NUR 531
Interprofessional Leadership in
Healthcare
Proctored Midterm Exam
2026
(With Solutions)
1. Case: A 68-year-old with progressive dyspnea, orthopnea, and 3+ pitting edema. BNP is
markedly elevated and chest x-ray shows cardiomegaly.
Question: Which pathophysiologic mechanism best explains his symptoms?
o A. Decreased pulmonary surfactant production
o B. Left ventricular systolic dysfunction causing increased pulmonary venous
pressure
o C. Primary pulmonary vascular obstruction
o D. Diaphragmatic paralysis
Answer: B. Left ventricular systolic dysfunction causing increased pulmonary
venous pressure
Rationale: LV systolic failure raises left atrial and pulmonary venous pressures,
producing pulmonary congestion, orthopnea, and peripheral edema consistent
with congestive heart failure.
2. Case: A 45-year-old with community-acquired pneumonia is started on levofloxacin. He
is also taking tizanidine for spasticity.
Question: What is the most important drug interaction concern?
o A. Increased risk of serotonin syndrome
o B. Reduced antibiotic efficacy due to enzyme induction
o C. Excessive hypotension from additive vasodilation
o D. Severe hypotension and sedation from CYP1A2 inhibition increasing tizanidine
levels
Answer: D. Severe hypotension and sedation from CYP1A2 inhibition increasing
tizanidine levels
Rationale: Fluoroquinolones inhibit CYP1A2 and can raise tizanidine
concentrations, causing profound hypotension and sedation; coadministration is
contraindicated.
3. Case: A 30-year-old presents with acute onset severe abdominal pain, hypotension, and
a rigid abdomen. Labs show leukocytosis and elevated lactate.
Question: Which diagnosis is most consistent with this presentation?
o A. Acute pancreatitis
, o B. Perforated viscus with secondary peritonitis and sepsis
o C. Small bowel obstruction without strangulation
o D. Viral gastroenteritis
Answer: B. Perforated viscus with secondary peritonitis and sepsis
Rationale: Rigid abdomen, hypotension, leukocytosis, and elevated lactate
indicate peritonitis with systemic inflammatory response and possible septic
shock from perforation.
4. Case: A 72-year-old on warfarin presents with new atrial fibrillation and is started on
amiodarone. INR increases markedly.
Question: What is the mechanism for the interaction?
o A. Amiodarone induces CYP3A4 increasing warfarin clearance
o B. Amiodarone inhibits warfarin metabolism via CYP inhibition increasing INR
o C. Amiodarone increases vitamin K synthesis
o D. Amiodarone chelates warfarin in the gut
Answer: B. Amiodarone inhibits warfarin metabolism via CYP inhibition
increasing INR
Rationale: Amiodarone inhibits multiple CYP enzymes, reducing warfarin
clearance and potentiating anticoagulation, requiring warfarin dose reduction
and close INR monitoring.
5. Case: A 55-year-old with chronic kidney disease stage 4 develops hyperphosphatemia
and secondary hyperparathyroidism.
Question: Which pathophysiologic change drives secondary hyperparathyroidism in
CKD?
o A. Increased renal 1-alpha hydroxylase activity
o B. Decreased calcitriol production leading to hypocalcemia and PTH elevation
o C. Excess intestinal calcium absorption
o D. Primary parathyroid adenoma
Answer: B. Decreased calcitriol production leading to hypocalcemia and PTH
elevation
Rationale: CKD reduces 1-alpha hydroxylase activity, lowering calcitriol, causing
hypocalcemia and phosphate retention that stimulate PTH secretion (secondary
hyperparathyroidism).
6. Case: A 28-year-old with status epilepticus receives IV lorazepam followed by IV
fosphenytoin. Which pharmacokinetic property of fosphenytoin is clinically important?
o A. Zero-order kinetics at therapeutic concentrations
o B. High oral bioavailability only
o C. Rapid conversion to phenytoin with predictable loading dose when given IV
o D. Exclusively renal elimination
Answer: C. Rapid conversion to phenytoin with predictable loading dose when
given IV
Rationale: Fosphenytoin is a prodrug rapidly converted to phenytoin; IV dosing
allows rapid attainment of therapeutic levels and is preferred in status
epilepticus.
7. Case: A 60-year-old with suspected pulmonary embolism has a Wells score indicating
moderate probability. D-dimer is elevated. Which imaging is most appropriate next?
o A. Ventilation–perfusion scan only
, o B. CT pulmonary angiography (CTPA)
o C. Lower extremity ultrasound only
o D. Chest x-ray
Answer: B. CT pulmonary angiography (CTPA)
Rationale: In moderate to high pretest probability with positive D-dimer, CTPA is
the diagnostic imaging of choice for PE.
