NSG 533 Exam #2 Case-Study Practice Questions
Question 1: NSAID Use in Osteoarthritis with CV Risk
A 72-year-old male with osteoarthritis and a history of myocardial infarction (MI) presents
with worsening knee pain. He has tried acetaminophen, but it provides inadequate relief. His
other medical history includes hypertension, GERD, and stage 2 chronic kidney disease
(CKD).
Which of the following is the best option for pain management in this patient?
A) Ibuprofen
B) Naproxen
C) Celecoxib
D) Diclofenac
✅ Correct Answer: C) Celecoxib
Rationale:
Celecoxib (COX-2 selective NSAID) has lower GI risk than non-selective NSAIDs and
less impact on platelet function, making it a better choice in patients with CV risk.
❌ A) Ibuprofen & B) Naproxen → Non-selective NSAIDs, which increase MI/stroke
risk and should be avoided in patients with previous MI.
❌ D) Diclofenac → High CV risk, worse than other NSAIDs.
💡 Key Takeaways:
Acetaminophen is first-line for OA pain but has limited efficacy.
If an NSAID is required, celecoxib is preferred in high CV risk patients.
All NSAIDs increase CV risk but naproxen is the safest among non-selectives.
Always consider GI and renal risks when prescribing NSAIDs.
Question 2: Opioid Selection in a Patient with True Morphine Allergy
A 56-year-old woman with chronic back pain has been on morphine ER 30 mg BID. She
recently developed anaphylaxis (facial swelling, wheezing, and hypotension). She still
requires opioid therapy.
Which of the following is the best alternative opioid?
A) Hydrocodone
B) Oxycodone
C) Methadone
D) Fentanyl
,✅ Correct Answer: D) Fentanyl
Rationale:
Fentanyl is a synthetic opioid and does not cross-react with morphine in true opioid
allergy cases.
❌ A) Hydrocodone & B) Oxycodone → Both are semi-synthetic opioids derived
from morphine, making them highly cross-reactive in true opioid allergy.
❌ C) Methadone → Although synthetic, it prolongs QT interval and is not ideal for
chronic pain due to complex PK.
💡 Key Takeaways:
True opioid allergy is rare but requires complete avoidance of morphine-like
opioids.
Safe alternatives include synthetic opioids (fentanyl, methadone, tramadol).
Incomplete cross-tolerance should be considered when rotating opioids.
Question 3: Acute Migraine Treatment in CAD
A 52-year-old female with coronary artery disease (CAD) and hypertension presents with a
migraine with aura. She took ibuprofen without relief.
Which of the following is the best abortive therapy?
A) Sumatriptan
B) Ergotamine
C) Metoclopramide
D) Propranolol
✅ Correct Answer: C) Metoclopramide
Rationale:
Triptans and ergotamines are contraindicated in CAD due to vasoconstriction and
stroke/MI risk.
❌ A) Sumatriptan & B) Ergotamine → Potent vasoconstrictors that increase
stroke/MI risk.
✅ C) Metoclopramide → First-line alternative in CAD patients, treats nausea and
pain.
❌ D) Propranolol → Used for prevention, not acute treatment.
💡 Key Takeaways:
, Triptans and ergotamines should never be used in CAD, stroke, or uncontrolled
HTN.
IV metoclopramide or prochlorperazine is a good alternative abortive therapy.
NSAIDs or acetaminophen can be used if no contraindications exist.
Question 4: Acute Gout Treatment in CKD
A 62-year-old man with CKD stage 3, hypertension, and GERD presents with acute joint
pain, erythema, and swelling in the first metatarsophalangeal (MTP) joint.
What is the most appropriate first-line therapy for his acute gout attack?
A) Indomethacin
B) Colchicine
C) Allopurinol
D) Prednisone
✅ Correct Answer: D) Prednisone
Rationale:
NSAIDs and colchicine should be avoided in CKD due to renal clearance concerns.
❌ A) Indomethacin (NSAID) → Nephrotoxic, contraindicated in CKD.
❌ B) Colchicine → Renally cleared, increased toxicity risk in CKD.
❌ C) Allopurinol → Used for chronic urate lowering, not acute attacks.
💡 Key Takeaways:
Corticosteroids are first-line for gout in CKD.
Colchicine is ineffective if not given within 36 hours of onset.
Never start allopurinol during an acute attack.
Question 5: Empiric Cellulitis Treatment (MRSA Risk)
A 45-year-old male presents with erythema, warmth, and tenderness in his left leg. He has
fever (101.5°F), tachycardia, and leukocytosis. The infection is spreading rapidly.
Which empiric antibiotic is most appropriate?
