NURS 6512 Exam 3 V1 | NURS 6512 Advanced Pharmacology | Actual
Q&A with Rationale (NURS 6512 Exam 3) | Walden
1. Mr. Henderson, a 74-year-old male with a history of heart failure (HFrEF) and chronic
kidney disease (Stage 3b), is currently taking Lisinopril 20mg daily and Furosemide 40mg
daily. During his follow-up, his potassium is 5.2 mEq/L and his GFR has decreased slightly to
40 mL/min. The provider is considering adding Spironolactone to his regimen. Which of the
following is the most appropriate clinical decision based on his current profile?
A. Initiate Spironolactone at 12.5mg daily with close monitoring of potassium and renal
function.
B. Increase Furosemide to 80mg daily to offset the potassium-sparing effects before
starting Spironolactone.
C. Discontinue Lisinopril and start Spironolactone 25mg daily to manage potassium levels.
D. Avoid Spironolactone as the risk of hyperkalemia is significantly elevated given his renal
status and current ACE inhibitor use.
Answer: D
Rationale: In patients with a GFR below 45 mL/min and concurrent use of ACE inhibitors,
the risk of life-threatening hyperkalemia is substantially increased when adding
potassium-sparing diuretics. Clinical guidelines suggest caution or avoidance of
aldosterone antagonists when baseline potassium exceeds 5.0 mEq/L or GFR is
significantly impaired. Therefore, the safest evidence-based decision is to avoid adding
Spironolactone at this time to prevent electrolyte-induced cardiac complications.
2. A 45-year-old female, Mrs. Rodriguez, is being treated for Major Depressive Disorder with
Sertraline 100mg daily. She presents to the clinic complaining of severe muscle rigidity, high
fever, and altered mental status. Her husband mentions she recently started taking a new
medication for migraines prescribed by another provider, but he cannot remember the name.
Which medication most likely precipitated this reaction, and what is the underlying
mechanism?
A. Topiramate, causing acute metabolic acidosis and secondary encephalopathy.
B. Propranolol, causing a paradoxical hypertensive crisis and neurological symptoms.
C. Metoclopramide, causing neuroleptic malignant syndrome due to dopamine blockade.
D. Sumatriptan, leading to excessive serotonin stimulation in the central nervous system.
Answer: D
Rationale: The patient’s presentation of rigidity, fever, and altered mental status in the
context of SSRI use is highly suggestive of Serotonin Syndrome, which is often precipitated
,by the addition of triptans. Triptans serve as serotonin receptor agonists and, when
combined with SSRIs, can lead to dangerous levels of serotonergic activity. The provider
must immediately discontinue the offending agents and provide supportive care to manage
the neuromuscular and autonomic instability.
3. James, a 32-year-old male with Bipolar I disorder, has been stable on Lithium Carbonate
600mg BID for two years. He recently contracted a severe gastrointestinal virus characterized
by vomiting and diarrhea and has been taking Ibuprofen 400mg every 6 hours for body aches.
He now presents with coarse tremors, ataxia, and confusion. What is the most likely
pharmacological explanation for his symptoms?
A. Increased renal clearance of Lithium due to the high volume of fluid loss from GI
symptoms.
B. Reduced renal excretion of Lithium caused by NSAID-induced inhibition of prostaglandin
synthesis.
C. A drug-drug interaction where Ibuprofen competes for protein binding sites with
Lithium.
D. The gastrointestinal virus has caused a decrease in the absorption rate of Lithium in the
small intestine.
Answer: B
Rationale: Lithium is exclusively excreted by the kidneys, and its clearance is highly
dependent on renal perfusion and prostaglandin activity. NSAIDs like Ibuprofen inhibit
prostaglandins, which leads to reduced renal blood flow and a subsequent decrease in
Lithium excretion, raising serum levels to toxic ranges. The patient’s dehydration from the
GI virus further exacerbates this toxicity by promoting sodium and lithium reabsorption in
the proximal tubule.
4. A 68-year-old patient with Type 2 Diabetes and a history of frequent urinary tract
infections is currently taking Metformin 1000mg BID. The provider is considering adding an
SGLT2 inhibitor (Empagliflozin) to improve glycemic control and provide cardiovascular
protection. Which factor is the most significant concern when prescribing this drug class to
this specific patient?
A. The risk of weight gain associated with SGLT2 inhibitor therapy.
B. Development of hypertension due to the osmotic diuretic effect of the medication.
C. Potential for severe hypoglycemia when used in combination with Metformin.
D. Increased risk of mycotic genital infections and recurrent UTIs due to glycosuria.
Answer: D
Rationale: SGLT2 inhibitors function by promoting the excretion of glucose in the urine,
which creates a favorable environment for bacterial and fungal growth in the urinary tract.