8. Case: A patient with severe sepsis requires vasopressor support. Norepinephrine is
chosen as first-line. What is the primary physiologic effect that supports its use?
o A. Pure β₂ agonism causing vasodilation
o B. α₁-mediated vasoconstriction increasing systemic vascular resistance and MAP
o C. Dopaminergic renal vasodilation only
o D. Direct myocardial suppression
Answer: B. α₁-mediated vasoconstriction increasing systemic vascular
resistance and MAP
Rationale: Norepinephrine’s α₁ effects raise SVR and MAP, improving perfusion
pressure in septic shock while modestly increasing cardiac output.
9. Case: A 40-year-old with newly diagnosed type 1 diabetes presents with polyuria and
Kussmaul respirations. Serum potassium is 5.8 mEq/L. Which statement is correct
regarding potassium management during DKA treatment?
o A. Start insulin immediately without checking K⁺
o B. If K⁺ >5.5, delay potassium replacement but monitor closely as insulin will
lower serum K⁺
o C. Give large potassium bolus regardless of level
o D. Potassium is not affected by insulin therapy
Answer: B. If K⁺ >5.5, delay potassium replacement but monitor closely as
insulin will lower serum K⁺
Rationale: Insulin drives K⁺ intracellularly; if initial K⁺ is high, replacement can be
withheld but frequent monitoring is required because levels fall with insulin and
fluids.
10. Case: A 67-year-old with chronic atrial fibrillation is started on dabigatran. Which
adverse effect requires patient counseling and monitoring?
o A. Hypoglycemia
o B. Bleeding risk and need for renal function monitoring
o C. Ototoxicity
o D. Thyroid dysfunction
Answer: B. Bleeding risk and need for renal function monitoring
Rationale: Dabigatran is renally cleared; impaired renal function increases
bleeding risk and dosing adjustments or alternative agents may be needed.
Section B: True / False (10 statements)
11. Statement: In acute respiratory distress syndrome (ARDS), lung compliance is typically
increased.
Answer: False
Rationale: ARDS causes stiff, noncompliant lungs due to alveolar flooding and
inflammation.
12. Statement: A drug with a large volume of distribution is primarily confined to the
Interprofessional Leadership in
Healthcare
Proctored Midterm Exam
2026
(With Solutions)
1. Case: A 68-year-old with progressive dyspnea, orthopnea, and 3+ pitting edema. BNP is
markedly elevated and chest x-ray shows cardiomegaly.
Question: Which pathophysiologic mechanism best explains his symptoms?
o A. Decreased pulmonary surfactant production
o B. Left ventricular systolic dysfunction causing increased pulmonary venous
pressure
o C. Primary pulmonary vascular obstruction
o D. Diaphragmatic paralysis
Answer: B. Left ventricular systolic dysfunction causing increased pulmonary
venous pressure
Rationale: LV systolic failure raises left atrial and pulmonary venous pressures,
producing pulmonary congestion, orthopnea, and peripheral edema consistent
with congestive heart failure.
2. Case: A 45-year-old with community-acquired pneumonia is started on levofloxacin. He
is also taking tizanidine for spasticity.
Question: What is the most important drug interaction concern?
o A. Increased risk of serotonin syndrome
o B. Reduced antibiotic efficacy due to enzyme induction
o C. Excessive hypotension from additive vasodilation
o D. Severe hypotension and sedation from CYP1A2 inhibition increasing tizanidine
levels
Answer: D. Severe hypotension and sedation from CYP1A2 inhibition increasing
tizanidine levels
Rationale: Fluoroquinolones inhibit CYP1A2 and can raise tizanidine
concentrations, causing profound hypotension and sedation; coadministration is
contraindicated.
3. Case: A 30-year-old presents with acute onset severe abdominal pain, hypotension, and
a rigid abdomen. Labs show leukocytosis and elevated lactate.
Question: Which diagnosis is most consistent with this presentation?
o A. Acute pancreatitis
, o B. Perforated viscus with secondary peritonitis and sepsis
o C. Small bowel obstruction without strangulation
o D. Viral gastroenteritis
Answer: B. Perforated viscus with secondary peritonitis and sepsis
Rationale: Rigid abdomen, hypotension, leukocytosis, and elevated lactate
indicate peritonitis with systemic inflammatory response and possible septic
shock from perforation.
4. Case: A 72-year-old on warfarin presents with new atrial fibrillation and is started on
amiodarone. INR increases markedly.
