WILKES UNIVERSITY |
NSG 533 Advanced Pharmacology
Exam 2 - Pain Management and Analgesic
Pharmacotherapy
2026 Edition | 100 Questions | Correct Answers
and Detailed Rationales Included
Student Name:
Date:
Section / Cohort: Score ____________ / 100
Instructions
This practice examination contains 100 multiple-choice questions covering the pharmacologic management of
pain, including opioid analgesics and antagonists, nonsteroidal anti-inflammatory drugs and acetaminophen,
agents for neuropathic pain, local and general anesthetics, and drug therapy for gout, migraine, and muscle
spasm. Select the single best answer for each item. The correct answer and a detailed rationale are presented
immediately below each question so the examination may be used for self-paced study and review. Content
reflects core advanced pharmacology principles and current prescribing-safety considerations.
1. A nurse is preparing to administer morphine sulfate to a postoperative patient and is reviewing
how the drug produces analgesia. Morphine relieves pain primarily through which mechanism
of action?
A. Blocking sodium channels in peripheral pain fibers
B. Stimulating mu-opioid receptors in the central nervous system
C. Inhibiting cyclooxygenase enzymes at sites of tissue injury
D. Antagonizing NMDA receptors in the spinal cord
Correct Answer: B
Rationale: Morphine is a full agonist at mu-opioid receptors in the brain and spinal cord, which inhibits the
release of neurotransmitters and blunts the ascending transmission of pain signals, producing analgesia,
euphoria, and sedation. Option A describes local anesthetics such as lidocaine. Option C describes NSAIDs
1
such as ibuprofen. Option D describes drugs such as ketamine; methadone has only minor NMDA activity
and it is not the primary analgesic mechanism.
,NSG 533 Advanced Pharmacology | Exam 2 Practice Examination (2026) Wilkes University - Passan School of Nursing
2. Thirty minutes after receiving intravenous morphine, a postoperative patient is difficult to
arouse and has a respiratory rate of 10 breaths per minute with shallow respirations. Which
action should the nurse take first?
A. Stimulate the patient, apply oxygen, and withhold further opioid dosing
B. Administer a bolus dose of naloxone 2 mg intravenously
C. Increase the intravenous fluid rate and reposition the patient
D. Document the findings and reassess in 30 minutes
Correct Answer: A
Rationale: Sedation precedes respiratory depression, so a sedated patient with a respiratory rate of 10 should
first be aroused and stimulated while oxygen is applied and further opioid doses are withheld. High-dose
naloxone given as an undiluted bolus (Option B) can precipitate severe withdrawal, vomiting, and acute pain
crisis; naloxone is diluted and titrated to adequate respirations when stimulation fails. Options C and D fail to
address the cause and could allow deterioration. The nurse should also notify the provider and prepare naloxone
if stimulation does not improve ventilation.
3. A patient who received naloxone for opioid-induced respiratory depression becomes drowsy
again with a respiratory rate of 8 breaths per minute 45 minutes later. Which property of
naloxone best explains this recurrence?
A. Naloxone undergoes rapid hepatic metabolism to inactive metabolites
B. Naloxone has a delayed onset that limits its clinical effectiveness
C. Naloxone produces cumulative central nervous system depression
D. Naloxone has a shorter duration of action than most opioid agonists
Correct Answer: D
Rationale: Naloxone has a half-life of roughly 30 to 90 minutes, which is shorter than the duration of
morphine, fentanyl, and especially methadone, so recurrent respiratory depression (renarcotization) is expected
as the antagonist wears off. The patient requires repeat naloxone doses or a continuous infusion and prolonged
observation. Option A describes metabolism but is not the clinically relevant point about duration mismatch.
Naloxone acts within 1 to 2 minutes of intravenous administration, making Option B incorrect. Naloxone
reverses central nervous system depression rather than causing it, so Option C is wrong.
4. A patient has been using a transdermal fentanyl patch for cancer pain. Which statement by the
patient requires immediate follow-up by the nurse?
A. I apply the patch to a non-irritated area of my upper back and rotate sites
B. I keep the old patches folded and dispose of them away from children
C. I can use a heating pad over the patch when my back muscles ache
D. I was taking around-the-clock oral morphine before starting this patch
Correct Answer: C
2
,NSG 533 Advanced Pharmacology | Exam 2 Practice Examination (2026) Wilkes University - Passan School of Nursing
Rationale: External heat sources such as heating pads, hot tubs, saunas, or fever increase fentanyl absorption
from the patch and can cause fatal respiratory depression, so this statement requires immediate correction.
Option A reflects correct practice: application to intact, non-irritated skin with site rotation. Option B reflects
safe disposal because residual fentanyl in used patches has caused pediatric deaths. Option D is appropriate
because transdermal fentanyl is indicated only for patients who are already opioid tolerant, typically requiring at
least 60 mg of oral morphine per day for a week or longer.
