NSG 533 Exam 3 - Wilkes Advanced Pharmacology
(2026) Actual Questions & Study Guide Guarantee
Pass - Complete 99 Verified Q&A with Answers &
Rationales for Exam Prep
Q1
A patient with heart failure with reduced ejection fraction (HFrEF) is initiated on sacubitril/valsartan. Which
pharmacodynamic interaction best explains why concomitant use with a neprilysin inhibitor is
contraindicated?
A. Additive bradykinin accumulation leading to angioedema risk
B. Increased degradation of natriuretic peptides reducing efficacy
C. Enhanced angiotensin II formation causing vasoconstriction
D. Competitive inhibition at the AT1 receptor reducing blood pressure control
Answer: A
Rationale: Sacubitril inhibits neprilysin, which degrades bradykinin; combining with another neprilysin
inhibitor (e.g., omapatrilat) markedly increases bradykinin and angioedema risk. The other options
misstate mechanisms: neprilysin inhibition increases natriuretic peptides (B is opposite), does not increase
angiotensin II (C), and does not competitively block AT1 (D).
Q2
Which statement accurately reflects the 2025 ADA Standards of Care regarding the use of SGLT2
inhibitors in patients with type 2 diabetes and chronic kidney disease?
A. They are recommended only if eGFR is above 60 mL/min/1.73 m².
B. They should be avoided in patients with albuminuria due to risk of acute kidney injury.
C. They are recommended for kidney and cardiovascular protection irrespective of glycemic control.
D. They require discontinuation when eGFR falls below 45 mL/min/1.73 m².
Answer: C
Rationale: The 2025 ADA Standards recommend SGLT2 inhibitors for CKD and CV risk reduction
independent of A1C, with continued use at lower eGFR thresholds. Options A, B, and D contradict current
guidance, which supports use in CKD and does not mandate discontinuation at eGFR 45.
,Q3
A patient on warfarin is prescribed trimethoprim-sulfamethoxazole for a urinary tract infection. Which
mechanism best explains the resulting INR elevation?
A. Induction of CYP2C9 increasing warfarin metabolism
B. Inhibition of CYP2C9 and displacement from protein binding
C. Increased renal clearance of vitamin K
D. Enhanced absorption of warfarin due to altered gut flora
Answer: B
Rationale: TMP-SMX inhibits CYP2C9, reducing warfarin metabolism, and also displaces warfarin from
albumin, increasing free drug. The other options are incorrect: induction would lower INR, renal vitamin K
clearance is not the primary mechanism, and altered gut flora affects vitamin K production but is not the
main interaction.
Q4
Which antidepressant is most appropriate for a patient with major depressive disorder and coexisting
neuropathic pain, based on dual mechanism of action?
A. Fluoxetine
B. Sertraline
C. Duloxetine
D. Bupropion
Answer: C
Rationale: Duloxetine, an SNRI, is FDA-approved for both MDD and neuropathic pain, providing dual
benefit. SSRIs like fluoxetine and sertraline primarily treat depression, and bupropion lacks analgesic
properties.
Q5
A patient with asthma is prescribed propranolol for migraine prophylaxis. Which adverse effect is most
concerning?
A. Bronchoconstriction
B. Hyperglycemia
C. Hypertension
D. Diarrhea
Answer: A
Rationale: Non-selective beta-blockers like propranolol can cause bronchoconstriction by blocking beta-2
receptors in the lungs, worsening asthma. Hyperglycemia, hypertension, and diarrhea are not typical major
concerns.
,Q6
A patient on digoxin develops nausea, visual disturbances, and a heart rate of 50 bpm. Which electrolyte
abnormality most likely contributes to digoxin toxicity?
A. Hypercalcemia
B. Hypokalemia
C. Hypernatremia
D. Hypomagnesemia
Answer: B
Rationale: Hypokalemia increases digoxin binding to Na+/K+-ATPase, enhancing toxicity. Hypercalcemia
can also potentiate toxicity but is less common; hypernatremia and hypomagnesemia are not primary
contributors.
Q7
Which antibiotic requires dose adjustment in a patient with a creatinine clearance of 25 mL/min?
A. Azithromycin
B. Ceftriaxone
C. Levofloxacin
D. Doxycycline
Answer: C
Rationale: Levofloxacin is renally eliminated and requires dose reduction in renal impairment.
Azithromycin, ceftriaxone, and doxycycline are primarily hepatically cleared or have minimal renal
adjustment needs.
Q8
Which medication is contraindicated in a patient with a history of angioedema while on an ACE inhibitor?
