Fall SemeSter 2025 | VatI rN Pharmacology
comPreheNSIVe exam PreP | 450+ VerIFIed
PractIce QueStIoNS wIth correct aNSwerS &
detaIled ratIoNaleS | uPdated 2025–2026 Study
guIde For NurSINg StudeNtS, Nclex rN, aNd atI
Pharmacology maStery reVIew
Question 1:
A nurse is caring for a 65-year-old patient with hypertension who is prescribed lisinopril
20 mg daily. The patient reports a persistent dry cough that started two weeks after
initiation of the medication. The nurse recognizes this as a common side effect of ACE
inhibitors. Which action should the nurse take first?
A. Administer diphenhydramine to suppress the cough
B. Assess the patient's airway and respiratory status
C. Encourage the patient to increase fluid intake
D. Notify the provider to consider switching to an ARB like losartan
Rationale: Lisinopril, an ACE inhibitor, commonly causes a nonproductive dry cough
due to the accumulation of bradykinin in the lungs, affecting up to 20% of patients. This
is an application of pharmacological knowledge in monitoring for adverse effects. While
assessing respiratory status (B) is important, the first action is to notify the provider, as
switching to an angiotensin receptor blocker (ARB) like losartan resolves the cough in
most cases without losing antihypertensive efficacy. Options A and C do not address
the underlying mechanism and could mask symptoms or provide only temporary relief.
Nursing implications include educating patients on reporting this side effect early to
prevent discontinuation of therapy, which could lead to uncontrolled hypertension and
increased cardiovascular risk.
Question 2:
A postoperative patient is receiving morphine 2 mg IV every 4 hours as needed for pain.
The nurse notes the patient's respiratory rate has decreased to 10 breaths per minute,
and the patient is difficult to arouse. Which intervention should the nurse implement
immediately?
A. Administer flumazenil as a reversal agent
B. Stop the morphine infusion and administer naloxone
C. Increase the patient's oxygen flow rate to 6 L/min via nasal cannula
D. Position the patient in a semi-Fowler's position and reassess in 15 minutes
Rationale: Morphine, an opioid agonist, can cause respiratory depression through mu-
receptor activation in the brainstem, a life-threatening side effect requiring immediate
reversal. In this scenario, the patient's somnolence and bradypnea indicate opioid
overdose. Naloxone, an opioid antagonist, competitively binds to receptors to reverse
,effects, but the morphine must be stopped first to prevent re-sedation. Flumazenil (A) is
for benzodiazepine reversal, not opioids. Increasing oxygen (C) supports but does not
treat the cause, and delaying with repositioning (D) risks hypoxia and arrest. Application
in practice involves vigilant monitoring of sedation scores (e.g., Pasero Opioid-Induced
Sedation Scale) and vital signs in postoperative patients, with naloxone readily
available. Detailed nursing education on opioid titration prevents such events, aligning
with Joint Commission safety standards.
Question 3:
A patient with type 2 diabetes is started on metformin 500 mg twice daily. During the
health history, the nurse learns the patient has a history of chronic kidney disease with a
creatinine clearance of 40 mL/min. What is the most appropriate nursing action?
A. Proceed with the dose as ordered and monitor blood glucose daily
B. Hold the metformin and notify the provider for dose adjustment or alternative
therapy
C. Administer the medication with a full glass of water to enhance absorption
D. Teach the patient to take the medication at bedtime to minimize gastrointestinal
upset
Rationale: Metformin is contraindicated in patients with renal impairment (eGFR <45
mL/min) due to the risk of lactic acidosis from drug accumulation, a rare but fatal
complication. This application question tests understanding of pharmacokinetics and
contraindications in a vulnerable population. Holding the dose prevents harm, and
notifying the provider allows for alternatives like SGLT2 inhibitors or insulin. Proceeding
(A) risks acidosis, while hydration (C) or timing (D) does not mitigate renal clearance
issues. Nurses must apply evidence from FDA guidelines, routinely screening for renal
function via labs (e.g., serum creatinine) before and during therapy, and educating on
symptoms like muscle pain or fatigue to promote patient safety.