5. A nurse is teaching a pharmacology review group about codeine. Which statement accurately
describes an important pharmacogenetic consideration for codeine therapy?
A. Codeine is a prodrug converted to morphine by CYP2D6, and ultra-rapid metabolizers are
at risk of toxicity
B. Codeine is inactivated by CYP3A4, and poor metabolizers experience exaggerated
analgesia
C. Codeine binds irreversibly to opioid receptors, making dose titration unnecessary
D. Codeine is unaffected by genetics because it is excreted unchanged by the kidneys
Correct Answer: A
Rationale: Codeine itself has minimal analgesic activity and must be converted by CYP2D6 to morphine.
Ultra-rapid metabolizers generate supratherapeutic morphine levels and can develop respiratory depression
even at standard doses. Poor metabolizers receive little analgesic benefit rather than toxicity, making Option B
incorrect. Codeine binds reversibly to mu receptors like other opioids, so Option C is false. Codeine requires
metabolism and does not rely solely on renal excretion, so Option D is wrong.
6. A patient taking tramadol for chronic low back pain is newly prescribed sertraline for
depression. The nurse should prioritize teaching about which potential adverse effect of this
combination?
A. Severe hypotension requiring dose reduction of tramadol
B. Serotonin syndrome with agitation, hyperreflexia, and clonus
C. Hepatotoxicity with jaundice and dark urine
D. Immediate physical dependence on both medications
Correct Answer: B
Rationale: Tramadol has weak mu-agonist activity but also inhibits reuptake of serotonin and norepinephrine.
Combined with an SSRI such as sertraline, serotonergic tone can rise excessively and produce serotonin
syndrome, manifested by agitation, diaphoresis, tremor, hyperreflexia, clonus, hyperthermia, and diarrhea.
Tramadol also lowers the seizure threshold, which is a separate risk of the drug itself. Hypotension (Option A)
and hepatotoxicity (Option C) are not hallmark effects of this interaction. Physical dependence develops with
prolonged opioid exposure but is not an immediate consequence of adding sertraline, making Option D
incorrect.
3
, NSG 533 Advanced Pharmacology | Exam 2 Practice Examination (2026) Wilkes University - Passan School of Nursing
7. A patient stabilized on methadone for cancer-related pain is scheduled for an electrocardiogram.
The nurse recognizes that this test is ordered because methadone is associated with which
cardiac adverse effect?
A. Sinus bradycardia progressing to heart block
B. ST-segment elevation mimicking myocardial infarction
C. Widened QRS complex from sodium channel blockade
D. QT prolongation with risk of torsades de pointes
Correct Answer: D
Rationale: Methadone prolongs the QT interval in a dose-dependent manner and can precipitate torsades de
pointes, a polymorphic ventricular tachycardia that may degenerate into ventricular fibrillation. Risk is
increased with high doses, electrolyte disturbances such as hypokalemia and hypomagnesemia, and concurrent
QT-prolonging drugs, so baseline and follow-up ECGs are recommended. Bradycardia and heart block (Option
are not characteristic methadone effects. Methadone does not mimic myocardial infarction patterns (Option
or produce sodium-channel-mediated QRS widening like tricyclic antidepressants (Option C).
8. A patient is being converted from oral morphine to oral hydromorphone for better pain control.
When performing this equianalgesic calculation, the nurse recalls that hydromorphone is
approximately how much more potent than morphine?
A. About 5 times more potent
B. Approximately equal in potency
C. About 2 times more potent
D. About 50 times more potent
Correct Answer: A
Rationale: Standard equianalgesic tables list 7.5 mg of oral hydromorphone as approximately equivalent to 30
mg of oral morphine, making hydromorphone roughly 5 times more potent on a milligram basis. Intravenous
comparisons follow a similar ratio, with 1.5 mg of intravenous hydromorphone approximating 10 mg of
intravenous morphine. Assuming equal potency (Option B) or a 2-fold difference (Option C) would cause
underdosing, while a 50-fold estimate (Option D) resembles the potency comparison between fentanyl and
morphine and would cause a dangerous overdose if used for hydromorphone. After any rotation, the calculated
dose is reduced by 25 to 50 percent for incomplete cross-tolerance.
9. A nurse is discharging a patient with a new prescription for extended-release oxycodone
(OxyContin) for severe chronic pain. Which instruction is most important for the nurse to
include?