Patients with a history of frequent UTIs are at a higher risk for developing severe
, genitourinary infections when starting this class of medication. The provider must educate
the patient on strict hygiene and monitor for signs of infection while managing their
diabetic therapy.
5. Mrs. Bennett, a 55-year-old female, is being treated for chronic plaque psoriasis with
Methotrexate. She presents with significant bruising and fatigue. Laboratory results show a
White Blood Cell count of 2,500/mm3 and a platelet count of 80,000/mm3. Which of the
following is the most appropriate immediate action?
A. Continue Methotrexate but add a daily Folic Acid supplement to reduce side effects.
B. Hold the Methotrexate dose and order a liver biopsy to assess for cirrhosis.
C. Discontinue Methotrexate immediately due to evidence of myelosuppression.
D. Reduce the dose of Methotrexate by 50% and recheck labs in two weeks.
Answer: C
Rationale: Methotrexate is a folic acid antagonist that can cause severe bone marrow
suppression, manifesting as leucopenia and thrombocytopenia. The patient’s low WBC and
platelet counts indicate a dangerous level of myelosuppression that requires immediate
cessation of the drug. Continued use could lead to life-threatening infections or
hemorrhage, necessitating a complete re-evaluation of her treatment plan.
6. A 50-year-old male with persistent atrial fibrillation has been maintained on Warfarin with
an INR target of 2.0-3.0. He is diagnosed with a severe fungal infection and prescribed
Fluconazole. How should the provider adjust his pharmacological management?
A. Increase the dose of Warfarin because Fluconazole induces CYP450 enzymes.
B. Decrease the dose of Warfarin and monitor INR closely due to CYP2C9 inhibition by
Fluconazole.
C. Maintain the current Warfarin dose as Fluconazole does not affect the clotting cascade.
D. Switch the patient to Dabigatran immediately to avoid any metabolic interactions.
Answer: B
Rationale: Fluconazole is a potent inhibitor of the CYP2C9 enzyme, which is the primary
pathway for the metabolism of the more active S-isomer of Warfarin. Inhibiting this
enzyme leads to higher plasma concentrations of Warfarin, significantly increasing the INR
and the risk of bleeding. The provider must pre-emptively lower the Warfarin dose and
perform frequent INR monitoring until the antifungal course is completed.
7. A 28-year-old pregnant woman in her second trimester (20 weeks) presents with a blood
pressure of 155/95 mmHg. She has no prior history of hypertension. Which of the following
medications is considered a first-line agent for managing hypertension in pregnancy?
A. Lisinopril
Q&A with Rationale (NURS 6512 Exam 3) | Walden
1. Mr. Henderson, a 74-year-old male with a history of heart failure (HFrEF) and chronic
kidney disease (Stage 3b), is currently taking Lisinopril 20mg daily and Furosemide 40mg
daily. During his follow-up, his potassium is 5.2 mEq/L and his GFR has decreased slightly to
40 mL/min. The provider is considering adding Spironolactone to his regimen. Which of the
following is the most appropriate clinical decision based on his current profile?
A. Initiate Spironolactone at 12.5mg daily with close monitoring of potassium and renal
function.
B. Increase Furosemide to 80mg daily to offset the potassium-sparing effects before
starting Spironolactone.
C. Discontinue Lisinopril and start Spironolactone 25mg daily to manage potassium levels.
D. Avoid Spironolactone as the risk of hyperkalemia is significantly elevated given his renal
status and current ACE inhibitor use.
Answer: D
Rationale: In patients with a GFR below 45 mL/min and concurrent use of ACE inhibitors,
the risk of life-threatening hyperkalemia is substantially increased when adding
potassium-sparing diuretics. Clinical guidelines suggest caution or avoidance of
aldosterone antagonists when baseline potassium exceeds 5.0 mEq/L or GFR is
significantly impaired. Therefore, the safest evidence-based decision is to avoid adding
Spironolactone at this time to prevent electrolyte-induced cardiac complications.
2. A 45-year-old female, Mrs. Rodriguez, is being treated for Major Depressive Disorder with
Sertraline 100mg daily. She presents to the clinic complaining of severe muscle rigidity, high
fever, and altered mental status. Her husband mentions she recently started taking a new
medication for migraines prescribed by another provider, but he cannot remember the name.
Which medication most likely precipitated this reaction, and what is the underlying
mechanism?
A. Topiramate, causing acute metabolic acidosis and secondary encephalopathy.
B. Propranolol, causing a paradoxical hypertensive crisis and neurological symptoms.
C. Metoclopramide, causing neuroleptic malignant syndrome due to dopamine blockade.
D. Sumatriptan, leading to excessive serotonin stimulation in the central nervous system.
Answer: D
Rationale: The patient’s presentation of rigidity, fever, and altered mental status in the
context of SSRI use is highly suggestive of Serotonin Syndrome, which is often precipitated
,by the addition of triptans. Triptans serve as serotonin receptor agonists and, when
combined with SSRIs, can lead to dangerous levels of serotonergic activity. The provider
must immediately discontinue the offending agents and provide supportive care to manage
the neuromuscular and autonomic instability.