Question 4:
A nurse is administering vancomycin 1 g IV every 12 hours to a patient with MRSA
infection. The patient's trough level is 18 mcg/mL (therapeutic range 10-20 mcg/mL for
serious infections). The patient complains of tinnitus and a metallic taste. Which
nursing intervention is priority?
A. Continue the infusion and monitor for resolution of symptoms
B. Slow the infusion rate to prevent red man syndrome
C. Obtain stat audiometry testing and notify the provider
D. Administer diphenhydramine prophylactically with the next dose
Rationale: Vancomycin can cause ototoxicity (e.g., tinnitus, hearing loss) due to high
trough levels damaging the eighth cranial nerve, especially in prolonged therapy or renal
impairment. With a trough of 18 mcg/mL, the level is therapeutic but borderline high,
warranting close monitoring. Tinnitus signals potential toxicity, requiring immediate
,audiometry and provider notification for possible dose reduction or discontinuation.
Slowing infusion (B) addresses red man syndrome (histamine release), not ototoxicity.
Continuing (A) risks permanent damage, and diphenhydramine (D) is for infusion
reactions. Application involves therapeutic drug monitoring (TDM) protocols, with
nurses assessing for vestibular symptoms, ensuring peak/trough timing, and
collaborating on adjustments to balance efficacy against nephro- and oto-toxicity per
IDSA guidelines.
Question 5:
A 50-year-old patient with bipolar disorder is prescribed lithium carbonate 900 mg daily.
The nurse reviews labs showing a sodium level of 128 mEq/L and recent diuretic use for
hypertension. The patient reports nausea and hand tremors. What should the nurse
anticipate?
A. Continuation of lithium with increased hydration
B. Discontinuation of lithium due to risk of toxicity
C. Addition of an antipsychotic for symptom management
D. Switching to valproic acid as a mood stabilizer
Rationale: Lithium has a narrow therapeutic index (0.6-1.2 mEq/L), and hyponatremia
from diuretics (e.g., thiazides) reduces lithium clearance, elevating levels and causing
toxicity symptoms like nausea and tremors. This scenario applies pharmacodynamics
in polypharmacy contexts. Discontinuation prevents neurotoxicity (e.g., seizures,
coma), with urgent level checks. Hydration (A) helps mild cases but not with sodium
imbalance. Antipsychotics (C) or switching (D) are adjuncts, not immediate actions.
Nurses must monitor electrolytes, educate on dietary sodium consistency, and
recognize toxicity early, using tools like the Lithium Toxicity Rating Scale to guide
interventions and prevent hospitalization.
Question 6:
A patient receiving warfarin for atrial fibrillation has an INR of 3.8 (therapeutic 2-3). The
nurse notes the patient started a new prescription for fluconazole for a fungal infection.
Which nursing action is most appropriate?
A. Hold the next warfarin dose and recheck INR in 24 hours
B. Administer vitamin K 10 mg IV to reverse the elevation
C. Continue both medications and monitor for bleeding signs
D. Educate the patient on avoiding green leafy vegetables
Rationale: Fluconazole inhibits CYP2C9, reducing warfarin metabolism and increasing
INR, heightening bleeding risk (e.g., hemorrhage). This tests drug-drug interaction
knowledge in anticoagulation management. Holding warfarin allows INR stabilization
without over-correction; vitamin K (B) is for active bleeding or INR >10. Continuing (C) is
unsafe, and diet (D) is secondary. Application includes using interaction checkers (e.g.,
Lexicomp), frequent INR monitoring during new meds, and patient education on signs
, like hematuria. Per ACCP guidelines, this prevents thromboembolic or hemorrhagic
events in high-risk patients.
Question 7:
A nurse is preparing to administer insulin lispro to a patient with type 1 diabetes before
lunch. The patient's blood glucose is 150 mg/dL. The sliding scale orders rapid-acting
insulin for glucose >200 mg/dL. What should the nurse do?
