Pharmacotherapeutics for Advanced
Practice Nurses — Comprehensive
Study Guide (6th Edition Concepts)
1. Q: What is the primary goal of the "Start Low and Go Slow" prescribing principle in
geriatric pharmacotherapy?
A: To minimize adverse drug reactions by accounting for age-related changes in
pharmacokinetics (absorption, distribution, metabolism, excretion).
2. Q: A patient on warfarin develops a dangerously high INR. Besides stopping the warfarin,
what is the most appropriate immediate intervention?
A: Administer vitamin K (phytonadione) orally or intravenously, depending on the
urgency. Fresh frozen plasma may be used for severe bleeding.
3. Q: What is the significance of a drug's therapeutic index (TI)?
A: It represents the ratio between the toxic dose and the effective dose. A low TI (e.g.,
digoxin, warfarin) indicates a narrow safety margin and requires close monitoring.
4. Q: Which physiological change in pregnancy most significantly affects drug volume of
distribution and dosing?
A: Increased plasma volume (up to 50%), leading to lower plasma concentrations of
drugs.
5. Q: What is the cornerstone of preventing opioid use disorder when prescribing for
chronic non-cancer pain?
A: Employing a universal precautions approach: using a controlled substance agreement,
checking prescription drug monitoring programs (PDMPs) at every visit, and scheduling
regular follow-ups to assess function and pain.
Cardiovascular Pharmacotherapeutics
6. Q: For a patient with heart failure with reduced ejection fraction (HFrEF), which four
drug classes form the foundation of guideline-directed medical therapy (GDMT)?
A: Beta-blockers (carvedilol, metoprolol succinate), ACE Inhibitors/ARBs/ARNIs
(sacubitril/valsartan), Mineralocorticoid Receptor Antagonists (MRAs like
spironolactone), and SGLT2 Inhibitors (dapagliflozin, empagliflozin).
, 7. Q: Why are ACE Inhibitors contraindicated in pregnancy?
A: They can cause fetal injury, including oligohydramnios, fetal lung hypoplasia, skull
hypoplasia, and neonatal renal failure, especially in the 2nd and 3rd trimesters.
8. Q: What is the first-line pharmacotherapy for a healthy 45-year-old male with newly
diagnosed, uncomplicated essential hypertension?
A: A thiazide-like diuretic (e.g., chlorthalidone) or an ACE inhibitor/ARB. Choice depends
on comorbid conditions and patient demographics.
9. Q: When initiating amiodarone, what baseline monitoring is essential due to its risk of
severe toxicities?
A: LFTs, Thyroid Function Tests (TSH), Chest X-ray, Pulmonary Function Tests, and
Ophthalmologic exam.
10. Q: What is the mechanism of action of PCSK9 inhibitors (e.g., alirocumab) and their
primary indication?
A: They are monoclonal antibodies that bind PCSK9, increasing hepatic LDL receptor
recycling and dramatically lowering LDL-C. Used for familial hypercholesterolemia or
ASCVD patients not at goal on statins.
Psychiatric & Neurologic Pharmacotherapeutics
11. Q: What is the "black box warning" associated with most antidepressant SSRIs/SNRIs?
A: Increased risk of suicidal thinking and behavior in children, adolescents, and young
adults (ages 18-24) during initial treatment.
12. Q: Why should anticholinergic drugs (e.g., diphenhydramine) generally be avoided in the
elderly?
A: They increase the risk of confusion, falls, constipation, urinary retention, and delirium.
13. Q: What is the first-line, long-term prophylactic therapy for a patient with generalized
epilepsy?
A: Lamotrigine or levetiracetam are often considered first-line due to their broad
spectrum and tolerability.
14. Q: For acute migraine treatment, what is the role of a "triptan" medication (e.g.,
sumatriptan)?
A: They are selective serotonin (5-HT1B/1D) receptor agonists that cause cranial
vasoconstriction and inhibit neurogenic inflammation. Used for moderate to severe
attacks.
