D116 NURS 6800
Advanced Pharmacology
Objective Assessment
Review
(With Solutions)
2025
,1. A 65-year-old woman with new-onset atrial fibrillation is started on warfarin.
On day 5 her INR is 1.8 (target 2.0–3.0). What should the APRN do?
a. Increase warfarin dose by 10%
b. Continue current dose and recheck INR in 2 days
c. Hold warfarin for one dose and restart at same dose
d. Add low-molecular-weight heparin bridging
ANS: a. Increase warfarin dose by 10%
Rationale: An INR below target on day 5 indicates under-anticoagulation; a
modest dose increase optimizes therapeutic effect without excessive
overshoot.
2. A 42-year-old man with type 2 diabetes and an eGFR of 25 mL/min needs
glycemic control. Which agent is safest?
a. Metformin
b. Glyburide
c. Sitagliptin
d. Exenatide
ANS: c. Sitagliptin
Rationale: Sitagliptin can be dose-adjusted in CKD stages 3–4; metformin is
contraindicated at eGFR <30 mL/min, glyburide risks hypoglycemia, exenatide
accumulates.
3. A patient on high-dose opioids develops refractory constipation despite
laxatives. Which adjunct is most appropriate?
a. Methylnaltrexone
b. Diphenoxylate
c. Loperamide
d. Dicyclomine
ANS: a. Methylnaltrexone
Rationale: Methylnaltrexone antagonizes peripheral μ-opioid receptors in the
gut without reversing central analgesia.
4. In severe sepsis, a 70-year-old man on vancomycin has a trough of 10
µg/mL (goal 15–20 µg/mL). Next step?
a. Decrease dose
b. Shorten dosing interval
c. Switch to linezolid
d. Extend dosing interval
, ANS: b. Shorten dosing interval
Rationale: A subtherapeutic trough requires either increasing dose or more
frequent dosing; interval shortening raises trough concentrations.
5. A 25-year-old with acute bronchospasm receives nebulized albuterol and
reports tremor and tachycardia. Which mechanism explains these effects?
a. β₁‐adrenergic stimulation
b. β₂‐adrenergic stimulation
c. α₁‐adrenergic blockade
d. Muscarinic receptor antagonism
ANS: b. β₂‐adrenergic stimulation
Rationale: Albuterol at high doses spills over to β₁ receptors (tachycardia)
and stimulates β₂ receptors in skeletal muscle (tremor).
6. A 55-year-old on simvastatin develops myalgias and elevated CK. Which
interaction is most likely?
a. Simvastatin + amlodipine
b. Simvastatin + diltiazem
c. Simvastatin + lisinopril
d. Simvastatin + metoprolol
ANS: b. Simvastatin + diltiazem
Rationale: Diltiazem inhibits CYP3A4, raising simvastatin levels and
increasing myopathy risk.
7. A ventilated patient requires benzodiazepine sedation. Which drug poses
the least risk of prolonged sedation in organ failure?
a. Diazepam
b. Lorazepam
c. Midazolam
d. Chlordiazepoxide
ANS: b. Lorazepam
Rationale: Lorazepam is metabolized by glucuronidation to inactive
conjugates, reducing accumulation in hepatic or renal impairment.
8. A rheumatoid arthritis patient on methotrexate shows rising transaminases.
What is the best next step?
a. Add folinic acid
, b. Discontinue methotrexate
c. Switch to azathioprine
d. Increase dosing interval
ANS: a. Add folinic acid
Rationale: Folinic acid rescue mitigates methotrexate hepatotoxicity while
preserving its therapeutic effect; discontinuation is reserved for severe injury.
9. A 68-year-old with osteoporosis and GERD uses a PPI. Which
bisphosphonate avoids gastrointestinal absorption issues?
a. Alendronate daily orally
b. Zoledronic acid IV yearly
c. Risedronate monthly orally
d. Ibandronate orally every 3 months
ANS: b. Zoledronic acid IV yearly
Rationale: IV zoledronic acid bypasses GI tract, avoiding interactions with
acid suppression.
10. A patient in status epilepticus receives rapid IV phenytoin and becomes
hypotensive. Which explains this adverse effect?
a. Nitric oxide–mediated vasodilation
b. Direct cardiac sodium‐channel blockade
c. Histamine release causing vasodilation
d. α₁‐adrenergic receptor blockade
ANS: c. Histamine release causing vasodilation
Rationale: Rapid phenytoin infusion can trigger histamine release, leading to
peripheral vasodilation and hypotension.
11. A post-PCI patient on clopidogrel is a CYP2C19 poor metabolizer. What
modification is indicated?
a. Increase clopidogrel dose
b. Switch to prasugrel
c. Add aspirin
d. Discontinue antiplatelet therapy
ANS: b. Switch to prasugrel
Rationale: Prasugrel is less dependent on CYP2C19 for activation, ensuring
consistent platelet inhibition.