A. Lisinopril
B. Losartan
C. Aliskiren
D. Sacubitril/valsartan
Answer: D
Rationale: Sacubitril/valsartan is contraindicated due to increased angioedema risk from neprilysin
inhibition, especially after ACE inhibitor angioedema. Losartan and aliskiren are not absolutely
contraindicated, and lisinopril is the same class that caused the reaction.
, Q9
A patient with type 2 diabetes on metformin is scheduled for a contrast-enhanced CT scan. What is the
most appropriate action regarding metformin?
A. Continue metformin as usual.
B. Discontinue metformin 48 hours before the procedure.
C. Discontinue metformin on the day of the procedure and resume after 48 hours if renal function is
stable.
D. Reduce the metformin dose by half before the procedure.
Answer: C
Rationale: Current guidelines recommend holding metformin at the time of contrast administration and
resuming 48 hours later if renal function remains stable, to avoid lactic acidosis. Options A and B are not
aligned with guidelines, and D is not standard practice.
Q10
Which pharmacokinetic parameter is most important to consider when prescribing a drug with a narrow
therapeutic index?
A. Volume of distribution
B. Therapeutic drug monitoring
C. Protein binding
D. Half-life
Answer: B
Rationale: For narrow therapeutic index drugs, therapeutic drug monitoring is essential to maintain levels
within the therapeutic range and avoid toxicity. While volume of distribution, protein binding, and half-life
influence dosing, monitoring directly guides safe prescribing.
Q11
A patient with decompensated heart failure is initiated on sacubitril/valsartan. Which mechanism best
explains why this agent must not be co-administered with an ACE inhibitor within 36 hours of the last ACE
inhibitor dose?
A. Additive bradykinin accumulation from neprilysin and ACE inhibition precipitates refractory
hyperkalemia.
B. Combined neprilysin and ACE inhibition markedly increases bradykinin-mediated angioedema risk.
C. Valsartan displaces the ACE inhibitor from plasma protein binding, causing toxic free-drug levels.
D. Sacubitril inhibits CYP2C9, reducing ACE inhibitor clearance and causing accumulation.
Answer: B
Rationale: Neprilysin inhibition and ACE inhibition both impair bradykinin degradation, and their overlap
markedly increases angioedema risk, mandating a 36-hour washout. Hyperkalemia is a concern but not
the primary mechanism. Protein-binding displacement and CYP2C9 inhibition are not the pharmacologic
basis for this interaction.
(2026) Actual Questions & Study Guide Guarantee
Pass - Complete 99 Verified Q&A with Answers &
Rationales for Exam Prep
Q1
A patient with heart failure with reduced ejection fraction (HFrEF) is initiated on sacubitril/valsartan. Which
pharmacodynamic interaction best explains why concomitant use with a neprilysin inhibitor is
contraindicated?
A. Additive bradykinin accumulation leading to angioedema risk
B. Increased degradation of natriuretic peptides reducing efficacy
C. Enhanced angiotensin II formation causing vasoconstriction
D. Competitive inhibition at the AT1 receptor reducing blood pressure control
Answer: A
Rationale: Sacubitril inhibits neprilysin, which degrades bradykinin; combining with another neprilysin
inhibitor (e.g., omapatrilat) markedly increases bradykinin and angioedema risk. The other options
misstate mechanisms: neprilysin inhibition increases natriuretic peptides (B is opposite), does not increase
angiotensin II (C), and does not competitively block AT1 (D).
Q2
Which statement accurately reflects the 2025 ADA Standards of Care regarding the use of SGLT2
inhibitors in patients with type 2 diabetes and chronic kidney disease?
A. They are recommended only if eGFR is above 60 mL/min/1.73 m².
B. They should be avoided in patients with albuminuria due to risk of acute kidney injury.
C. They are recommended for kidney and cardiovascular protection irrespective of glycemic control.
D. They require discontinuation when eGFR falls below 45 mL/min/1.73 m².
Answer: C
Rationale: The 2025 ADA Standards recommend SGLT2 inhibitors for CKD and CV risk reduction
independent of A1C, with continued use at lower eGFR thresholds. Options A, B, and D contradict current
guidance, which supports use in CKD and does not mandate discontinuation at eGFR 45.
,Q3
A patient on warfarin is prescribed trimethoprim-sulfamethoxazole for a urinary tract infection. Which
mechanism best explains the resulting INR elevation?
A. Induction of CYP2C9 increasing warfarin metabolism
B. Inhibition of CYP2C9 and displacement from protein binding
C. Increased renal clearance of vitamin K
D. Enhanced absorption of warfarin due to altered gut flora
Answer: B
Rationale: TMP-SMX inhibits CYP2C9, reducing warfarin metabolism, and also displaces warfarin from
albumin, increasing free drug. The other options are incorrect: induction would lower INR, renal vitamin K
clearance is not the primary mechanism, and altered gut flora affects vitamin K production but is not the
main interaction.