, 15. Q: Which atypical antipsychotic requires mandatory monitoring of fasting lipids and
glucose due to high metabolic risk?
A: Olanzapine and clozapine carry the highest risk.
Endocrine & Metabolic Pharmacotherapeutics
16. Q: What is the preferred first-line agent for Type 2 Diabetes Mellitus, regardless of A1c,
due to cardiovascular and renal benefits?
A: An SGLT2 inhibitor (e.g., empagliflozin) or a GLP-1 receptor agonist (e.g.,
semaglutide), based on patient-specific comorbidities.
17. Q: Why is metformin withheld before procedures using iodinated contrast dye?
A: Risk of contrast-induced nephropathy and subsequent lactic acidosis, a rare but
serious complication of metformin.
18. Q: What is the initial hormone replacement for primary adrenal insufficiency (Addison's
disease)?
A: Glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement.
19. Q: A patient on levothyroxine starts ferrous sulfate. What counseling is critical?
A: Separate administration by at least 4 hours, as iron significantly reduces levothyroxine
absorption.
20. Q: What is the goal of using bisphosphonates (e.g., alendronate) in osteoporosis?
A: To inhibit osteoclast-mediated bone resorption, increase bone mineral density, and
reduce fracture risk.
Respiratory & Immunologic Pharmacotherapeutics
21. Q: What is the role of a long-acting muscarinic antagonist (LAMA) like tiotropium in
COPD management?
A: To provide 24-hour bronchodilation by blocking acetylcholine, reducing dynamic
hyperinflation, and improving exercise tolerance.
22. Q: For a patient with moderate persistent asthma, what defines "Step 3" therapy
according to GINA guidelines?
A: Low-dose ICS-formoterol used as both daily maintenance and reliever therapy
(preferred), or medium-dose ICS with a SABA reliever.
, 23. Q: What is the mechanism of monoclonal antibodies like omalizumab in severe asthma?
A: They inhibit IgE binding to mast cells and basophils, preventing allergen-triggered
degranulation.
24. Q: What is the first-line pharmacotherapy for chronic allergic rhinitis?
A: Intranasal corticosteroids (e.g., fluticasone, mometasone).
25. Q: Which vaccination is absolutely contraindicated in a patient receiving rituximab (a B-
cell depleter)?
A: Live vaccines (e.g., MMR, varicella, live influenza). Inactivated vaccines are safe but
may have reduced immunogenicity.
Infectious Disease Pharmacotherapeutics
26. Q: What is the most critical monitoring parameter when initiating vancomycin?
A: Trough serum concentrations (drawn just before the 4th dose) to ensure efficacy and
reduce nephrotoxicity risk. Area Under the Curve (AUC) monitoring is now
recommended.
27. Q: Why is combination therapy (usually 3-4 drugs) required for active tuberculosis?
A: To prevent the selection of drug-resistant mutants, as M. tuberculosis has a high
spontaneous mutation rate.
28. Q: What is the first-line treatment for uncomplicated cystitis in a non-pregnant woman?
A: Nitrofurantoin monohydrate/macrocrystals for 5 days, or fosfomycin single dose,
depending on local resistance patterns.
29. Q: When should antiretroviral therapy (ART) be initiated in a person newly diagnosed
with HIV, regardless of CD4 count?
A: Immediately upon diagnosis. ("Treatment as prevention" and for individual health
benefit).
30. Q: What is the primary serious adverse effect of fluoroquinolones (e.g., ciprofloxacin)
that led to FDA restrictions?
A: Disabling and potentially permanent side effects involving tendons, muscles, joints,
nerves, and the central nervous system.
Musculoskeletal & Pain Management
31. Q: What is the recommended maximum daily dose of acetaminophen for a chronic user?
A: 3,000 mg per day (reduced from 4,000 mg due to hepatotoxicity risk).
