NSG 533 Advanced Pharmacology Exam 2 Actual Exam
2026/2027 – Complete Guide with Detailed Rationales | 100%
Verified | Pass Guaranteed – A+ Graded
Section A: Pharmacokinetics, Pharmacodynamics, &
Pharmacogenomics (Questions 1–10)
Q1: A patient who is a CYP2D6 poor metabolizer is prescribed tramadol 50 mg every 6
hours for postoperative pain. Which concern is most significant for the prescriber?
A. The patient will experience excessive sedation due to rapid metabolism of tramadol
to its active metabolite O-desmethyltramadol
B. The patient will have inadequate analgesia because tramadol requires CYP2D6
metabolism to its active metabolite M1
C. The patient will develop serotonin syndrome due to excessive CYP2D6 activity
D. The patient will have increased risk of constipation due to higher active drug levels
Correct Answer: B
Rationale: Tramadol is a prodrug requiring CYP2D6 metabolism to its active metabolite
M1 (O-desmethyltramadol) for analgesic effect. Poor metabolizers have reduced
conversion, leading to inadequate pain control. Option A is incorrect—poor metabolizers
have less, not more, active metabolite. Option C is incorrect—poor metabolizers have
reduced, not excessive, CYP2D6 activity. Option D is unrelated to CYP2D6 status.
Q2: A patient with atrial fibrillation is prescribed warfarin 5 mg daily. The patient's
CYP2C9 and VKORC1 genotyping reveals reduced-function alleles. Which adjustment
should the prescriber consider?
,A. Increase the warfarin dose to achieve therapeutic INR faster
B. Start with a lower dose (e.g., 2–3 mg) and monitor INR more frequently due to
increased bleeding risk
C. Discontinue warfarin and switch to aspirin monotherapy
D. No dose adjustment is needed because genotype does not affect warfarin
metabolism
Correct Answer: B
Rationale: Reduced-function CYP2C9 and VKORC1 alleles decrease warfarin
metabolism and increase sensitivity, requiring lower initial doses and more frequent INR
monitoring to prevent bleeding. Option A would increase bleeding risk. Option C is
inappropriate for AFib stroke prevention. Option D is incorrect—pharmacogenomics
significantly affects warfarin dosing.
Q3: A patient is prescribed digoxin 0.25 mg daily for heart failure. The patient has a
serum creatinine of 2.8 mg/dL and is 78 years old. Which pharmacokinetic change is
most relevant to digoxin dosing in this patient?
A. Increased renal clearance requiring higher digoxin doses
B. Decreased renal clearance and reduced volume of distribution, increasing risk of
digoxin toxicity
C. Increased hepatic metabolism of digoxin
D. No change in digoxin pharmacokinetics with age or renal impairment
Correct Answer: B
Rationale: Digoxin is primarily renally excreted (unchanged) with a narrow therapeutic
index. In elderly patients with renal impairment, clearance is reduced and volume of
distribution is decreased (due to reduced lean body mass), increasing the risk of
toxicity. Dose reduction (e.g., 0.125 mg daily or every other day) and monitoring of
, serum levels (therapeutic 0.5–0.9 ng/mL) are essential. Options A, C, and D are
incorrect.
Q4: A patient is taking phenytoin 300 mg daily for seizure control. The patient is started
on fluconazole 200 mg daily for a fungal infection. Which drug-drug interaction should
the prescriber anticipate?
A. Fluconazole inhibits CYP2C9 and CYP2C19, increasing phenytoin levels and risk of
toxicity
B. Fluconazole induces CYP3A4, decreasing phenytoin levels and risk of breakthrough
seizures
C. Fluconazole has no effect on phenytoin metabolism
D. Fluconazole increases phenytoin renal excretion
Correct Answer: A
Rationale: Fluconazole is a potent inhibitor of CYP2C9 and CYP2C19, the primary
enzymes metabolizing phenytoin. Co-administration increases phenytoin levels, risking
toxicity (nystagmus, ataxia, confusion). Phenytoin dose reduction and level monitoring
are required. Options B, C, and D are incorrect.
Q5: A patient with depression is prescribed fluoxetine 20 mg daily. The patient is also
taking tramadol for chronic pain. Which drug-drug interaction is the prescriber most
concerned about?
