NR 567 Advanced Pharmacology AGACNP
ACTUAL EXAM 2026/2027: 100% Verified
Questions & Correct Answers
Question 1: A 68-year-old intubated septic shock patient on norepinephrine 0.3 mcg/kg/min (MAP
58 mmHg) is receiving empiric piperacillin-tazobactam 4.5 g q8h by intermittent bolus. Creatinine
clearance (measured 8-hr urine) is 35 mL/min. Which antimicrobial adjustment is MOST urgent?
A. Reduce piperacillin-tazobactam to 3.375 g q8h
B. Convert to extended-infusion 4.5 g over 3 h q8h
C. Switch to cefepime 1 g q12h
D. Increase frequency to 4.5 g q6h
Correct Answer: B
Rationale: In septic shock with CRCL <40 mL/min, standard intermittent dosing produces
sub-therapeutic peaks; extended-infusion maintains %T>MIC ≥50% for piperacillin against common
Gram-negatives while accounting for renal impairment per 2021 Surviving Sepsis Campaign
pharmacokinetic recommendations.
Question 2: A 55-year-old post-ROSC after VF arrest now on amiodarone 1 mg/min is developing
torsades de pointes (QTc 540 ms). Magnesium 2 g IV has failed. Next agent?
A. Lidocaine 1 mg/kg IV push
B. Isoproterenol 2 mcg/min
C. Esmolol 500 mcg/kg bolus then 50 mcg/kg/min
D. Procainamide 20 mg/min load
Correct Answer: B
Rationale: Overdrive pacing via isoproterenol shortens ventricular repolarization and suppresses
re-entry in acquired torsades; amiodarone’s class III effect prolongs QT further, making additional
sodium-channel blockade (lidocaine/procainamide) or β-blockade (esmolol) contraindicated.
Question 3: A 72 kg intubated COVID-ARDS patient (PF ratio 85) is on cisatracurium 3 mcg/kg/min.
Train-of-four is 0/4 with no twitches. Which paralytic-sparing strategy preserves ventilator
synchrony and avoids ICU-acquired weakness?
A. Add dexmedetomidine 0.2 mcg/kg/h and reduce cisatracurium to 1 mcg/kg/min
B. Switch to atracurium 5 mg q30min PRN
,C. Stop cisatracurium immediately; maintain propofol 50 mcg/kg/min
D. Add intermittent midazolam 2 mg q2h
Correct Answer: A
Rationale: Deep sedation with dexmedetomidine permits rapid-shallow breathing index reduction,
allowing 60-70% dose reduction of cisatracurium while maintaining ventilator synchrony; continuous
infusions >48 h correlate with ICU-AW, but low-dose adjunctive α2-agonist spares neuromuscular
blockade per 2022 SCCM guidelines.
Question 4: A 64-year-old on apixaban 5 mg BID for AF presents with GI bleed (Hb 7.2 g/dL). INR is
1.7, apixaban last taken 6 h ago. Which reversal sequence is MOST appropriate?
A. 4-factor PCC 50 units/kg IV + oral activated charcoal 50 g
B. Andexanet alfa 400 mg IV bolus then 4 mg/min × 120 min
C. Tranexamic acid 1 g IV q8h × 24 h
D. Vitamin K 10 mg IV × 1
Correct Answer: B
Rationale: Andexanet alfa is FDA-approved for life-threatening apixaban-related bleeding within 8
h; it rapidly restores thrombin generation (>90% in 2 min) and reduces anti-Xa activity by ≥90%,
outperforming PCC in ANNEXA-4 trial.
Question 5: A 78-year-old with acute hypercapnic COPD exacerbation (pH 7.22, PaCO₂ 78 mmHg)
is receiving BiPAP 18/6 cmH₂O. Heart rate 124, BP 166/92. Which pharmacologic intervention best
unloads respiratory muscles without worsening acidosis?
A. IV morphine 2 mg q1h PRN
B. Nebulized albuterol 5 mg + ipratropium 0.5 mg q20min × 3
C. IV dexmedetomidine 0.4 mcg/kg/h
D. IV ketamine 0.5 mg/kg bolus then 0.2 mg/kg/h
Correct Answer: D
Rationale: Low-dose ketamine provides dissociative analgesia/sedation, reduces dyspnea
perception, and preserves respiratory drive while decreasing oxygen consumption; unlike opioids it
does not accumulate to worsen hypercapnia and maintains airway reflexes.
Question 6: A 34-week pregnant eclamptic patient is on magnesium sulfate 2 g/h after 4 g load.
DTR 1+, urine output 25 mL/h, Mg level 3.8 mEq/L. Next step?
