NR 566 / NR566 Advanced Pharmacology for Care
of the Family Midterm Exam (2025/2026 Update)
Questions & Verified Answers | Grade A | 100%
Correct Solutions
DOMAIN 1: PHARMACOLOGY PRINCIPLES & SAFE PRESCRIBING (8 Questions)
Question 1 — Pharmacokinetics/Pharmacodynamics (Multiple Choice)
A 68-year-old patient with heart failure is started on digoxin 0.125 mg daily. The nurse
practitioner knows that digoxin has a narrow therapeutic index (NTI). Which statement best
describes the clinical significance of a drug's narrow therapeutic index?
A) The drug requires hepatic dose adjustment only in patients with cirrhosis
B) The toxic dose is very close to the therapeutic dose, requiring close monitoring
C) The drug can be safely administered without therapeutic drug monitoring
D) The drug has a very short half-life and requires frequent dosing
[CORRECT] B) The toxic dose is very close to the therapeutic dose, requiring close monitoring
Rationale: Digoxin is a classic narrow therapeutic index (NTI) drug. The therapeutic index is
the ratio between the toxic dose and the therapeutic dose. For NTI drugs, this ratio is small,
meaning there is a minimal margin of safety between effective and toxic concentrations.
Digoxin requires therapeutic drug monitoring (serum levels), careful dose titration, and
vigilant assessment for toxicity (nausea, vomiting, visual disturbances, arrhythmias). Other
NTI drugs include warfarin and lithium.
Question 2 — Pharmacokinetics/Pharmacodynamics (Select-All-That-Apply)
Which of the following factors affect drug absorption? (Select all that apply)
A) Route of administration
B) Lipid solubility of the drug
C) Blood flow to the absorption site
D) pH of the environment
E) Molecular size of the drug
,F) Patient's glomerular filtration rate
[CORRECT] A, B, C, D, E
Rationale: Drug absorption is influenced by multiple factors: (A) Route of administration
determines whether first-pass metabolism occurs (oral vs. sublingual/IV/transdermal); (B)
Lipid-soluble drugs cross cell membranes more easily; (C) Blood flow affects the rate of drug
delivery from the absorption site; (D) pH affects drug ionization (weak acids absorb better in
acidic environments, weak bases in alkaline); (E) Smaller molecules diffuse more readily.
Glomerular filtration rate (F) affects drug elimination, not absorption.
Question 3 — CYP450 System & Drug-Drug Interactions (Case Study/Scenario-Based)
A 55-year-old patient with atrial fibrillation is taking apixaban (Eliquis) 5 mg BID. He presents
with a fungal toenail infection and requests treatment. The NP considers prescribing
itraconazole. What is the primary concern with this combination?
A) Itraconazole induces CYP3A4, decreasing apixaban levels and increasing stroke risk
B) Itraconazole inhibits CYP3A4, increasing apixaban levels and bleeding risk
C) Itraconazole competes for albumin binding, displacing apixaban
D) There is no significant interaction between these medications
[CORRECT] B) Itraconazole inhibits CYP3A4, increasing apixaban levels and bleeding risk
Rationale: Apixaban is metabolized primarily by CYP3A4. Itraconazole is a potent CYP3A4
inhibitor. When a CYP3A4 inhibitor is combined with a CYP3A4 substrate like apixaban, the
metabolism of apixaban decreases, leading to increased plasma concentrations and
significantly elevated bleeding risk. This combination should be avoided or used with extreme
caution and close monitoring. Azole antifungals (itraconazole, ketoconazole, voriconazole) are
well-documented CYP3A4 inhibitors.
Question 4 — CYP450 System & Drug-Drug Interactions (Multiple Choice)
A patient on warfarin (CYP2C9 substrate) is started on a new medication. The NP reviews the
medication list and identifies which drug as a CYP2C9 inhibitor that would increase warfarin's
anticoagulant effect?
