower
doses (5 units, A) may be insufficient for patients with A1C >8%. Higher doses (C,
D) increase the risk of hypoglycemia.
Question 6
A 62-year-old patient with type 2 diabetes is on metformin and glipizide and has
an A1C of 9.0%. Which of the following is the most appropriate next step?
A) Add a DPP-4 inhibitor
B) Add a TZD
C) Add a GLP-1 receptor agonist
D) Add insulin
Answer: C) Add a GLP-1 receptor agonist
Rationale: GLP-1 receptor agonists are preferred as add-on therapy to metformin
when A1C is above target, particularly in patients with cardiovascular risk factors.
They provide glycemic control, weight loss, and cardiovascular benefit. DPP-4
inhibitors (A) are less potent. TZDs (B) have fluid retention risks. Insulin (D) may
be considered but is not first-line add-on.
Question 7
A patient with type 2 diabetes and CKD (eGFR 35 mL/min/1.73 m²) is on
metformin 1000 mg twice daily. What dose adjustment is required for metformin?
A) No adjustment needed
B) Reduce metformin to 1000 mg daily (50% reduction)
C) Discontinue metformin
D) Increase metformin to 2000 mg daily
Answer: B) Reduce metformin to 1000 mg daily (50% reduction)
Rationale: At eGFR 30-45 mL/min/1.73 m², metformin dose should be reduced by
50%. At eGFR <30, metformin is contraindicated. No adjustment (A) at eGFR 35
is inappropriate. Discontinuation (C) is only required at eGFR <30.