A. Stop infusion; give calcium gluconate 1 g IV
B. Continue current rate; recheck Mg in 4 h
C. Reduce to 1 g/h; add hydralazine 10 mg IV
D. Switch to labetalol 20 mg IV q10min
Correct Answer: A
,Rationale: Mg >3.5 mEq/L with clinical toxicity (decreased DTRs, oliguria) mandates immediate
cessation and 1 g calcium gluconate to antagonize cardiac/neuromuscular effects; further dosing
risks respiratory arrest per ACOG 2023 preeclampsia guidelines.
Question 7: A 22-year-old salicylate overdose (ASA 90 mg/kg ingested 4 h ago) has arterial pH
7.48, PaCO₂ 20 mmHg, HCO₃ 18 mEq/L, and tinnitus. Urine pH 6.0. Which intervention maximizes
salicylate elimination?
A. IV sodium bicarbonate 150 mEq in 1 L D5W at 250 mL/h to target urine pH ≥7.5
B. Acetazolamide 250 mg IV q6h
C. N-acetylcysteine 140 mg/kg load
D. HD initiated when ASA >60 mg/dL
Correct Answer: A
Rationale: Alkalinization traps ionized salicylate in urine, increasing renal clearance 5-10 fold;
maintaining urine pH ≥7.5 is superior to dialysis threshold alone and should precede HD unless
cerebral edema or refractory acidosis develops.
Question 8: A 58-year-old on therapeutic heparin 18 units/kg/h for PE develops HIT (platelets 48k,
4-T score 7). Which immediate replacement anticoagulant and dose is BEST?
A. Argatroban 2 mcg/kg/min IV (hepatic function normal)
B. Bivalirudin 0.15 mg/kg/h IV
C. Fondaparinux 7.5 mg SC daily
D. Apixaban 10 mg BID
Correct Answer: A
Rationale: Argatroban is FDA-approved for HIT with rapid steady-state (5-10 min), non-renal
clearance, and predictable aPTT prolongation; starting 2 mcg/kg/min achieves therapeutic aPTT
1.5-3× baseline within 4 h per 2018 ASH guidelines.
Question 9: A 69-year-old with septic shock on CRRT (CVVHDF 35 mL/kg/h) is prescribed
meropenem 1 g q8h. Filter clearance 25 mL/min. Which dosing adjustment achieves 100%T>MIC
for Pseudomonas MIC 2 mg/L?
A. Increase to 2 g q8h
B. Extend infusion to 1 g over 3 h q8h
C. Switch to imipenem 500 mg q6h
D. No change; monitor levels
Correct Answer: A
Rationale: CRRT adds ~25-30 mL/min clearance; Monte-Carlo simulations show 2 g q8h produces
PTA >90% for MIC 2 mg/L, whereas standard 1 g under-doses in high-efficiency CRRT per 2020
AKI dosing consensus.
, Question 10: A 77-year-old with acute decompensated HFrEF (EF 20%) on dobutamine 5
mcg/kg/min develops new-onset atrial fibrillation (HR 150). BP 88/54. Which rate-control agent is
LEAST likely to precipitate cardiogenic shock?
A. Diltiazem 0.25 mg/kg IV push
B. Amiodarone 150 mg IV over 10 min
C. Digoxin 0.25 mg IV q2h × 2
D. Esmolol 500 mcg/kg bolus
Correct Answer: C
Rationale: Digoxin slows AV nodal conduction via vagomimetic effect without negative inotropy; it
preserves cardiac output in advanced HFrEF while achieving rate control over 4-6 h, unlike
calcium-channel or β-blockers that reduce contractility.
Question 11: A 14-year-old with status asthmaticus (pH 7.26, PaCO₂ 55) on non-invasive
ventilation receives magnesium sulfate 2 g IV. Ten minutes later BP 70/40, HR 140, absent breath
sounds. Next agent?
A. Epinephrine 0.3 mg IM
B. Terbutaline 0.25 mg SC
C. Methylprednisolone 125 mg IV
D. Heliox 70:30
Correct Answer: A
Rationale: Acute hypotension with silent chest indicates critical airway obstruction and impending
arrest; intramuscular epinephrine (1:1000) provides rapid β2 bronchodilation and α1 vasopressor
support, reversing both airway edema and shock.
Question 12: A 60-year-old liver transplant on tacrolimus 3 mg BID develops vancomycin-resistant
Enterococcus (VRE) bacteremia. MIC for linezolid 2 mg/L (intermediate). Which antibiotic achieves
adequate exposure without calcineurin interaction?
A. Daptomycin 8 mg/kg IV daily
B. Linezolid 600 mg IV q12h
C. Tigecycline 100 mg load then 50 mg q12h
D. Nitrofurantoin 100 mg PO q8h
Correct Answer: A
Rationale: Daptomycin is bactericidal against VRE, does not inhibit CYP3A4, and achieves >90%
target attainment at 8 mg/kg for MIC ≤2 mg/L; linezolid increases tacrolimus levels via CYP3A2
competition, raising nephrotoxicity risk.