A) Rifampin
B) Phenytoin
C) Fluconazole
, D) Carbamazepine
[CORRECT] C) Fluconazole
Rationale: Fluconazole is a potent CYP2C9 inhibitor. When combined with warfarin (a CYP2C9
substrate), fluconazole decreases warfarin metabolism, leading to increased INR and bleeding
risk. Rifampin, phenytoin, and carbamazepine are CYP450 inducers (not inhibitors) that would
decrease warfarin levels and increase thrombosis risk. The NP must monitor INR closely when
adding any CYP2C9 inhibitor to warfarin therapy.
Question 5 — Adverse Drug Reactions, Medication Errors, and Reporting (Multiple Choice)
A 72-year-old patient develops angioedema after starting lisinopril for hypertension. The NP
recognizes this as a serious adverse drug reaction. Which is the most appropriate immediate
action?
A) Switch to losartan and continue monitoring in the clinic
B) Discontinue lisinopril immediately, assess airway, and administer epinephrine if indicated
C) Reduce the lisinopril dose by 50% and observe
D) Prescribe diphenhydramine and continue lisinopril
[CORRECT] B) Discontinue lisinopril immediately, assess airway, and administer epinephrine if
indicated
Rationale: ACE inhibitor-induced angioedema is a medical emergency caused by bradykinin
accumulation. It can progress rapidly to airway obstruction. The NP must immediately
discontinue the ACE inhibitor, assess the patient's airway patency, and be prepared to
administer epinephrine and secure the airway if respiratory compromise develops. ARBs do
not cause angioedema via bradykinin (though rare cross-reactivity exists), but the immediate
priority is airway management. This reaction must be reported to FDA MedWatch.
Question 6 — Adverse Drug Reactions, Medication Errors, and Reporting (Select-All-That-
Apply)
Which of the following are required components of a complete medication error report?
(Select all that apply)
A) Patient demographics and medical record number
B) Description of the error including drug name, dose, and route
C) Patient outcome and any interventions required
of the Family Midterm Exam (2025/2026 Update)
Questions & Verified Answers | Grade A | 100%
Correct Solutions
DOMAIN 1: PHARMACOLOGY PRINCIPLES & SAFE PRESCRIBING (8 Questions)
Question 1 — Pharmacokinetics/Pharmacodynamics (Multiple Choice)
A 68-year-old patient with heart failure is started on digoxin 0.125 mg daily. The nurse
practitioner knows that digoxin has a narrow therapeutic index (NTI). Which statement best
describes the clinical significance of a drug's narrow therapeutic index?
A) The drug requires hepatic dose adjustment only in patients with cirrhosis
B) The toxic dose is very close to the therapeutic dose, requiring close monitoring
C) The drug can be safely administered without therapeutic drug monitoring
D) The drug has a very short half-life and requires frequent dosing
[CORRECT] B) The toxic dose is very close to the therapeutic dose, requiring close monitoring
Rationale: Digoxin is a classic narrow therapeutic index (NTI) drug. The therapeutic index is
the ratio between the toxic dose and the therapeutic dose. For NTI drugs, this ratio is small,
meaning there is a minimal margin of safety between effective and toxic concentrations.
Digoxin requires therapeutic drug monitoring (serum levels), careful dose titration, and
vigilant assessment for toxicity (nausea, vomiting, visual disturbances, arrhythmias). Other
NTI drugs include warfarin and lithium.
Question 2 — Pharmacokinetics/Pharmacodynamics (Select-All-That-Apply)
Which of the following factors affect drug absorption? (Select all that apply)
A) Route of administration
B) Lipid solubility of the drug
C) Blood flow to the absorption site
D) pH of the environment
E) Molecular size of the drug
,F) Patient's glomerular filtration rate
[CORRECT] A, B, C, D, E
Rationale: Drug absorption is influenced by multiple factors: (A) Route of administration
determines whether first-pass metabolism occurs (oral vs. sublingual/IV/transdermal); (B)
Lipid-soluble drugs cross cell membranes more easily; (C) Blood flow affects the rate of drug
delivery from the absorption site; (D) pH affects drug ionization (weak acids absorb better in
acidic environments, weak bases in alkaline); (E) Smaller molecules diffuse more readily.