A) Cephalexin
B) Clindamycin
Question 1: NSAID Use in Osteoarthritis with CV Risk
A 72-year-old male with osteoarthritis and a history of myocardial infarction (MI) presents
with worsening knee pain. He has tried acetaminophen, but it provides inadequate relief. His
other medical history includes hypertension, GERD, and stage 2 chronic kidney disease
(CKD).
Which of the following is the best option for pain management in this patient?
A) Ibuprofen
B) Naproxen
C) Celecoxib
D) Diclofenac
✅ Correct Answer: C) Celecoxib
Rationale:
Celecoxib (COX-2 selective NSAID) has lower GI risk than non-selective NSAIDs and
less impact on platelet function, making it a better choice in patients with CV risk.
❌ A) Ibuprofen & B) Naproxen → Non-selective NSAIDs, which increase MI/stroke
risk and should be avoided in patients with previous MI.
❌ D) Diclofenac → High CV risk, worse than other NSAIDs.
💡 Key Takeaways:
Acetaminophen is first-line for OA pain but has limited efficacy.
If an NSAID is required, celecoxib is preferred in high CV risk patients.
All NSAIDs increase CV risk but naproxen is the safest among non-selectives.
Always consider GI and renal risks when prescribing NSAIDs.
Question 2: Opioid Selection in a Patient with True Morphine Allergy
A 56-year-old woman with chronic back pain has been on morphine ER 30 mg BID. She
recently developed anaphylaxis (facial swelling, wheezing, and hypotension). She still
requires opioid therapy.
Which of the following is the best alternative opioid?
A) Hydrocodone
B) Oxycodone
C) Methadone
D) Fentanyl
,✅ Correct Answer: D) Fentanyl
Rationale:
Fentanyl is a synthetic opioid and does not cross-react with morphine in true opioid
allergy cases.
❌ A) Hydrocodone & B) Oxycodone → Both are semi-synthetic opioids derived
from morphine, making them highly cross-reactive in true opioid allergy.
❌ C) Methadone → Although synthetic, it prolongs QT interval and is not ideal for
chronic pain due to complex PK.
💡 Key Takeaways:
True opioid allergy is rare but requires complete avoidance of morphine-like
opioids.
Safe alternatives include synthetic opioids (fentanyl, methadone, tramadol).
Incomplete cross-tolerance should be considered when rotating opioids.
Question 3: Acute Migraine Treatment in CAD
A 52-year-old female with coronary artery disease (CAD) and hypertension presents with a
migraine with aura. She took ibuprofen without relief.
Which of the following is the best abortive therapy?
A) Sumatriptan
B) Ergotamine
C) Metoclopramide
D) Propranolol
✅ Correct Answer: C) Metoclopramide
Rationale:
Triptans and ergotamines are contraindicated in CAD due to vasoconstriction and
stroke/MI risk.
❌ A) Sumatriptan & B) Ergotamine → Potent vasoconstrictors that increase
stroke/MI risk.
✅ C) Metoclopramide → First-line alternative in CAD patients, treats nausea and
pain.
❌ D) Propranolol → Used for prevention, not acute treatment.
💡 Key Takeaways:
, Triptans and ergotamines should never be used in CAD, stroke, or uncontrolled
HTN.
IV metoclopramide or prochlorperazine is a good alternative abortive therapy.
NSAIDs or acetaminophen can be used if no contraindications exist.
Question 4: Acute Gout Treatment in CKD
A 62-year-old man with CKD stage 3, hypertension, and GERD presents with acute joint
pain, erythema, and swelling in the first metatarsophalangeal (MTP) joint.
What is the most appropriate first-line therapy for his acute gout attack?
A) Indomethacin
B) Colchicine
C) Allopurinol
D) Prednisone
✅ Correct Answer: D) Prednisone
Rationale:
NSAIDs and colchicine should be avoided in CKD due to renal clearance concerns.
❌ A) Indomethacin (NSAID) → Nephrotoxic, contraindicated in CKD.
❌ B) Colchicine → Renally cleared, increased toxicity risk in CKD.
❌ C) Allopurinol → Used for chronic urate lowering, not acute attacks.
💡 Key Takeaways:
Corticosteroids are first-line for gout in CKD.
Colchicine is ineffective if not given within 36 hours of onset.
Never start allopurinol during an acute attack.
Question 5: Empiric Cellulitis Treatment (MRSA Risk)
A 45-year-old male presents with erythema, warmth, and tenderness in his left leg. He has
fever (101.5°F), tachycardia, and leukocytosis. The infection is spreading rapidly.
Which empiric antibiotic is most appropriate?
A) Cephalexin
B) Clindamycin