ACTUAL EXAM 2026/2027: 100% Verified
Questions & Correct Answers
Question 1: A 68-year-old intubated septic shock patient on norepinephrine 0.3 mcg/kg/min (MAP
58 mmHg) is receiving empiric piperacillin-tazobactam 4.5 g q8h by intermittent bolus. Creatinine
clearance (measured 8-hr urine) is 35 mL/min. Which antimicrobial adjustment is MOST urgent?
A. Reduce piperacillin-tazobactam to 3.375 g q8h
B. Convert to extended-infusion 4.5 g over 3 h q8h
C. Switch to cefepime 1 g q12h
D. Increase frequency to 4.5 g q6h
Correct Answer: B
Rationale: In septic shock with CRCL <40 mL/min, standard intermittent dosing produces
sub-therapeutic peaks; extended-infusion maintains %T>MIC ≥50% for piperacillin against common
Gram-negatives while accounting for renal impairment per 2021 Surviving Sepsis Campaign
pharmacokinetic recommendations.
Question 2: A 55-year-old post-ROSC after VF arrest now on amiodarone 1 mg/min is developing
torsades de pointes (QTc 540 ms). Magnesium 2 g IV has failed. Next agent?
A. Lidocaine 1 mg/kg IV push
B. Isoproterenol 2 mcg/min
C. Esmolol 500 mcg/kg bolus then 50 mcg/kg/min
D. Procainamide 20 mg/min load
Correct Answer: B
Rationale: Overdrive pacing via isoproterenol shortens ventricular repolarization and suppresses
re-entry in acquired torsades; amiodarone’s class III effect prolongs QT further, making additional
sodium-channel blockade (lidocaine/procainamide) or β-blockade (esmolol) contraindicated.
Question 3: A 72 kg intubated COVID-ARDS patient (PF ratio 85) is on cisatracurium 3 mcg/kg/min.
Train-of-four is 0/4 with no twitches. Which paralytic-sparing strategy preserves ventilator
synchrony and avoids ICU-acquired weakness?
A. Add dexmedetomidine 0.2 mcg/kg/h and reduce cisatracurium to 1 mcg/kg/min
B. Switch to atracurium 5 mg q30min PRN
,C. Stop cisatracurium immediately; maintain propofol 50 mcg/kg/min
D. Add intermittent midazolam 2 mg q2h
Correct Answer: A
Rationale: Deep sedation with dexmedetomidine permits rapid-shallow breathing index reduction,
allowing 60-70% dose reduction of cisatracurium while maintaining ventilator synchrony; continuous
infusions >48 h correlate with ICU-AW, but low-dose adjunctive α2-agonist spares neuromuscular
blockade per 2022 SCCM guidelines.
Question 4: A 64-year-old on apixaban 5 mg BID for AF presents with GI bleed (Hb 7.2 g/dL). INR is
1.7, apixaban last taken 6 h ago. Which reversal sequence is MOST appropriate?
A. 4-factor PCC 50 units/kg IV + oral activated charcoal 50 g
B. Andexanet alfa 400 mg IV bolus then 4 mg/min × 120 min
C. Tranexamic acid 1 g IV q8h × 24 h
D. Vitamin K 10 mg IV × 1
Correct Answer: B
Rationale: Andexanet alfa is FDA-approved for life-threatening apixaban-related bleeding within 8
h; it rapidly restores thrombin generation (>90% in 2 min) and reduces anti-Xa activity by ≥90%,
outperforming PCC in ANNEXA-4 trial.
Question 5: A 78-year-old with acute hypercapnic COPD exacerbation (pH 7.22, PaCO₂ 78 mmHg)
is receiving BiPAP 18/6 cmH₂O. Heart rate 124, BP 166/92. Which pharmacologic intervention best
unloads respiratory muscles without worsening acidosis?
A. IV morphine 2 mg q1h PRN
B. Nebulized albuterol 5 mg + ipratropium 0.5 mg q20min × 3
C. IV dexmedetomidine 0.4 mcg/kg/h
D. IV ketamine 0.5 mg/kg bolus then 0.2 mg/kg/h
Correct Answer: D
Rationale: Low-dose ketamine provides dissociative analgesia/sedation, reduces dyspnea
perception, and preserves respiratory drive while decreasing oxygen consumption; unlike opioids it
does not accumulate to worsen hypercapnia and maintains airway reflexes.
Question 6: A 34-week pregnant eclamptic patient is on magnesium sulfate 2 g/h after 4 g load.
DTR 1+, urine output 25 mL/h, Mg level 3.8 mEq/L. Next step?