A. Swallow the tablet whole and never crush, chew, or split it
B. Crush the tablet if you have trouble swallowing it whole
C. Take an extra tablet whenever breakthrough pain occurs
D. Stop the medication once your pain drops below 5 out of 10
4
NSG 533 Advanced Pharmacology
Exam 2 - Pain Management and Analgesic
Pharmacotherapy
2026 Edition | 100 Questions | Correct Answers
and Detailed Rationales Included
Student Name:
Date:
Section / Cohort: Score ____________ / 100
Instructions
This practice examination contains 100 multiple-choice questions covering the pharmacologic management of
pain, including opioid analgesics and antagonists, nonsteroidal anti-inflammatory drugs and acetaminophen,
agents for neuropathic pain, local and general anesthetics, and drug therapy for gout, migraine, and muscle
spasm. Select the single best answer for each item. The correct answer and a detailed rationale are presented
immediately below each question so the examination may be used for self-paced study and review. Content
reflects core advanced pharmacology principles and current prescribing-safety considerations.
1. A nurse is preparing to administer morphine sulfate to a postoperative patient and is reviewing
how the drug produces analgesia. Morphine relieves pain primarily through which mechanism
of action?
A. Blocking sodium channels in peripheral pain fibers
B. Stimulating mu-opioid receptors in the central nervous system
C. Inhibiting cyclooxygenase enzymes at sites of tissue injury
D. Antagonizing NMDA receptors in the spinal cord
Correct Answer: B
Rationale: Morphine is a full agonist at mu-opioid receptors in the brain and spinal cord, which inhibits the
release of neurotransmitters and blunts the ascending transmission of pain signals, producing analgesia,
euphoria, and sedation. Option A describes local anesthetics such as lidocaine. Option C describes NSAIDs
1
such as ibuprofen. Option D describes drugs such as ketamine; methadone has only minor NMDA activity
and it is not the primary analgesic mechanism.
,NSG 533 Advanced Pharmacology | Exam 2 Practice Examination (2026) Wilkes University - Passan School of Nursing
2. Thirty minutes after receiving intravenous morphine, a postoperative patient is difficult to
arouse and has a respiratory rate of 10 breaths per minute with shallow respirations. Which
action should the nurse take first?
A. Stimulate the patient, apply oxygen, and withhold further opioid dosing
B. Administer a bolus dose of naloxone 2 mg intravenously
C. Increase the intravenous fluid rate and reposition the patient
D. Document the findings and reassess in 30 minutes
Correct Answer: A
Rationale: Sedation precedes respiratory depression, so a sedated patient with a respiratory rate of 10 should
first be aroused and stimulated while oxygen is applied and further opioid doses are withheld. High-dose
naloxone given as an undiluted bolus (Option B) can precipitate severe withdrawal, vomiting, and acute pain
crisis; naloxone is diluted and titrated to adequate respirations when stimulation fails. Options C and D fail to
address the cause and could allow deterioration. The nurse should also notify the provider and prepare naloxone
if stimulation does not improve ventilation.
3. A patient who received naloxone for opioid-induced respiratory depression becomes drowsy
again with a respiratory rate of 8 breaths per minute 45 minutes later. Which property of
naloxone best explains this recurrence?
A. Naloxone undergoes rapid hepatic metabolism to inactive metabolites
B. Naloxone has a delayed onset that limits its clinical effectiveness
C. Naloxone produces cumulative central nervous system depression
D. Naloxone has a shorter duration of action than most opioid agonists
Correct Answer: D
Rationale: Naloxone has a half-life of roughly 30 to 90 minutes, which is shorter than the duration of
morphine, fentanyl, and especially methadone, so recurrent respiratory depression (renarcotization) is expected
as the antagonist wears off. The patient requires repeat naloxone doses or a continuous infusion and prolonged
observation. Option A describes metabolism but is not the clinically relevant point about duration mismatch.
Naloxone acts within 1 to 2 minutes of intravenous administration, making Option B incorrect. Naloxone
reverses central nervous system depression rather than causing it, so Option C is wrong.
4. A patient has been using a transdermal fentanyl patch for cancer pain. Which statement by the
patient requires immediate follow-up by the nurse?
A. I apply the patch to a non-irritated area of my upper back and rotate sites
B. I keep the old patches folded and dispose of them away from children
C. I can use a heating pad over the patch when my back muscles ache
D. I was taking around-the-clock oral morphine before starting this patch
Correct Answer: C
2
,NSG 533 Advanced Pharmacology | Exam 2 Practice Examination (2026) Wilkes University - Passan School of Nursing
Rationale: External heat sources such as heating pads, hot tubs, saunas, or fever increase fentanyl absorption
from the patch and can cause fatal respiratory depression, so this statement requires immediate correction.
Option A reflects correct practice: application to intact, non-irritated skin with site rotation. Option B reflects
safe disposal because residual fentanyl in used patches has caused pediatric deaths. Option D is appropriate
because transdermal fentanyl is indicated only for patients who are already opioid tolerant, typically requiring at
least 60 mg of oral morphine per day for a week or longer.
