GALEN NUR 210 EXAM: Advanced Pharmacology Principles
Comprehensive Nursing Pharmacology Examination
Total Questions: 150
Difficulty Level: Expert/Complicated
Target Audience: Advanced Nursing Students (Galen College of Nursing)
Exam Duration: 3.5 Hours
Passing Score: 85% (128/150)
Content Focus: Complex Clinical Scenarios, Advanced Pharmacokinetics, Critical Thinking
SECTION 1: ADVANCED PHARMACOKINETICS AND
PHARMACODYNAMICS (Questions 1-20)
1. A 72-year-old patient with congestive heart failure and chronic kidney disease (Stage 3) is
prescribed digoxin 0.125 mg daily. The patient's serum creatinine is 2.1 mg/dL, and digoxin level is
1.8 ng/mL. Which assessment finding would indicate digoxin toxicity requiring immediate
intervention?
A. Heart rate of 72 bpm with occasional premature ventricular contractions
B. Serum potassium of 3.8 mEq/L with mild nausea
C. Visual disturbances including yellow-green halos around lights and heart rate of 48 bpm
D. Mild fatigue and occasional dizziness when standing quickly
Correct Answer: C
Rationale: Digoxin toxicity presents with characteristic visual disturbances (yellow-green halos,
chromatopsia), bradycardia, nausea, vomiting, and cardiac dysrhythmias. This patient has multiple risk
factors: advanced age, renal impairment (decreased excretion), and potential electrolyte imbalances. A
heart rate of 48 bpm with visual disturbances indicates significant toxicity requiring immediate
intervention. The therapeutic range for digoxin is 0.8-2.0 ng/mL, but toxicity can occur at lower levels
in elderly patients or those with renal impairment. The nurse should hold the medication, obtain a stat
ECG, and notify the healthcare provider.
2. A patient is receiving a continuous intravenous infusion of heparin for treatment of deep vein
thrombosis. The aPTT is 110 seconds (normal 25-35 seconds). The nurse notes that the patient has
developed petechiae on the chest and abdomen and reports severe back pain. What is the nurse's
priority action?
A. Decrease the heparin infusion rate by 50% and continue monitoring
B. Administer protamine sulfate as prescribed and stop the heparin infusion
,C. Obtain a complete blood count and assess for heparin-induced thrombocytopenia (HIT)
D. Apply warm compresses to the petechiae and administer analgesic for back pain
Correct Answer: C
Rationale: This patient is exhibiting signs of heparin-induced thrombocytopenia (HIT), a life-
threatening complication characterized by a drop in platelet count, thrombosis (paradoxical), and
potentially skin necrosis. The back pain may indicate adrenal hemorrhage. While the aPTT is elevated
(indicating bleeding risk), the petechiae and back pain are more concerning for HIT. The nurse should
immediately obtain a CBC (platelet count), stop the heparin infusion, and notify the healthcare
provider. Protamine sulfate is used for heparin overdose/bleeding, not HIT. In HIT, heparin is stopped
and a direct thrombin inhibitor (argatroban, lepirudin) is started.
3. A patient is prescribed warfarin for atrial fibrillation. The INR is 5.2. The patient has no signs of
bleeding. The healthcare provider orders vitamin K 1 mg IV. What is the most important nursing
consideration when administering IV vitamin K?
A. Administer the medication rapidly to achieve quick reversal
B. Administer the medication slowly over 1-2 minutes to prevent anaphylactoid reactions
C. Administer the medication via IM injection to avoid IV complications
D. Administer the medication with normal saline to dilute the concentration
Correct Answer: B
Rationale: IV vitamin K (phytonadione) should be administered slowly (over 1-2 minutes) to prevent
severe anaphylactoid reactions, including facial flushing, hypotension, and respiratory distress. Rapid
administration can cause these reactions even in patients without prior exposure. While the INR of 5.2
requires reversal, patient safety dictates slow administration. The nurse should also be prepared to
manage potential adverse reactions. SC or IM routes may be preferred in some situations, but the
order specifies IV.
