NURS 6521 Advanced Pharmacology - Original Practice Midterm | Page 1
,NURS 6521 Midterm Exam | Advanced Pharmacology | Walden
University | Q & A | 2026/2027 Edition (PDF)
1. A patient with severe hepatic cirrhosis begins an oral drug that normally undergoes extensive first-pass
metabolism. Whichchange is most likely?
A) Lower systemic exposure because absorption stops
B) Faster renal filtration despite unchanged kidneys
C) Higher systemic exposure from reduced first-pass metabolism
D) Complete loss of receptor affinity
Correct Answer: C) Higher systemic exposure from reduced first-pass metabolism
Rationale: Cirrhosis can reduce hepatic extraction, allowing more orally administered drug to reach systemic
circulation and increasing exposure. This can require dose reduction for high-extraction drugs. Intestinal absorption
does not simply stop, renal filtration is not automatically accelerated, and receptor affinity is a pharmacodynamic
property rather than a direct consequence of cirrhosis.
2. Renal function declines substantially in an older adult receiving a drug eliminated mainly unchanged in urine. The
mostappropriate dosing principle is to:
A) Increase every dose to overcome reduced filtration
B) Reduce the maintenance dose or extend the dosing interval when indicated
C) Shorten the interval to prevent accumulation
D) Keep the regimen unchanged because renal function affects only absorption
Correct Answer: B) Reduce the maintenance dose or extend the dosing interval when indicated
Rationale: Reduced renal clearance can prolong half-life and cause drug accumulation, so maintenance dosing often
requires reduction or a longer interval. Increasing dose or frequency worsens accumulation. Renal dysfunction
primarily alters elimination for such a drug; it does not merely change gastrointestinal absorption.
3. A highly albumin-bound medication is started in a patient with marked hypoalbuminemia. What initial
pharmacokinetic effectis most plausible?
A) An increased unbound fraction of the medication
B) A guaranteed decrease in receptor sensitivity
C) Complete prevention of hepatic metabolism
D) An immediate increase in albumin synthesis
Correct Answer: A) An increased unbound fraction of the medication
Rationale: With less albumin available, a highly protein-bound drug can have a larger free, pharmacologically active
fraction. This may increase effect or toxicity even when total drug concentration appears acceptable.
Hypoalbuminemia does not guarantee receptor desensitization, block hepatic metabolism completely, or immediately
stimulate enough albumin synthesis to normalize binding.
4. After repeated dosing, a drug reaches steady state. In general, steady state occurs when:
A) The rate of drug administration equals the rate of elimination
B) All administered drug is protein bound
C) The drug has no remaining adverse effects
D) Bioavailability becomes exactly 100%
NURS 6521 Advanced Pharmacology - Original Practice Midterm | Page 2
, Correct Answer: A) The rate of drug administration equals the rate of elimination
Rationale: Steady state reflects a dynamic balance in which drug input equals drug elimination, producing a relatively
stable average concentration. It does not require complete protein binding or elimination of adverse effects.
Bioavailability is determined by formulation, route, and first-pass processes and does not become 100% merely
because steady state is reached.
5. A medication has a long elimination half-life and must achieve therapeutic concentrations quickly. Which strategy
bestaddresses this need?
A) Wait five half-lives before giving the first dose
B) Administer an appropriate loading dose
C) Decrease bioavailability intentionally
D) Use only subtherapeutic maintenance doses
Correct Answer: B) Administer an appropriate loading dose
Rationale: A loading dose can rapidly establish a target concentration, particularly for drugs with long half-lives.
Waiting several half-lives delays treatment, while intentionally lowering bioavailability or using subtherapeutic
maintenance doses undermines the therapeutic goal. Maintenance dosing subsequently replaces the amount
eliminated over time.
6. A strong CYP3A4 inhibitor is added to a regimen containing a CYP3A4 substrate with a narrow therapeutic index.
Theprescriber should anticipate:
A) Accelerated substrate metabolism and treatment failure
B) No interaction because CYP enzymes affect only absorption
C) Potentially increased substrate concentrations and toxicity
D) Loss of all renal elimination
Correct Answer: C) Potentially increased substrate concentrations and toxicity
Rationale: Inhibiting the enzyme responsible for a substrate's metabolism can raise its concentration and toxicity risk,
especially when the therapeutic index is narrow. Enzyme induction, not inhibition, tends to accelerate metabolism.
CYP interactions involve metabolism rather than only absorption, and hepatic enzyme inhibition does not abolish renal
elimination.
7. A CYP enzyme inducer is introduced during stable therapy with an active drug metabolized by that enzyme. Which
outcomeis most likely after induction develops?
A) Reduced drug exposure and possible loss of efficacy
B) Immediate irreversible receptor blockade
C) Increased exposure from slower metabolism
D) Guaranteed renal failure
Correct Answer: A) Reduced drug exposure and possible loss of efficacy
Rationale: Enzyme induction increases metabolic capacity and can lower concentrations of an active parent drug,
potentially reducing efficacy. The effect generally develops as enzyme expression changes rather than through
immediate receptor blockade. Increased exposure is more typical of inhibition, and induction does not inherently
cause renal failure.