A. Increased risk of bleeding due to antiplatelet effects
B. Serotonin syndrome from combined serotonergic effects of fluoxetine and tramadol
C. Decreased fluoxetine absorption due to tramadol's effect on gastric emptying
D. Increased tramadol metabolism leading to reduced analgesia
Correct Answer: B
2026/2027 – Complete Guide with Detailed Rationales | 100%
Verified | Pass Guaranteed – A+ Graded
Section A: Pharmacokinetics, Pharmacodynamics, &
Pharmacogenomics (Questions 1–10)
Q1: A patient who is a CYP2D6 poor metabolizer is prescribed tramadol 50 mg every 6
hours for postoperative pain. Which concern is most significant for the prescriber?
A. The patient will experience excessive sedation due to rapid metabolism of tramadol
to its active metabolite O-desmethyltramadol
B. The patient will have inadequate analgesia because tramadol requires CYP2D6
metabolism to its active metabolite M1
C. The patient will develop serotonin syndrome due to excessive CYP2D6 activity
D. The patient will have increased risk of constipation due to higher active drug levels
Correct Answer: B
Rationale: Tramadol is a prodrug requiring CYP2D6 metabolism to its active metabolite
M1 (O-desmethyltramadol) for analgesic effect. Poor metabolizers have reduced
conversion, leading to inadequate pain control. Option A is incorrect—poor metabolizers
have less, not more, active metabolite. Option C is incorrect—poor metabolizers have
reduced, not excessive, CYP2D6 activity. Option D is unrelated to CYP2D6 status.
Q2: A patient with atrial fibrillation is prescribed warfarin 5 mg daily. The patient's
CYP2C9 and VKORC1 genotyping reveals reduced-function alleles. Which adjustment
should the prescriber consider?
,A. Increase the warfarin dose to achieve therapeutic INR faster
B. Start with a lower dose (e.g., 2–3 mg) and monitor INR more frequently due to
increased bleeding risk
C. Discontinue warfarin and switch to aspirin monotherapy
D. No dose adjustment is needed because genotype does not affect warfarin
metabolism
Correct Answer: B
Rationale: Reduced-function CYP2C9 and VKORC1 alleles decrease warfarin
metabolism and increase sensitivity, requiring lower initial doses and more frequent INR
monitoring to prevent bleeding. Option A would increase bleeding risk. Option C is
inappropriate for AFib stroke prevention. Option D is incorrect—pharmacogenomics
significantly affects warfarin dosing.
Q3: A patient is prescribed digoxin 0.25 mg daily for heart failure. The patient has a
serum creatinine of 2.8 mg/dL and is 78 years old. Which pharmacokinetic change is
most relevant to digoxin dosing in this patient?
A. Increased renal clearance requiring higher digoxin doses
B. Decreased renal clearance and reduced volume of distribution, increasing risk of
digoxin toxicity
C. Increased hepatic metabolism of digoxin
D. No change in digoxin pharmacokinetics with age or renal impairment
Correct Answer: B
Rationale: Digoxin is primarily renally excreted (unchanged) with a narrow therapeutic
index. In elderly patients with renal impairment, clearance is reduced and volume of
distribution is decreased (due to reduced lean body mass), increasing the risk of
toxicity. Dose reduction (e.g., 0.125 mg daily or every other day) and monitoring of
, serum levels (therapeutic 0.5–0.9 ng/mL) are essential. Options A, C, and D are
incorrect.
Q4: A patient is taking phenytoin 300 mg daily for seizure control. The patient is started
on fluconazole 200 mg daily for a fungal infection. Which drug-drug interaction should
the prescriber anticipate?
A. Fluconazole inhibits CYP2C9 and CYP2C19, increasing phenytoin levels and risk of
toxicity
B. Fluconazole induces CYP3A4, decreasing phenytoin levels and risk of breakthrough
seizures
C. Fluconazole has no effect on phenytoin metabolism
D. Fluconazole increases phenytoin renal excretion
Correct Answer: A
Rationale: Fluconazole is a potent inhibitor of CYP2C9 and CYP2C19, the primary
enzymes metabolizing phenytoin. Co-administration increases phenytoin levels, risking
toxicity (nystagmus, ataxia, confusion). Phenytoin dose reduction and level monitoring
are required. Options B, C, and D are incorrect.
Q5: A patient with depression is prescribed fluoxetine 20 mg daily. The patient is also
taking tramadol for chronic pain. Which drug-drug interaction is the prescriber most
concerned about?
A. Increased risk of bleeding due to antiplatelet effects
B. Serotonin syndrome from combined serotonergic effects of fluoxetine and tramadol
C. Decreased fluoxetine absorption due to tramadol's effect on gastric emptying
D. Increased tramadol metabolism leading to reduced analgesia
Correct Answer: B