4. A patient with liver cirrhosis is prescribed morphine sulfate 2 mg IV for severe pain. After
administration, the patient becomes somnolent with a respiratory rate of 8 breaths per minute and
pinpoint pupils. Which medication should the nurse anticipate administering?
A. Flumazenil 0.2 mg IV
B. Naloxone 0.4 mg IV
C. Acetylcysteine 140 mg/kg PO
D. Physostigmine 2 mg IV
Correct Answer: B
Rationale: This patient is experiencing opioid toxicity (respiratory depression, pinpoint pupils,
somnolence) likely due to reduced hepatic metabolism of morphine in cirrhosis. Naloxone is the
specific opioid antagonist and should be administered immediately. The initial dose is 0.4-2 mg IV,
,repeated as needed. Flumazenil reverses benzodiazepines. Acetylcysteine treats acetaminophen
toxicity. Physostigmine reverses anticholinergic toxicity.
5. A patient is prescribed furosemide 40 mg IV push for acute pulmonary edema. The nurse notes
that the patient's serum potassium is 3.2 mEq/L (normal 3.5-5.0 mEq/L) and serum magnesium is 1.6
mEq/L (normal 1.8-2.6 mEq/L). Which nursing action is most appropriate?
A. Administer the furosemide as prescribed and monitor urine output
B. Hold the furosemide and notify the healthcare provider of the electrolyte abnormalities
C. Administer the furosemide and administer potassium chloride 40 mEq IV push
D. Administer the furosemide and encourage potassium-rich foods
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes significant potassium and magnesium wasting.
This patient already has hypokalemia (3.2 mEq/L) and hypomagnesemia (1.6 mEq/L). Administering
furosemide will further decrease potassium and magnesium levels, potentially causing cardiac
dysrhythmias, especially in a patient with acute pulmonary edema who may be on digoxin or other
medications. The nurse should hold the medication and notify the healthcare provider to address the
electrolyte imbalances before or concurrent with furosemide administration. IV potassium is not given
as a push (would cause cardiac arrest).
6. A patient is receiving IV vancomycin 1 g every 12 hours. The patient's trough level is 18 mcg/mL
(therapeutic range 10-15 mcg/mL). Which nursing action is most appropriate?
A. Administer the next dose as scheduled
B. Hold the next dose and notify the healthcare provider
C. Increase the dose to 1.5 g
D. Decrease the interval to every 8 hours
Correct Answer: B
Rationale: A vancomycin trough level of 18 mcg/mL is above the therapeutic range (10-15 mcg/mL)
and indicates potential toxicity, including nephrotoxicity and ototoxicity. The nurse should hold the
next dose and notify the healthcare provider for dose adjustment. The provider may order a decreased
dose or increased interval. Monitoring trough levels is essential for vancomycin because it has a
narrow therapeutic index and can cause serious adverse effects.
7. A patient with a history of seizures is prescribed phenytoin 300 mg daily. The patient's phenytoin
level is 8 mcg/mL (therapeutic range 10-20 mcg/mL). The patient reports increased seizure
frequency. What is the most likely cause of the subtherapeutic level?
, A. The patient is taking phenytoin with meals, decreasing absorption
B. The patient is taking phenytoin with phenobarbital, which increases metabolism
C. The patient is taking phenytoin with valproic acid, which decreases protein binding
D. The patient is taking phenytoin with cimetidine, which decreases metabolism
Correct Answer: B
Rationale: Phenytoin has nonlinear (Michaelis-Menten) pharmacokinetics, meaning small changes in
dose can cause large changes in serum levels. A level of 8 mcg/mL is subtherapeutic, and the increased
seizure frequency indicates the patient is not protected. Phenobarbital induces CYP450 enzymes,
increasing phenytoin metabolism and decreasing levels. Valproic acid displaces phenytoin from protein
binding sites, increasing free (active) drug levels. Cimetidine decreases phenytoin metabolism
(increases levels). Taking phenytoin with meals decreases absorption but is less significant than enzyme
induction.