5. A nurse is teaching a pharmacology review group about codeine. Which statement accurately
describes an important pharmacogenetic consideration for codeine therapy?
A. Codeine is a prodrug converted to morphine by CYP2D6, and ultra-rapid metabolizers are
at risk of toxicity
B. Codeine is inactivated by CYP3A4, and poor metabolizers experience exaggerated
analgesia
C. Codeine binds irreversibly to opioid receptors, making dose titration unnecessary
D. Codeine is unaffected by genetics because it is excreted unchanged by the kidneys
Correct Answer: A
Rationale: Codeine itself has minimal analgesic activity and must be converted by CYP2D6 to morphine.
Ultra-rapid metabolizers generate supratherapeutic morphine levels and can develop respiratory depression
even at standard doses. Poor metabolizers receive little analgesic benefit rather than toxicity, making Option B
incorrect. Codeine binds reversibly to mu receptors like other opioids, so Option C is false. Codeine requires
metabolism and does not rely solely on renal excretion, so Option D is wrong.
6. A patient taking tramadol for chronic low back pain is newly prescribed sertraline for
depression. The nurse should prioritize teaching about which potential adverse effect of this
combination?
A. Severe hypotension requiring dose reduction of tramadol
B. Serotonin syndrome with agitation, hyperreflexia, and clonus
C. Hepatotoxicity with jaundice and dark urine
D. Immediate physical dependence on both medications
Correct Answer: B
Rationale: Tramadol has weak mu-agonist activity but also inhibits reuptake of serotonin and norepinephrine.
Combined with an SSRI such as sertraline, serotonergic tone can rise excessively and produce serotonin
syndrome, manifested by agitation, diaphoresis, tremor, hyperreflexia, clonus, hyperthermia, and diarrhea.
Tramadol also lowers the seizure threshold, which is a separate risk of the drug itself. Hypotension (Option A)
and hepatotoxicity (Option C) are not hallmark effects of this interaction. Physical dependence develops with
prolonged opioid exposure but is not an immediate consequence of adding sertraline, making Option D
incorrect.
3
, NSG 533 Advanced Pharmacology | Exam 2 Practice Examination (2026) Wilkes University - Passan School of Nursing
7. A patient stabilized on methadone for cancer-related pain is scheduled for an electrocardiogram.
The nurse recognizes that this test is ordered because methadone is associated with which
cardiac adverse effect?
A. Sinus bradycardia progressing to heart block
B. ST-segment elevation mimicking myocardial infarction
C. Widened QRS complex from sodium channel blockade
D. QT prolongation with risk of torsades de pointes
Correct Answer: D
Rationale: Methadone prolongs the QT interval in a dose-dependent manner and can precipitate torsades de
pointes, a polymorphic ventricular tachycardia that may degenerate into ventricular fibrillation. Risk is
increased with high doses, electrolyte disturbances such as hypokalemia and hypomagnesemia, and concurrent
QT-prolonging drugs, so baseline and follow-up ECGs are recommended. Bradycardia and heart block (Option
are not characteristic methadone effects. Methadone does not mimic myocardial infarction patterns (Option
or produce sodium-channel-mediated QRS widening like tricyclic antidepressants (Option C).
8. A patient is being converted from oral morphine to oral hydromorphone for better pain control.
When performing this equianalgesic calculation, the nurse recalls that hydromorphone is
approximately how much more potent than morphine?
A. About 5 times more potent
B. Approximately equal in potency
C. About 2 times more potent
D. About 50 times more potent
Correct Answer: A
Rationale: Standard equianalgesic tables list 7.5 mg of oral hydromorphone as approximately equivalent to 30
mg of oral morphine, making hydromorphone roughly 5 times more potent on a milligram basis. Intravenous
comparisons follow a similar ratio, with 1.5 mg of intravenous hydromorphone approximating 10 mg of
intravenous morphine. Assuming equal potency (Option B) or a 2-fold difference (Option C) would cause
underdosing, while a 50-fold estimate (Option D) resembles the potency comparison between fentanyl and
morphine and would cause a dangerous overdose if used for hydromorphone. After any rotation, the calculated
dose is reduced by 25 to 50 percent for incomplete cross-tolerance.
9. A nurse is discharging a patient with a new prescription for extended-release oxycodone
(OxyContin) for severe chronic pain. Which instruction is most important for the nurse to
include?
A. Swallow the tablet whole and never crush, chew, or split it
B. Crush the tablet if you have trouble swallowing it whole
C. Take an extra tablet whenever breakthrough pain occurs
D. Stop the medication once your pain drops below 5 out of 10
4