A. Administer the scheduled dose regardless of the glucose level
B. Withhold the insulin and notify the provider of hypoglycemia risk
C. Give a correction dose based on the insulin sensitivity factor
D. Administer the full meal bolus and monitor postprandial glucose
Rationale: Insulin lispro is a rapid-acting analog used for prandial coverage to match
carbohydrate intake, not just correction. At 150 mg/dL (normal), the scheduled bolus
prevents post-meal hyperglycemia without hypoglycemia risk. Sliding scale (C) is for
corrections only. Withholding (B) risks spikes, and ignoring glucose (A) overlooks
holistic management. Application involves carb counting and basal-bolus regimens per
ADA standards; nurses calculate doses (e.g., 1 unit/15g carbs), teach injection sites,
and monitor for hypo/hyperglycemia, emphasizing individualized therapy to achieve
A1C <7%.
Question 8:
A patient with tuberculosis is on a regimen including isoniazid, rifampin, pyrazinamide,
and ethambutol. The nurse observes scleral icterus and dark urine in the patient. Which
medication is most likely responsible, and what is the priority nursing action?
A. Isoniazid; administer vitamin B6 to prevent neuropathy
B. Rifampin; monitor liver function tests and notify the provider
C. Pyrazinamide; encourage fluid intake to flush the system
D. Ethambutol; assess visual acuity immediately
Rationale: Rifampin is hepatotoxic, causing elevated liver enzymes, jaundice (scleral
icterus), and bilirubinuria (dark urine) in 1-2% of patients, especially with underlying
liver disease or alcohol use. This application scenario requires recognizing adverse
effects in multi-drug TB therapy. Priority is LFT monitoring (e.g., ALT/AST) and provider
notification for possible discontinuation or dose adjustment to prevent fulminant
hepatitis. Isoniazid (A) causes neuropathy, not hepatotoxicity primarily; pyrazinamide
(C) is also hepatotoxic but less associated with jaundice; ethambutol (D) affects vision.
Nurses apply CDC guidelines by baseline and monthly LFTs, educating on symptoms
like fatigue or abdominal pain, and ensuring DOT (directly observed therapy)
compliance while balancing treatment efficacy against toxicity.
comPreheNSIVe exam PreP | 450+ VerIFIed
PractIce QueStIoNS wIth correct aNSwerS &
detaIled ratIoNaleS | uPdated 2025–2026 Study
guIde For NurSINg StudeNtS, Nclex rN, aNd atI
Pharmacology maStery reVIew
Question 1:
A nurse is caring for a 65-year-old patient with hypertension who is prescribed lisinopril
20 mg daily. The patient reports a persistent dry cough that started two weeks after
initiation of the medication. The nurse recognizes this as a common side effect of ACE
inhibitors. Which action should the nurse take first?
A. Administer diphenhydramine to suppress the cough
B. Assess the patient's airway and respiratory status
C. Encourage the patient to increase fluid intake
D. Notify the provider to consider switching to an ARB like losartan
Rationale: Lisinopril, an ACE inhibitor, commonly causes a nonproductive dry cough
due to the accumulation of bradykinin in the lungs, affecting up to 20% of patients. This
is an application of pharmacological knowledge in monitoring for adverse effects. While
assessing respiratory status (B) is important, the first action is to notify the provider, as
switching to an angiotensin receptor blocker (ARB) like losartan resolves the cough in
most cases without losing antihypertensive efficacy. Options A and C do not address
the underlying mechanism and could mask symptoms or provide only temporary relief.
Nursing implications include educating patients on reporting this side effect early to
prevent discontinuation of therapy, which could lead to uncontrolled hypertension and
increased cardiovascular risk.
Question 2:
A postoperative patient is receiving morphine 2 mg IV every 4 hours as needed for pain.
The nurse notes the patient's respiratory rate has decreased to 10 breaths per minute,
and the patient is difficult to arouse. Which intervention should the nurse implement
immediately?