Question: What is the mechanism for the interaction?
o A. Amiodarone induces CYP3A4 increasing warfarin clearance
o B. Amiodarone inhibits warfarin metabolism via CYP inhibition increasing INR
o C. Amiodarone increases vitamin K synthesis
o D. Amiodarone chelates warfarin in the gut
Answer: B. Amiodarone inhibits warfarin metabolism via CYP inhibition
increasing INR
Rationale: Amiodarone inhibits multiple CYP enzymes, reducing warfarin
clearance and potentiating anticoagulation, requiring warfarin dose reduction
and close INR monitoring.
5. Case: A 55-year-old with chronic kidney disease stage 4 develops hyperphosphatemia
and secondary hyperparathyroidism.
Question: Which pathophysiologic change drives secondary hyperparathyroidism in
CKD?
o A. Increased renal 1-alpha hydroxylase activity
o B. Decreased calcitriol production leading to hypocalcemia and PTH elevation
o C. Excess intestinal calcium absorption
o D. Primary parathyroid adenoma
Answer: B. Decreased calcitriol production leading to hypocalcemia and PTH
elevation
Rationale: CKD reduces 1-alpha hydroxylase activity, lowering calcitriol, causing
hypocalcemia and phosphate retention that stimulate PTH secretion (secondary
hyperparathyroidism).
6. Case: A 28-year-old with status epilepticus receives IV lorazepam followed by IV
fosphenytoin. Which pharmacokinetic property of fosphenytoin is clinically important?
o A. Zero-order kinetics at therapeutic concentrations
o B. High oral bioavailability only
o C. Rapid conversion to phenytoin with predictable loading dose when given IV
o D. Exclusively renal elimination
Answer: C. Rapid conversion to phenytoin with predictable loading dose when
given IV
Rationale: Fosphenytoin is a prodrug rapidly converted to phenytoin; IV dosing
allows rapid attainment of therapeutic levels and is preferred in status
epilepticus.
7. Case: A 60-year-old with suspected pulmonary embolism has a Wells score indicating
moderate probability. D-dimer is elevated. Which imaging is most appropriate next?
o A. Ventilation–perfusion scan only
, o B. CT pulmonary angiography (CTPA)
o C. Lower extremity ultrasound only
o D. Chest x-ray
Answer: B. CT pulmonary angiography (CTPA)
Rationale: In moderate to high pretest probability with positive D-dimer, CTPA is
the diagnostic imaging of choice for PE.
8. Case: A patient with severe sepsis requires vasopressor support. Norepinephrine is
chosen as first-line. What is the primary physiologic effect that supports its use?
o A. Pure β₂ agonism causing vasodilation
o B. α₁-mediated vasoconstriction increasing systemic vascular resistance and MAP
o C. Dopaminergic renal vasodilation only
o D. Direct myocardial suppression
Answer: B. α₁-mediated vasoconstriction increasing systemic vascular
resistance and MAP
Rationale: Norepinephrine’s α₁ effects raise SVR and MAP, improving perfusion
pressure in septic shock while modestly increasing cardiac output.
9. Case: A 40-year-old with newly diagnosed type 1 diabetes presents with polyuria and
Kussmaul respirations. Serum potassium is 5.8 mEq/L. Which statement is correct
regarding potassium management during DKA treatment?
o A. Start insulin immediately without checking K⁺
o B. If K⁺ >5.5, delay potassium replacement but monitor closely as insulin will
lower serum K⁺
o C. Give large potassium bolus regardless of level
o D. Potassium is not affected by insulin therapy
Answer: B. If K⁺ >5.5, delay potassium replacement but monitor closely as
insulin will lower serum K⁺
Rationale: Insulin drives K⁺ intracellularly; if initial K⁺ is high, replacement can be
withheld but frequent monitoring is required because levels fall with insulin and
fluids.
10. Case: A 67-year-old with chronic atrial fibrillation is started on dabigatran. Which
adverse effect requires patient counseling and monitoring?
o A. Hypoglycemia
o B. Bleeding risk and need for renal function monitoring
o C. Ototoxicity
o D. Thyroid dysfunction
Answer: B. Bleeding risk and need for renal function monitoring
Rationale: Dabigatran is renally cleared; impaired renal function increases
bleeding risk and dosing adjustments or alternative agents may be needed.
Section B: True / False (10 statements)
11. Statement: In acute respiratory distress syndrome (ARDS), lung compliance is typically
increased.
Answer: False
Rationale: ARDS causes stiff, noncompliant lungs due to alveolar flooding and
inflammation.
12. Statement: A drug with a large volume of distribution is primarily confined to the