Practice Nurses — Comprehensive
Study Guide (6th Edition Concepts)
1. Q: What is the primary goal of the "Start Low and Go Slow" prescribing principle in
geriatric pharmacotherapy?
A: To minimize adverse drug reactions by accounting for age-related changes in
pharmacokinetics (absorption, distribution, metabolism, excretion).
2. Q: A patient on warfarin develops a dangerously high INR. Besides stopping the warfarin,
what is the most appropriate immediate intervention?
A: Administer vitamin K (phytonadione) orally or intravenously, depending on the
urgency. Fresh frozen plasma may be used for severe bleeding.
3. Q: What is the significance of a drug's therapeutic index (TI)?
A: It represents the ratio between the toxic dose and the effective dose. A low TI (e.g.,
digoxin, warfarin) indicates a narrow safety margin and requires close monitoring.
4. Q: Which physiological change in pregnancy most significantly affects drug volume of
distribution and dosing?
A: Increased plasma volume (up to 50%), leading to lower plasma concentrations of
drugs.
5. Q: What is the cornerstone of preventing opioid use disorder when prescribing for
chronic non-cancer pain?
A: Employing a universal precautions approach: using a controlled substance agreement,
checking prescription drug monitoring programs (PDMPs) at every visit, and scheduling
regular follow-ups to assess function and pain.
Cardiovascular Pharmacotherapeutics
6. Q: For a patient with heart failure with reduced ejection fraction (HFrEF), which four
drug classes form the foundation of guideline-directed medical therapy (GDMT)?
A: Beta-blockers (carvedilol, metoprolol succinate), ACE Inhibitors/ARBs/ARNIs
(sacubitril/valsartan), Mineralocorticoid Receptor Antagonists (MRAs like
spironolactone), and SGLT2 Inhibitors (dapagliflozin, empagliflozin).
, 7. Q: Why are ACE Inhibitors contraindicated in pregnancy?
A: They can cause fetal injury, including oligohydramnios, fetal lung hypoplasia, skull
hypoplasia, and neonatal renal failure, especially in the 2nd and 3rd trimesters.
8. Q: What is the first-line pharmacotherapy for a healthy 45-year-old male with newly
diagnosed, uncomplicated essential hypertension?
A: A thiazide-like diuretic (e.g., chlorthalidone) or an ACE inhibitor/ARB. Choice depends
on comorbid conditions and patient demographics.
9. Q: When initiating amiodarone, what baseline monitoring is essential due to its risk of
severe toxicities?
A: LFTs, Thyroid Function Tests (TSH), Chest X-ray, Pulmonary Function Tests, and
Ophthalmologic exam.
10. Q: What is the mechanism of action of PCSK9 inhibitors (e.g., alirocumab) and their
primary indication?
A: They are monoclonal antibodies that bind PCSK9, increasing hepatic LDL receptor
recycling and dramatically lowering LDL-C. Used for familial hypercholesterolemia or
ASCVD patients not at goal on statins.
Psychiatric & Neurologic Pharmacotherapeutics
11. Q: What is the "black box warning" associated with most antidepressant SSRIs/SNRIs?
A: Increased risk of suicidal thinking and behavior in children, adolescents, and young
adults (ages 18-24) during initial treatment.
12. Q: Why should anticholinergic drugs (e.g., diphenhydramine) generally be avoided in the
elderly?
A: They increase the risk of confusion, falls, constipation, urinary retention, and delirium.
13. Q: What is the first-line, long-term prophylactic therapy for a patient with generalized
epilepsy?
A: Lamotrigine or levetiracetam are often considered first-line due to their broad
spectrum and tolerability.
14. Q: For acute migraine treatment, what is the role of a "triptan" medication (e.g.,
sumatriptan)?
A: They are selective serotonin (5-HT1B/1D) receptor agonists that cause cranial
vasoconstriction and inhibit neurogenic inflammation. Used for moderate to severe
attacks.