A. Administer flumazenil as a reversal agent
B. Stop the morphine infusion and administer naloxone
C. Increase the patient's oxygen flow rate to 6 L/min via nasal cannula
D. Position the patient in a semi-Fowler's position and reassess in 15 minutes
Rationale: Morphine, an opioid agonist, can cause respiratory depression through mu-
receptor activation in the brainstem, a life-threatening side effect requiring immediate
reversal. In this scenario, the patient's somnolence and bradypnea indicate opioid
overdose. Naloxone, an opioid antagonist, competitively binds to receptors to reverse
,effects, but the morphine must be stopped first to prevent re-sedation. Flumazenil (A) is
for benzodiazepine reversal, not opioids. Increasing oxygen (C) supports but does not
treat the cause, and delaying with repositioning (D) risks hypoxia and arrest. Application
in practice involves vigilant monitoring of sedation scores (e.g., Pasero Opioid-Induced
Sedation Scale) and vital signs in postoperative patients, with naloxone readily
available. Detailed nursing education on opioid titration prevents such events, aligning
with Joint Commission safety standards.
Question 3:
A patient with type 2 diabetes is started on metformin 500 mg twice daily. During the
health history, the nurse learns the patient has a history of chronic kidney disease with a
creatinine clearance of 40 mL/min. What is the most appropriate nursing action?
A. Proceed with the dose as ordered and monitor blood glucose daily
B. Hold the metformin and notify the provider for dose adjustment or alternative
therapy
C. Administer the medication with a full glass of water to enhance absorption
D. Teach the patient to take the medication at bedtime to minimize gastrointestinal
upset
Rationale: Metformin is contraindicated in patients with renal impairment (eGFR <45
mL/min) due to the risk of lactic acidosis from drug accumulation, a rare but fatal
complication. This application question tests understanding of pharmacokinetics and
contraindications in a vulnerable population. Holding the dose prevents harm, and
notifying the provider allows for alternatives like SGLT2 inhibitors or insulin. Proceeding
(A) risks acidosis, while hydration (C) or timing (D) does not mitigate renal clearance
issues. Nurses must apply evidence from FDA guidelines, routinely screening for renal
function via labs (e.g., serum creatinine) before and during therapy, and educating on
symptoms like muscle pain or fatigue to promote patient safety.
Question 4:
A nurse is administering vancomycin 1 g IV every 12 hours to a patient with MRSA
infection. The patient's trough level is 18 mcg/mL (therapeutic range 10-20 mcg/mL for
serious infections). The patient complains of tinnitus and a metallic taste. Which
nursing intervention is priority?
A. Continue the infusion and monitor for resolution of symptoms
B. Slow the infusion rate to prevent red man syndrome
C. Obtain stat audiometry testing and notify the provider
D. Administer diphenhydramine prophylactically with the next dose
Rationale: Vancomycin can cause ototoxicity (e.g., tinnitus, hearing loss) due to high
trough levels damaging the eighth cranial nerve, especially in prolonged therapy or renal
impairment. With a trough of 18 mcg/mL, the level is therapeutic but borderline high,
warranting close monitoring. Tinnitus signals potential toxicity, requiring immediate
,audiometry and provider notification for possible dose reduction or discontinuation.
Slowing infusion (B) addresses red man syndrome (histamine release), not ototoxicity.
Continuing (A) risks permanent damage, and diphenhydramine (D) is for infusion
reactions. Application involves therapeutic drug monitoring (TDM) protocols, with
nurses assessing for vestibular symptoms, ensuring peak/trough timing, and
collaborating on adjustments to balance efficacy against nephro- and oto-toxicity per
IDSA guidelines.
Question 5:
A 50-year-old patient with bipolar disorder is prescribed lithium carbonate 900 mg daily.
The nurse reviews labs showing a sodium level of 128 mEq/L and recent diuretic use for
hypertension. The patient reports nausea and hand tremors. What should the nurse
anticipate?
A. Continuation of lithium with increased hydration
B. Discontinuation of lithium due to risk of toxicity
C. Addition of an antipsychotic for symptom management
D. Switching to valproic acid as a mood stabilizer
Rationale: Lithium has a narrow therapeutic index (0.6-1.2 mEq/L), and hyponatremia
from diuretics (e.g., thiazides) reduces lithium clearance, elevating levels and causing
toxicity symptoms like nausea and tremors. This scenario applies pharmacodynamics
in polypharmacy contexts. Discontinuation prevents neurotoxicity (e.g., seizures,
coma), with urgent level checks. Hydration (A) helps mild cases but not with sodium
imbalance. Antipsychotics (C) or switching (D) are adjuncts, not immediate actions.