Glomerular filtration rate (F) affects drug elimination, not absorption.
Question 3 — CYP450 System & Drug-Drug Interactions (Case Study/Scenario-Based)
A 55-year-old patient with atrial fibrillation is taking apixaban (Eliquis) 5 mg BID. He presents
with a fungal toenail infection and requests treatment. The NP considers prescribing
itraconazole. What is the primary concern with this combination?
A) Itraconazole induces CYP3A4, decreasing apixaban levels and increasing stroke risk
B) Itraconazole inhibits CYP3A4, increasing apixaban levels and bleeding risk
C) Itraconazole competes for albumin binding, displacing apixaban
D) There is no significant interaction between these medications
[CORRECT] B) Itraconazole inhibits CYP3A4, increasing apixaban levels and bleeding risk
Rationale: Apixaban is metabolized primarily by CYP3A4. Itraconazole is a potent CYP3A4
inhibitor. When a CYP3A4 inhibitor is combined with a CYP3A4 substrate like apixaban, the
metabolism of apixaban decreases, leading to increased plasma concentrations and
significantly elevated bleeding risk. This combination should be avoided or used with extreme
caution and close monitoring. Azole antifungals (itraconazole, ketoconazole, voriconazole) are
well-documented CYP3A4 inhibitors.
Question 4 — CYP450 System & Drug-Drug Interactions (Multiple Choice)
A patient on warfarin (CYP2C9 substrate) is started on a new medication. The NP reviews the
medication list and identifies which drug as a CYP2C9 inhibitor that would increase warfarin's
anticoagulant effect?
A) Rifampin
B) Phenytoin
C) Fluconazole
, D) Carbamazepine
[CORRECT] C) Fluconazole
Rationale: Fluconazole is a potent CYP2C9 inhibitor. When combined with warfarin (a CYP2C9
substrate), fluconazole decreases warfarin metabolism, leading to increased INR and bleeding
risk. Rifampin, phenytoin, and carbamazepine are CYP450 inducers (not inhibitors) that would
decrease warfarin levels and increase thrombosis risk. The NP must monitor INR closely when
adding any CYP2C9 inhibitor to warfarin therapy.
Question 5 — Adverse Drug Reactions, Medication Errors, and Reporting (Multiple Choice)
A 72-year-old patient develops angioedema after starting lisinopril for hypertension. The NP
recognizes this as a serious adverse drug reaction. Which is the most appropriate immediate
action?
A) Switch to losartan and continue monitoring in the clinic
B) Discontinue lisinopril immediately, assess airway, and administer epinephrine if indicated
C) Reduce the lisinopril dose by 50% and observe
D) Prescribe diphenhydramine and continue lisinopril
[CORRECT] B) Discontinue lisinopril immediately, assess airway, and administer epinephrine if
indicated
Rationale: ACE inhibitor-induced angioedema is a medical emergency caused by bradykinin
accumulation. It can progress rapidly to airway obstruction. The NP must immediately
discontinue the ACE inhibitor, assess the patient's airway patency, and be prepared to
administer epinephrine and secure the airway if respiratory compromise develops. ARBs do
not cause angioedema via bradykinin (though rare cross-reactivity exists), but the immediate
priority is airway management. This reaction must be reported to FDA MedWatch.
Question 6 — Adverse Drug Reactions, Medication Errors, and Reporting (Select-All-That-
Apply)
Which of the following are required components of a complete medication error report?
(Select all that apply)
A) Patient demographics and medical record number
B) Description of the error including drug name, dose, and route
C) Patient outcome and any interventions required