Advanced Pharmacology
Objective Assessment
Review
(With Solutions)
2025
,1. A 65-year-old woman with new-onset atrial fibrillation is started on warfarin.
On day 5 her INR is 1.8 (target 2.0–3.0). What should the APRN do?
a. Increase warfarin dose by 10%
b. Continue current dose and recheck INR in 2 days
c. Hold warfarin for one dose and restart at same dose
d. Add low-molecular-weight heparin bridging
ANS: a. Increase warfarin dose by 10%
Rationale: An INR below target on day 5 indicates under-anticoagulation; a
modest dose increase optimizes therapeutic effect without excessive
overshoot.
2. A 42-year-old man with type 2 diabetes and an eGFR of 25 mL/min needs
glycemic control. Which agent is safest?
a. Metformin
b. Glyburide
c. Sitagliptin
d. Exenatide
ANS: c. Sitagliptin
Rationale: Sitagliptin can be dose-adjusted in CKD stages 3–4; metformin is
contraindicated at eGFR <30 mL/min, glyburide risks hypoglycemia, exenatide
accumulates.
3. A patient on high-dose opioids develops refractory constipation despite
laxatives. Which adjunct is most appropriate?
a. Methylnaltrexone
b. Diphenoxylate
c. Loperamide
d. Dicyclomine
ANS: a. Methylnaltrexone
Rationale: Methylnaltrexone antagonizes peripheral μ-opioid receptors in the
gut without reversing central analgesia.
4. In severe sepsis, a 70-year-old man on vancomycin has a trough of 10
µg/mL (goal 15–20 µg/mL). Next step?
a. Decrease dose
b. Shorten dosing interval
c. Switch to linezolid
d. Extend dosing interval
, ANS: b. Shorten dosing interval
Rationale: A subtherapeutic trough requires either increasing dose or more
frequent dosing; interval shortening raises trough concentrations.
5. A 25-year-old with acute bronchospasm receives nebulized albuterol and
reports tremor and tachycardia. Which mechanism explains these effects?
a. β₁‐adrenergic stimulation
b. β₂‐adrenergic stimulation
c. α₁‐adrenergic blockade
d. Muscarinic receptor antagonism
ANS: b. β₂‐adrenergic stimulation
Rationale: Albuterol at high doses spills over to β₁ receptors (tachycardia)
and stimulates β₂ receptors in skeletal muscle (tremor).
6. A 55-year-old on simvastatin develops myalgias and elevated CK. Which
interaction is most likely?
a. Simvastatin + amlodipine
b. Simvastatin + diltiazem
c. Simvastatin + lisinopril
d. Simvastatin + metoprolol
ANS: b. Simvastatin + diltiazem
Rationale: Diltiazem inhibits CYP3A4, raising simvastatin levels and
increasing myopathy risk.
7. A ventilated patient requires benzodiazepine sedation. Which drug poses
the least risk of prolonged sedation in organ failure?
a. Diazepam
b. Lorazepam
c. Midazolam
d. Chlordiazepoxide
ANS: b. Lorazepam
Rationale: Lorazepam is metabolized by glucuronidation to inactive
conjugates, reducing accumulation in hepatic or renal impairment.
8. A rheumatoid arthritis patient on methotrexate shows rising transaminases.
What is the best next step?
a. Add folinic acid
, b. Discontinue methotrexate
c. Switch to azathioprine
d. Increase dosing interval
ANS: a. Add folinic acid
Rationale: Folinic acid rescue mitigates methotrexate hepatotoxicity while
preserving its therapeutic effect; discontinuation is reserved for severe injury.
9. A 68-year-old with osteoporosis and GERD uses a PPI. Which
bisphosphonate avoids gastrointestinal absorption issues?
a. Alendronate daily orally
b. Zoledronic acid IV yearly
c. Risedronate monthly orally
d. Ibandronate orally every 3 months
ANS: b. Zoledronic acid IV yearly
Rationale: IV zoledronic acid bypasses GI tract, avoiding interactions with
acid suppression.
10. A patient in status epilepticus receives rapid IV phenytoin and becomes
hypotensive. Which explains this adverse effect?
a. Nitric oxide–mediated vasodilation
b. Direct cardiac sodium‐channel blockade
c. Histamine release causing vasodilation
d. α₁‐adrenergic receptor blockade
ANS: c. Histamine release causing vasodilation
Rationale: Rapid phenytoin infusion can trigger histamine release, leading to
peripheral vasodilation and hypotension.
11. A post-PCI patient on clopidogrel is a CYP2C19 poor metabolizer. What
modification is indicated?
a. Increase clopidogrel dose
b. Switch to prasugrel
c. Add aspirin
d. Discontinue antiplatelet therapy
ANS: b. Switch to prasugrel
Rationale: Prasugrel is less dependent on CYP2C19 for activation, ensuring
consistent platelet inhibition.