Nurses must monitor electrolytes, educate on dietary sodium consistency, and
recognize toxicity early, using tools like the Lithium Toxicity Rating Scale to guide
interventions and prevent hospitalization.
Question 6:
A patient receiving warfarin for atrial fibrillation has an INR of 3.8 (therapeutic 2-3). The
nurse notes the patient started a new prescription for fluconazole for a fungal infection.
Which nursing action is most appropriate?
A. Hold the next warfarin dose and recheck INR in 24 hours
B. Administer vitamin K 10 mg IV to reverse the elevation
C. Continue both medications and monitor for bleeding signs
D. Educate the patient on avoiding green leafy vegetables
Rationale: Fluconazole inhibits CYP2C9, reducing warfarin metabolism and increasing
INR, heightening bleeding risk (e.g., hemorrhage). This tests drug-drug interaction
knowledge in anticoagulation management. Holding warfarin allows INR stabilization
without over-correction; vitamin K (B) is for active bleeding or INR >10. Continuing (C) is
unsafe, and diet (D) is secondary. Application includes using interaction checkers (e.g.,
Lexicomp), frequent INR monitoring during new meds, and patient education on signs
, like hematuria. Per ACCP guidelines, this prevents thromboembolic or hemorrhagic
events in high-risk patients.
Question 7:
A nurse is preparing to administer insulin lispro to a patient with type 1 diabetes before
lunch. The patient's blood glucose is 150 mg/dL. The sliding scale orders rapid-acting
insulin for glucose >200 mg/dL. What should the nurse do?
A. Administer the scheduled dose regardless of the glucose level
B. Withhold the insulin and notify the provider of hypoglycemia risk
C. Give a correction dose based on the insulin sensitivity factor
D. Administer the full meal bolus and monitor postprandial glucose
Rationale: Insulin lispro is a rapid-acting analog used for prandial coverage to match
carbohydrate intake, not just correction. At 150 mg/dL (normal), the scheduled bolus
prevents post-meal hyperglycemia without hypoglycemia risk. Sliding scale (C) is for
corrections only. Withholding (B) risks spikes, and ignoring glucose (A) overlooks
holistic management. Application involves carb counting and basal-bolus regimens per
ADA standards; nurses calculate doses (e.g., 1 unit/15g carbs), teach injection sites,
and monitor for hypo/hyperglycemia, emphasizing individualized therapy to achieve
A1C <7%.
Question 8:
A patient with tuberculosis is on a regimen including isoniazid, rifampin, pyrazinamide,
and ethambutol. The nurse observes scleral icterus and dark urine in the patient. Which
medication is most likely responsible, and what is the priority nursing action?
A. Isoniazid; administer vitamin B6 to prevent neuropathy
B. Rifampin; monitor liver function tests and notify the provider
C. Pyrazinamide; encourage fluid intake to flush the system
D. Ethambutol; assess visual acuity immediately
Rationale: Rifampin is hepatotoxic, causing elevated liver enzymes, jaundice (scleral
icterus), and bilirubinuria (dark urine) in 1-2% of patients, especially with underlying
liver disease or alcohol use. This application scenario requires recognizing adverse
effects in multi-drug TB therapy. Priority is LFT monitoring (e.g., ALT/AST) and provider
notification for possible discontinuation or dose adjustment to prevent fulminant
hepatitis. Isoniazid (A) causes neuropathy, not hepatotoxicity primarily; pyrazinamide
(C) is also hepatotoxic but less associated with jaundice; ethambutol (D) affects vision.
Nurses apply CDC guidelines by baseline and monthly LFTs, educating on symptoms
like fatigue or abdominal pain, and ensuring DOT (directly observed therapy)
compliance while balancing treatment efficacy against toxicity.