8. A patient is prescribed digoxin and verapamil for atrial fibrillation. The nurse should monitor the
patient for which potential interaction?
A. Increased digoxin levels due to verapamil inhibiting P-glycoprotein
B. Decreased digoxin levels due to verapamil inducing metabolism
C. Increased verapamil levels due to digoxin inhibiting metabolism
D. No significant interaction between these medications
Correct Answer: A
Rationale: Verapamil inhibits P-glycoprotein, an efflux transporter that pumps digoxin out of cells. This
inhibition increases digoxin absorption, decreases renal excretion, and increases serum digoxin levels
by 50-75%. This can lead to digoxin toxicity. The nurse should monitor digoxin levels closely, watch for
signs of toxicity (nausea, visual disturbances, bradycardia), and report any changes. Dose reduction of
digoxin may be necessary.
9. A patient is receiving an IV infusion of dopamine 5 mcg/kg/min for cardiogenic shock. The nurse
notes that the patient's urine output has decreased from 40 mL/hr to 15 mL/hr over the past 2
hours. What is the nurse's priority action?
A. Increase the dopamine infusion rate to improve renal perfusion
B. Assess the patient's blood pressure and heart rate
C. Administer a fluid bolus of normal saline
D. Obtain a stat creatinine and notify the healthcare provider
Correct Answer: B
Rationale: Dopamine is a dose-dependent catecholamine with varying effects: low dose (1-3
mcg/kg/min) increases renal perfusion; moderate dose (3-10 mcg/kg/min) increases contractility; high
dose (>10 mcg/kg/min) causes vasoconstriction. The decreased urine output may indicate that the
patient is receiving a higher dose (vasoconstriction) or that renal function is deteriorating. The nurse
Comprehensive Nursing Pharmacology Examination
Total Questions: 150
Difficulty Level: Expert/Complicated
Target Audience: Advanced Nursing Students (Galen College of Nursing)
Exam Duration: 3.5 Hours
Passing Score: 85% (128/150)
Content Focus: Complex Clinical Scenarios, Advanced Pharmacokinetics, Critical Thinking
SECTION 1: ADVANCED PHARMACOKINETICS AND
PHARMACODYNAMICS (Questions 1-20)
1. A 72-year-old patient with congestive heart failure and chronic kidney disease (Stage 3) is
prescribed digoxin 0.125 mg daily. The patient's serum creatinine is 2.1 mg/dL, and digoxin level is
1.8 ng/mL. Which assessment finding would indicate digoxin toxicity requiring immediate
intervention?
A. Heart rate of 72 bpm with occasional premature ventricular contractions
B. Serum potassium of 3.8 mEq/L with mild nausea
C. Visual disturbances including yellow-green halos around lights and heart rate of 48 bpm
D. Mild fatigue and occasional dizziness when standing quickly
Correct Answer: C
Rationale: Digoxin toxicity presents with characteristic visual disturbances (yellow-green halos,
chromatopsia), bradycardia, nausea, vomiting, and cardiac dysrhythmias. This patient has multiple risk
factors: advanced age, renal impairment (decreased excretion), and potential electrolyte imbalances. A
heart rate of 48 bpm with visual disturbances indicates significant toxicity requiring immediate
intervention. The therapeutic range for digoxin is 0.8-2.0 ng/mL, but toxicity can occur at lower levels
in elderly patients or those with renal impairment. The nurse should hold the medication, obtain a stat
ECG, and notify the healthcare provider.
2. A patient is receiving a continuous intravenous infusion of heparin for treatment of deep vein
thrombosis. The aPTT is 110 seconds (normal 25-35 seconds). The nurse notes that the patient has
developed petechiae on the chest and abdomen and reports severe back pain. What is the nurse's
priority action?