A. Stop infusion; give calcium gluconate 1 g IV
B. Continue current rate; recheck Mg in 4 h
C. Reduce to 1 g/h; add hydralazine 10 mg IV
D. Switch to labetalol 20 mg IV q10min
Correct Answer: A
,Rationale: Mg >3.5 mEq/L with clinical toxicity (decreased DTRs, oliguria) mandates immediate
cessation and 1 g calcium gluconate to antagonize cardiac/neuromuscular effects; further dosing
risks respiratory arrest per ACOG 2023 preeclampsia guidelines.
Question 7: A 22-year-old salicylate overdose (ASA 90 mg/kg ingested 4 h ago) has arterial pH
7.48, PaCO₂ 20 mmHg, HCO₃ 18 mEq/L, and tinnitus. Urine pH 6.0. Which intervention maximizes
salicylate elimination?
A. IV sodium bicarbonate 150 mEq in 1 L D5W at 250 mL/h to target urine pH ≥7.5
B. Acetazolamide 250 mg IV q6h
C. N-acetylcysteine 140 mg/kg load
D. HD initiated when ASA >60 mg/dL
Correct Answer: A
Rationale: Alkalinization traps ionized salicylate in urine, increasing renal clearance 5-10 fold;
maintaining urine pH ≥7.5 is superior to dialysis threshold alone and should precede HD unless
cerebral edema or refractory acidosis develops.
Question 8: A 58-year-old on therapeutic heparin 18 units/kg/h for PE develops HIT (platelets 48k,
4-T score 7). Which immediate replacement anticoagulant and dose is BEST?
A. Argatroban 2 mcg/kg/min IV (hepatic function normal)
B. Bivalirudin 0.15 mg/kg/h IV
C. Fondaparinux 7.5 mg SC daily
D. Apixaban 10 mg BID
Correct Answer: A
Rationale: Argatroban is FDA-approved for HIT with rapid steady-state (5-10 min), non-renal
clearance, and predictable aPTT prolongation; starting 2 mcg/kg/min achieves therapeutic aPTT
1.5-3× baseline within 4 h per 2018 ASH guidelines.
Question 9: A 69-year-old with septic shock on CRRT (CVVHDF 35 mL/kg/h) is prescribed
meropenem 1 g q8h. Filter clearance 25 mL/min. Which dosing adjustment achieves 100%T>MIC
for Pseudomonas MIC 2 mg/L?
A. Increase to 2 g q8h
B. Extend infusion to 1 g over 3 h q8h
C. Switch to imipenem 500 mg q6h
D. No change; monitor levels
Correct Answer: A
Rationale: CRRT adds ~25-30 mL/min clearance; Monte-Carlo simulations show 2 g q8h produces
PTA >90% for MIC 2 mg/L, whereas standard 1 g under-doses in high-efficiency CRRT per 2020
AKI dosing consensus.
, Question 10: A 77-year-old with acute decompensated HFrEF (EF 20%) on dobutamine 5
mcg/kg/min develops new-onset atrial fibrillation (HR 150). BP 88/54. Which rate-control agent is
LEAST likely to precipitate cardiogenic shock?
A. Diltiazem 0.25 mg/kg IV push
B. Amiodarone 150 mg IV over 10 min
C. Digoxin 0.25 mg IV q2h × 2
D. Esmolol 500 mcg/kg bolus
Correct Answer: C
Rationale: Digoxin slows AV nodal conduction via vagomimetic effect without negative inotropy; it
preserves cardiac output in advanced HFrEF while achieving rate control over 4-6 h, unlike
calcium-channel or β-blockers that reduce contractility.
Question 11: A 14-year-old with status asthmaticus (pH 7.26, PaCO₂ 55) on non-invasive
ventilation receives magnesium sulfate 2 g IV. Ten minutes later BP 70/40, HR 140, absent breath
sounds. Next agent?
A. Epinephrine 0.3 mg IM
B. Terbutaline 0.25 mg SC
C. Methylprednisolone 125 mg IV
D. Heliox 70:30
Correct Answer: A
Rationale: Acute hypotension with silent chest indicates critical airway obstruction and impending
arrest; intramuscular epinephrine (1:1000) provides rapid β2 bronchodilation and α1 vasopressor
support, reversing both airway edema and shock.
Question 12: A 60-year-old liver transplant on tacrolimus 3 mg BID develops vancomycin-resistant
Enterococcus (VRE) bacteremia. MIC for linezolid 2 mg/L (intermediate). Which antibiotic achieves
adequate exposure without calcineurin interaction?
A. Daptomycin 8 mg/kg IV daily
B. Linezolid 600 mg IV q12h
C. Tigecycline 100 mg load then 50 mg q12h
D. Nitrofurantoin 100 mg PO q8h
Correct Answer: A
Rationale: Daptomycin is bactericidal against VRE, does not inhibit CYP3A4, and achieves >90%
target attainment at 8 mg/kg for MIC ≤2 mg/L; linezolid increases tacrolimus levels via CYP3A2
competition, raising nephrotoxicity risk.