8. Two drugs produce the same maximal effect, but Drug X achieves 50% of maximal effect at a lower concentration
than DrugY. Drug X has:
A) Greater potency
B) Greater maximal efficacy by definition
C) Lower affinity by definition
NURS 6521 Advanced Pharmacology - Original Practice Midterm | Page 3
,NURS 6521 Midterm Exam | Advanced Pharmacology | Walden
University | Q & A | 2026/2027 Edition (PDF)
1. A patient with severe hepatic cirrhosis begins an oral drug that normally undergoes extensive first-pass
metabolism. Whichchange is most likely?
A) Lower systemic exposure because absorption stops
B) Faster renal filtration despite unchanged kidneys
C) Higher systemic exposure from reduced first-pass metabolism
D) Complete loss of receptor affinity
Correct Answer: C) Higher systemic exposure from reduced first-pass metabolism
Rationale: Cirrhosis can reduce hepatic extraction, allowing more orally administered drug to reach systemic
circulation and increasing exposure. This can require dose reduction for high-extraction drugs. Intestinal absorption
does not simply stop, renal filtration is not automatically accelerated, and receptor affinity is a pharmacodynamic
property rather than a direct consequence of cirrhosis.
2. Renal function declines substantially in an older adult receiving a drug eliminated mainly unchanged in urine. The
mostappropriate dosing principle is to:
A) Increase every dose to overcome reduced filtration
B) Reduce the maintenance dose or extend the dosing interval when indicated
C) Shorten the interval to prevent accumulation
D) Keep the regimen unchanged because renal function affects only absorption
Correct Answer: B) Reduce the maintenance dose or extend the dosing interval when indicated
Rationale: Reduced renal clearance can prolong half-life and cause drug accumulation, so maintenance dosing often
requires reduction or a longer interval. Increasing dose or frequency worsens accumulation. Renal dysfunction
primarily alters elimination for such a drug; it does not merely change gastrointestinal absorption.
3. A highly albumin-bound medication is started in a patient with marked hypoalbuminemia. What initial
pharmacokinetic effectis most plausible?
A) An increased unbound fraction of the medication
B) A guaranteed decrease in receptor sensitivity
C) Complete prevention of hepatic metabolism
D) An immediate increase in albumin synthesis
Correct Answer: A) An increased unbound fraction of the medication
Rationale: With less albumin available, a highly protein-bound drug can have a larger free, pharmacologically active
fraction. This may increase effect or toxicity even when total drug concentration appears acceptable.
Hypoalbuminemia does not guarantee receptor desensitization, block hepatic metabolism completely, or immediately
stimulate enough albumin synthesis to normalize binding.
4. After repeated dosing, a drug reaches steady state. In general, steady state occurs when:
A) The rate of drug administration equals the rate of elimination
B) All administered drug is protein bound
C) The drug has no remaining adverse effects
D) Bioavailability becomes exactly 100%
NURS 6521 Advanced Pharmacology - Original Practice Midterm | Page 2
, Correct Answer: A) The rate of drug administration equals the rate of elimination
Rationale: Steady state reflects a dynamic balance in which drug input equals drug elimination, producing a relatively
stable average concentration. It does not require complete protein binding or elimination of adverse effects.
Bioavailability is determined by formulation, route, and first-pass processes and does not become 100% merely
because steady state is reached.
5. A medication has a long elimination half-life and must achieve therapeutic concentrations quickly. Which strategy
bestaddresses this need?
A) Wait five half-lives before giving the first dose
B) Administer an appropriate loading dose
C) Decrease bioavailability intentionally
D) Use only subtherapeutic maintenance doses
Correct Answer: B) Administer an appropriate loading dose
Rationale: A loading dose can rapidly establish a target concentration, particularly for drugs with long half-lives.
Waiting several half-lives delays treatment, while intentionally lowering bioavailability or using subtherapeutic
maintenance doses undermines the therapeutic goal. Maintenance dosing subsequently replaces the amount
eliminated over time.
6. A strong CYP3A4 inhibitor is added to a regimen containing a CYP3A4 substrate with a narrow therapeutic index.
Theprescriber should anticipate:
A) Accelerated substrate metabolism and treatment failure
B) No interaction because CYP enzymes affect only absorption
C) Potentially increased substrate concentrations and toxicity
D) Loss of all renal elimination
Correct Answer: C) Potentially increased substrate concentrations and toxicity
Rationale: Inhibiting the enzyme responsible for a substrate's metabolism can raise its concentration and toxicity risk,
especially when the therapeutic index is narrow. Enzyme induction, not inhibition, tends to accelerate metabolism.
CYP interactions involve metabolism rather than only absorption, and hepatic enzyme inhibition does not abolish renal
elimination.
7. A CYP enzyme inducer is introduced during stable therapy with an active drug metabolized by that enzyme. Which
outcomeis most likely after induction develops?
A) Reduced drug exposure and possible loss of efficacy
B) Immediate irreversible receptor blockade
C) Increased exposure from slower metabolism
D) Guaranteed renal failure
Correct Answer: A) Reduced drug exposure and possible loss of efficacy
Rationale: Enzyme induction increases metabolic capacity and can lower concentrations of an active parent drug,
potentially reducing efficacy. The effect generally develops as enzyme expression changes rather than through
immediate receptor blockade. Increased exposure is more typical of inhibition, and induction does not inherently
cause renal failure.
8. Two drugs produce the same maximal effect, but Drug X achieves 50% of maximal effect at a lower concentration
than DrugY. Drug X has:
A) Greater potency
B) Greater maximal efficacy by definition
C) Lower affinity by definition
NURS 6521 Advanced Pharmacology - Original Practice Midterm | Page 3