Q4
Which antidepressant is most appropriate for a patient with major depressive disorder and coexisting
neuropathic pain, based on dual mechanism of action?
A. Fluoxetine
B. Sertraline
C. Duloxetine
D. Bupropion
Answer: C
Rationale: Duloxetine, an SNRI, is FDA-approved for both MDD and neuropathic pain, providing dual
benefit. SSRIs like fluoxetine and sertraline primarily treat depression, and bupropion lacks analgesic
properties.
Q5
A patient with asthma is prescribed propranolol for migraine prophylaxis. Which adverse effect is most
concerning?
A. Bronchoconstriction
B. Hyperglycemia
C. Hypertension
D. Diarrhea
Answer: A
Rationale: Non-selective beta-blockers like propranolol can cause bronchoconstriction by blocking beta-2
receptors in the lungs, worsening asthma. Hyperglycemia, hypertension, and diarrhea are not typical major
concerns.
,Q6
A patient on digoxin develops nausea, visual disturbances, and a heart rate of 50 bpm. Which electrolyte
abnormality most likely contributes to digoxin toxicity?
A. Hypercalcemia
B. Hypokalemia
C. Hypernatremia
D. Hypomagnesemia
Answer: B
Rationale: Hypokalemia increases digoxin binding to Na+/K+-ATPase, enhancing toxicity. Hypercalcemia
can also potentiate toxicity but is less common; hypernatremia and hypomagnesemia are not primary
contributors.
Q7
Which antibiotic requires dose adjustment in a patient with a creatinine clearance of 25 mL/min?
A. Azithromycin
B. Ceftriaxone
C. Levofloxacin
D. Doxycycline
Answer: C
Rationale: Levofloxacin is renally eliminated and requires dose reduction in renal impairment.
Azithromycin, ceftriaxone, and doxycycline are primarily hepatically cleared or have minimal renal
adjustment needs.
Q8
Which medication is contraindicated in a patient with a history of angioedema while on an ACE inhibitor?
A. Lisinopril
B. Losartan
C. Aliskiren
D. Sacubitril/valsartan
Answer: D
Rationale: Sacubitril/valsartan is contraindicated due to increased angioedema risk from neprilysin
inhibition, especially after ACE inhibitor angioedema. Losartan and aliskiren are not absolutely
contraindicated, and lisinopril is the same class that caused the reaction.
, Q9
A patient with type 2 diabetes on metformin is scheduled for a contrast-enhanced CT scan. What is the
most appropriate action regarding metformin?
A. Continue metformin as usual.
B. Discontinue metformin 48 hours before the procedure.
C. Discontinue metformin on the day of the procedure and resume after 48 hours if renal function is
stable.
D. Reduce the metformin dose by half before the procedure.
Answer: C
Rationale: Current guidelines recommend holding metformin at the time of contrast administration and
resuming 48 hours later if renal function remains stable, to avoid lactic acidosis. Options A and B are not
aligned with guidelines, and D is not standard practice.
Q10
Which pharmacokinetic parameter is most important to consider when prescribing a drug with a narrow
therapeutic index?
A. Volume of distribution
B. Therapeutic drug monitoring
C. Protein binding
D. Half-life
Answer: B
Rationale: For narrow therapeutic index drugs, therapeutic drug monitoring is essential to maintain levels
within the therapeutic range and avoid toxicity. While volume of distribution, protein binding, and half-life
influence dosing, monitoring directly guides safe prescribing.
Q11
A patient with decompensated heart failure is initiated on sacubitril/valsartan. Which mechanism best
explains why this agent must not be co-administered with an ACE inhibitor within 36 hours of the last ACE
inhibitor dose?
A. Additive bradykinin accumulation from neprilysin and ACE inhibition precipitates refractory
hyperkalemia.
B. Combined neprilysin and ACE inhibition markedly increases bradykinin-mediated angioedema risk.
C. Valsartan displaces the ACE inhibitor from plasma protein binding, causing toxic free-drug levels.
D. Sacubitril inhibits CYP2C9, reducing ACE inhibitor clearance and causing accumulation.
Answer: B
Rationale: Neprilysin inhibition and ACE inhibition both impair bradykinin degradation, and their overlap
markedly increases angioedema risk, mandating a 36-hour washout. Hyperkalemia is a concern but not
the primary mechanism. Protein-binding displacement and CYP2C9 inhibition are not the pharmacologic
basis for this interaction.