, 15. Q: Which atypical antipsychotic requires mandatory monitoring of fasting lipids and
glucose due to high metabolic risk?
A: Olanzapine and clozapine carry the highest risk.
Endocrine & Metabolic Pharmacotherapeutics
16. Q: What is the preferred first-line agent for Type 2 Diabetes Mellitus, regardless of A1c,
due to cardiovascular and renal benefits?
A: An SGLT2 inhibitor (e.g., empagliflozin) or a GLP-1 receptor agonist (e.g.,
semaglutide), based on patient-specific comorbidities.
17. Q: Why is metformin withheld before procedures using iodinated contrast dye?
A: Risk of contrast-induced nephropathy and subsequent lactic acidosis, a rare but
serious complication of metformin.
18. Q: What is the initial hormone replacement for primary adrenal insufficiency (Addison's
disease)?
A: Glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement.
19. Q: A patient on levothyroxine starts ferrous sulfate. What counseling is critical?
A: Separate administration by at least 4 hours, as iron significantly reduces levothyroxine
absorption.
20. Q: What is the goal of using bisphosphonates (e.g., alendronate) in osteoporosis?
A: To inhibit osteoclast-mediated bone resorption, increase bone mineral density, and
reduce fracture risk.
Respiratory & Immunologic Pharmacotherapeutics
21. Q: What is the role of a long-acting muscarinic antagonist (LAMA) like tiotropium in
COPD management?
A: To provide 24-hour bronchodilation by blocking acetylcholine, reducing dynamic
hyperinflation, and improving exercise tolerance.
22. Q: For a patient with moderate persistent asthma, what defines "Step 3" therapy
according to GINA guidelines?
A: Low-dose ICS-formoterol used as both daily maintenance and reliever therapy
(preferred), or medium-dose ICS with a SABA reliever.
, 23. Q: What is the mechanism of monoclonal antibodies like omalizumab in severe asthma?
A: They inhibit IgE binding to mast cells and basophils, preventing allergen-triggered
degranulation.
24. Q: What is the first-line pharmacotherapy for chronic allergic rhinitis?
A: Intranasal corticosteroids (e.g., fluticasone, mometasone).
25. Q: Which vaccination is absolutely contraindicated in a patient receiving rituximab (a B-
cell depleter)?
A: Live vaccines (e.g., MMR, varicella, live influenza). Inactivated vaccines are safe but
may have reduced immunogenicity.
Infectious Disease Pharmacotherapeutics
26. Q: What is the most critical monitoring parameter when initiating vancomycin?
A: Trough serum concentrations (drawn just before the 4th dose) to ensure efficacy and
reduce nephrotoxicity risk. Area Under the Curve (AUC) monitoring is now
recommended.
27. Q: Why is combination therapy (usually 3-4 drugs) required for active tuberculosis?
A: To prevent the selection of drug-resistant mutants, as M. tuberculosis has a high
spontaneous mutation rate.
28. Q: What is the first-line treatment for uncomplicated cystitis in a non-pregnant woman?
A: Nitrofurantoin monohydrate/macrocrystals for 5 days, or fosfomycin single dose,
depending on local resistance patterns.
29. Q: When should antiretroviral therapy (ART) be initiated in a person newly diagnosed
with HIV, regardless of CD4 count?
A: Immediately upon diagnosis. ("Treatment as prevention" and for individual health
benefit).
30. Q: What is the primary serious adverse effect of fluoroquinolones (e.g., ciprofloxacin)
that led to FDA restrictions?
A: Disabling and potentially permanent side effects involving tendons, muscles, joints,
nerves, and the central nervous system.
Musculoskeletal & Pain Management
31. Q: What is the recommended maximum daily dose of acetaminophen for a chronic user?
A: 3,000 mg per day (reduced from 4,000 mg due to hepatotoxicity risk).