A. Decrease the heparin infusion rate by 50% and continue monitoring
B. Administer protamine sulfate as prescribed and stop the heparin infusion
,C. Obtain a complete blood count and assess for heparin-induced thrombocytopenia (HIT)
D. Apply warm compresses to the petechiae and administer analgesic for back pain
Correct Answer: C
Rationale: This patient is exhibiting signs of heparin-induced thrombocytopenia (HIT), a life-
threatening complication characterized by a drop in platelet count, thrombosis (paradoxical), and
potentially skin necrosis. The back pain may indicate adrenal hemorrhage. While the aPTT is elevated
(indicating bleeding risk), the petechiae and back pain are more concerning for HIT. The nurse should
immediately obtain a CBC (platelet count), stop the heparin infusion, and notify the healthcare
provider. Protamine sulfate is used for heparin overdose/bleeding, not HIT. In HIT, heparin is stopped
and a direct thrombin inhibitor (argatroban, lepirudin) is started.
3. A patient is prescribed warfarin for atrial fibrillation. The INR is 5.2. The patient has no signs of
bleeding. The healthcare provider orders vitamin K 1 mg IV. What is the most important nursing
consideration when administering IV vitamin K?
A. Administer the medication rapidly to achieve quick reversal
B. Administer the medication slowly over 1-2 minutes to prevent anaphylactoid reactions
C. Administer the medication via IM injection to avoid IV complications
D. Administer the medication with normal saline to dilute the concentration
Correct Answer: B
Rationale: IV vitamin K (phytonadione) should be administered slowly (over 1-2 minutes) to prevent
severe anaphylactoid reactions, including facial flushing, hypotension, and respiratory distress. Rapid
administration can cause these reactions even in patients without prior exposure. While the INR of 5.2
requires reversal, patient safety dictates slow administration. The nurse should also be prepared to
manage potential adverse reactions. SC or IM routes may be preferred in some situations, but the
order specifies IV.
4. A patient with liver cirrhosis is prescribed morphine sulfate 2 mg IV for severe pain. After
administration, the patient becomes somnolent with a respiratory rate of 8 breaths per minute and
pinpoint pupils. Which medication should the nurse anticipate administering?
A. Flumazenil 0.2 mg IV
B. Naloxone 0.4 mg IV
C. Acetylcysteine 140 mg/kg PO
D. Physostigmine 2 mg IV
Correct Answer: B
Rationale: This patient is experiencing opioid toxicity (respiratory depression, pinpoint pupils,
somnolence) likely due to reduced hepatic metabolism of morphine in cirrhosis. Naloxone is the
specific opioid antagonist and should be administered immediately. The initial dose is 0.4-2 mg IV,
,repeated as needed. Flumazenil reverses benzodiazepines. Acetylcysteine treats acetaminophen
toxicity. Physostigmine reverses anticholinergic toxicity.
5. A patient is prescribed furosemide 40 mg IV push for acute pulmonary edema. The nurse notes
that the patient's serum potassium is 3.2 mEq/L (normal 3.5-5.0 mEq/L) and serum magnesium is 1.6
mEq/L (normal 1.8-2.6 mEq/L). Which nursing action is most appropriate?
A. Administer the furosemide as prescribed and monitor urine output
B. Hold the furosemide and notify the healthcare provider of the electrolyte abnormalities
C. Administer the furosemide and administer potassium chloride 40 mEq IV push
D. Administer the furosemide and encourage potassium-rich foods
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes significant potassium and magnesium wasting.
This patient already has hypokalemia (3.2 mEq/L) and hypomagnesemia (1.6 mEq/L). Administering
furosemide will further decrease potassium and magnesium levels, potentially causing cardiac
dysrhythmias, especially in a patient with acute pulmonary edema who may be on digoxin or other
medications. The nurse should hold the medication and notify the healthcare provider to address the
electrolyte imbalances before or concurrent with furosemide administration. IV potassium is not given
as a push (would cause cardiac arrest).