3. James, a 32-year-old male with Bipolar I disorder, has been stable on Lithium Carbonate
600mg BID for two years. He recently contracted a severe gastrointestinal virus characterized
by vomiting and diarrhea and has been taking Ibuprofen 400mg every 6 hours for body aches.
He now presents with coarse tremors, ataxia, and confusion. What is the most likely
pharmacological explanation for his symptoms?
A. Increased renal clearance of Lithium due to the high volume of fluid loss from GI
symptoms.
B. Reduced renal excretion of Lithium caused by NSAID-induced inhibition of prostaglandin
synthesis.
C. A drug-drug interaction where Ibuprofen competes for protein binding sites with
Lithium.
D. The gastrointestinal virus has caused a decrease in the absorption rate of Lithium in the
small intestine.
Answer: B
Rationale: Lithium is exclusively excreted by the kidneys, and its clearance is highly
dependent on renal perfusion and prostaglandin activity. NSAIDs like Ibuprofen inhibit
prostaglandins, which leads to reduced renal blood flow and a subsequent decrease in
Lithium excretion, raising serum levels to toxic ranges. The patient’s dehydration from the
GI virus further exacerbates this toxicity by promoting sodium and lithium reabsorption in
the proximal tubule.
4. A 68-year-old patient with Type 2 Diabetes and a history of frequent urinary tract
infections is currently taking Metformin 1000mg BID. The provider is considering adding an
SGLT2 inhibitor (Empagliflozin) to improve glycemic control and provide cardiovascular
protection. Which factor is the most significant concern when prescribing this drug class to
this specific patient?
A. The risk of weight gain associated with SGLT2 inhibitor therapy.
B. Development of hypertension due to the osmotic diuretic effect of the medication.
C. Potential for severe hypoglycemia when used in combination with Metformin.
D. Increased risk of mycotic genital infections and recurrent UTIs due to glycosuria.
Answer: D
Rationale: SGLT2 inhibitors function by promoting the excretion of glucose in the urine,
which creates a favorable environment for bacterial and fungal growth in the urinary tract.
Patients with a history of frequent UTIs are at a higher risk for developing severe
, genitourinary infections when starting this class of medication. The provider must educate
the patient on strict hygiene and monitor for signs of infection while managing their
diabetic therapy.
5. Mrs. Bennett, a 55-year-old female, is being treated for chronic plaque psoriasis with
Methotrexate. She presents with significant bruising and fatigue. Laboratory results show a
White Blood Cell count of 2,500/mm3 and a platelet count of 80,000/mm3. Which of the
following is the most appropriate immediate action?
A. Continue Methotrexate but add a daily Folic Acid supplement to reduce side effects.
B. Hold the Methotrexate dose and order a liver biopsy to assess for cirrhosis.
C. Discontinue Methotrexate immediately due to evidence of myelosuppression.
D. Reduce the dose of Methotrexate by 50% and recheck labs in two weeks.
Answer: C
Rationale: Methotrexate is a folic acid antagonist that can cause severe bone marrow
suppression, manifesting as leucopenia and thrombocytopenia. The patient’s low WBC and
platelet counts indicate a dangerous level of myelosuppression that requires immediate
cessation of the drug. Continued use could lead to life-threatening infections or
hemorrhage, necessitating a complete re-evaluation of her treatment plan.
6. A 50-year-old male with persistent atrial fibrillation has been maintained on Warfarin with
an INR target of 2.0-3.0. He is diagnosed with a severe fungal infection and prescribed
Fluconazole. How should the provider adjust his pharmacological management?
A. Increase the dose of Warfarin because Fluconazole induces CYP450 enzymes.
B. Decrease the dose of Warfarin and monitor INR closely due to CYP2C9 inhibition by
Fluconazole.
C. Maintain the current Warfarin dose as Fluconazole does not affect the clotting cascade.
D. Switch the patient to Dabigatran immediately to avoid any metabolic interactions.
Answer: B
Rationale: Fluconazole is a potent inhibitor of the CYP2C9 enzyme, which is the primary
pathway for the metabolism of the more active S-isomer of Warfarin. Inhibiting this
enzyme leads to higher plasma concentrations of Warfarin, significantly increasing the INR
and the risk of bleeding. The provider must pre-emptively lower the Warfarin dose and
perform frequent INR monitoring until the antifungal course is completed.
7. A 28-year-old pregnant woman in her second trimester (20 weeks) presents with a blood
pressure of 155/95 mmHg. She has no prior history of hypertension. Which of the following
medications is considered a first-line agent for managing hypertension in pregnancy?
A. Lisinopril