6. A patient is receiving IV vancomycin 1 g every 12 hours. The patient's trough level is 18 mcg/mL
(therapeutic range 10-15 mcg/mL). Which nursing action is most appropriate?
A. Administer the next dose as scheduled
B. Hold the next dose and notify the healthcare provider
C. Increase the dose to 1.5 g
D. Decrease the interval to every 8 hours
Correct Answer: B
Rationale: A vancomycin trough level of 18 mcg/mL is above the therapeutic range (10-15 mcg/mL)
and indicates potential toxicity, including nephrotoxicity and ototoxicity. The nurse should hold the
next dose and notify the healthcare provider for dose adjustment. The provider may order a decreased
dose or increased interval. Monitoring trough levels is essential for vancomycin because it has a
narrow therapeutic index and can cause serious adverse effects.
7. A patient with a history of seizures is prescribed phenytoin 300 mg daily. The patient's phenytoin
level is 8 mcg/mL (therapeutic range 10-20 mcg/mL). The patient reports increased seizure
frequency. What is the most likely cause of the subtherapeutic level?
, A. The patient is taking phenytoin with meals, decreasing absorption
B. The patient is taking phenytoin with phenobarbital, which increases metabolism
C. The patient is taking phenytoin with valproic acid, which decreases protein binding
D. The patient is taking phenytoin with cimetidine, which decreases metabolism
Correct Answer: B
Rationale: Phenytoin has nonlinear (Michaelis-Menten) pharmacokinetics, meaning small changes in
dose can cause large changes in serum levels. A level of 8 mcg/mL is subtherapeutic, and the increased
seizure frequency indicates the patient is not protected. Phenobarbital induces CYP450 enzymes,
increasing phenytoin metabolism and decreasing levels. Valproic acid displaces phenytoin from protein
binding sites, increasing free (active) drug levels. Cimetidine decreases phenytoin metabolism
(increases levels). Taking phenytoin with meals decreases absorption but is less significant than enzyme
induction.
8. A patient is prescribed digoxin and verapamil for atrial fibrillation. The nurse should monitor the
patient for which potential interaction?
A. Increased digoxin levels due to verapamil inhibiting P-glycoprotein
B. Decreased digoxin levels due to verapamil inducing metabolism
C. Increased verapamil levels due to digoxin inhibiting metabolism
D. No significant interaction between these medications
Correct Answer: A
Rationale: Verapamil inhibits P-glycoprotein, an efflux transporter that pumps digoxin out of cells. This
inhibition increases digoxin absorption, decreases renal excretion, and increases serum digoxin levels
by 50-75%. This can lead to digoxin toxicity. The nurse should monitor digoxin levels closely, watch for
signs of toxicity (nausea, visual disturbances, bradycardia), and report any changes. Dose reduction of
digoxin may be necessary.
9. A patient is receiving an IV infusion of dopamine 5 mcg/kg/min for cardiogenic shock. The nurse
notes that the patient's urine output has decreased from 40 mL/hr to 15 mL/hr over the past 2
hours. What is the nurse's priority action?
A. Increase the dopamine infusion rate to improve renal perfusion
B. Assess the patient's blood pressure and heart rate
C. Administer a fluid bolus of normal saline
D. Obtain a stat creatinine and notify the healthcare provider
Correct Answer: B
Rationale: Dopamine is a dose-dependent catecholamine with varying effects: low dose (1-3
mcg/kg/min) increases renal perfusion; moderate dose (3-10 mcg/kg/min) increases contractility; high
dose (>10 mcg/kg/min) causes vasoconstriction. The decreased urine output may indicate that the
patient is receiving a higher dose (vasoconstriction) or that renal function is deteriorating. The nurse
