NURS 6521 Midterm Exam 2026 Update: Advanced Pharmacology Practice Questions with Complete
Solutions and Rationales for Nurse Practitioners Mastering Drug Therapy, Safety, and Prescriptive
Reasoning.
Version 4 – Questions 1–150 (Multiple Choice, Answers +
Explanations)
1. A patient with type 2 diabetes and heart failure with reduced ejection fraction is started on
empagliflozin. What is the primary benefit beyond glycemic control?
A) Weight loss
B) Reduced cardiovascular mortality and heart failure hospitalization
C) Lower blood pressure
D) Decreased triglyceride levels
Correct Answer: B – Empagliflozin (SGLT2 inhibitor) reduces CV mortality and HF hospitalization in
HFrEF regardless of diabetes status.
2. A patient on verapamil presents with constipation, bradycardia, and ankle edema. Which effect is
most concerning?
A) Constipation
B) Bradycardia
C) Ankle edema
D) Headache
Correct Answer: B – Verapamil (non-dihydropyridine CCB) causes bradycardia and heart block;
constipation is common but not life-threatening.
3. A patient with bipolar disorder on lithium develops a new tremor, polyuria, and weight gain.
Lithium level is 1.2 mEq/L. What is the most appropriate next step?
A) Increase lithium dose
B) Add valproate
C) Check renal function and thyroid studies
D) Switch to carbamazepine
Correct Answer: C – Lithium at 1.2 mEq/L may be therapeutic but polyuria suggests nephrogenic DI;
weight gain suggests hypothyroidism.
,4. Which medication is most appropriate for a patient with cirrhosis and acute variceal bleeding?
A) Propranolol
B) Octreotide
C) Spironolactone
D) Lactulose
Correct Answer: B – Octreotide (somatostatin analog) reduces portal pressure and is used with
endoscopic therapy for acute variceal bleeding.
5. A patient on warfarin has an INR of 1.8 (goal 2-3). The patient reports eating large amounts of
spinach daily. What is the most likely cause?
A) Warfarin resistance
B) Vitamin K excess from spinach
C) Malabsorption
D) Drug interaction with aspirin
Correct Answer: B – Spinach is high in vitamin K, which antagonizes warfarin and lowers INR.
6. A patient with myasthenia gravis is prescribed azithromycin for pneumonia. What is the risk?
A) No significant risk
B) Worsening of myasthenia gravis
C) Serotonin syndrome
D) QT prolongation only
Correct Answer: B – Macrolides (azithromycin, erythromycin) can worsen myasthenia gravis symptoms.
7. Which drug is first-line for trigeminal neuralgia?
A) Gabapentin
B) Carbamazepine
C) Pregabalin
D) Amitriptyline
Correct Answer: B – Carbamazepine is first-line for trigeminal neuralgia; oxcarbazepine is an
alternative.
8. A patient on digoxin has a potassium of 3.1 mEq/L and reports nausea and yellow vision. What is
the priority?
,A) Give potassium chloride IV
B) Hold digoxin and check digoxin level
C) Administer digoxin immune fab
D) Give magnesium sulfate
Correct Answer: B – Hypokalemia + nausea + yellow vision = digoxin toxicity; hold digoxin, check
level, then replete potassium.
9. A patient with Parkinson's disease on carbidopa/levodopa develops sudden confusion, rigidity,
and fever. What is the most likely diagnosis?
A) Serotonin syndrome
B) Neuroleptic malignant syndrome
C) Parkinson's disease progression
D) Levodopa toxicity
Correct Answer: B – Abrupt withdrawal of levodopa can cause NMS-like syndrome (rigidity, fever,
autonomic instability).
10. Which antidepressant is most likely to cause hyponatremia (SIADH) in older adults?
A) Bupropion
B) Sertraline
C) Mirtazapine
D) Trazodone
Correct Answer: B – SSRIs (especially sertraline, fluoxetine) cause SIADH more often than other
antidepressants in older adults.
11. A patient with gout and CKD stage 4 needs urate-lowering therapy. Which drug is preferred?
A) Allopurinol
B) Febuxostat
C) Probenecid
D) Colchicine
Correct Answer: A – Allopurinol is preferred (dose adjust for renal function); febuxostat is alternative;
probenecid ineffective in CKD.
12. A patient on metformin and sitagliptin presents with severe epigastric pain radiating to the
back, with elevated lipase. Which drug is most likely causative?
A) Metformin
, B) Sitagliptin
C) Both
D) Neither
Correct Answer: B – DPP-4 inhibitors (sitagliptin, linagliptin) have a rare association with acute
pancreatitis.
13. A patient on amiodarone develops a new-onset gray-blue skin discoloration on sun-exposed
areas. What should the nurse advise?
A) Stop amiodarone immediately
B) Use sun protection; discoloration may partially reverse after stopping
C) Apply topical steroids
D) It is a sign of amiodarone toxicity requiring hospitalization
Correct Answer: B – Blue-gray skin discoloration is a cosmetic side effect of chronic amiodarone; sun
protection helps.
14. Which medication is used to reverse the neuromuscular blockade of rocuronium?
A) Neostigmine
B) Sugammadex
C) Atropine
D) Edrophonium
Correct Answer: B – Sugammadex encapsulates rocuronium and vecuronium, providing rapid reversal.
15. A patient with schizophrenia on clozapine has a white blood cell count of 2,500/mm³. What is
the priority?
A) Continue clozapine and repeat CBC in 1 week
B) Stop clozapine immediately and initiate infection precautions
C) Add filgrastim (G-CSF)
D) Reduce clozapine dose by 50%
Correct Answer: B – WBC <3,000/mm³ or ANC <1,500/mm³ requires clozapine discontinuation per
REMS protocol.
16. Which drug is most effective for reducing mortality in heart failure with reduced ejection
fraction?
A) Furosemide
B) Digoxin
Solutions and Rationales for Nurse Practitioners Mastering Drug Therapy, Safety, and Prescriptive
Reasoning.
Version 4 – Questions 1–150 (Multiple Choice, Answers +
Explanations)
1. A patient with type 2 diabetes and heart failure with reduced ejection fraction is started on
empagliflozin. What is the primary benefit beyond glycemic control?
A) Weight loss
B) Reduced cardiovascular mortality and heart failure hospitalization
C) Lower blood pressure
D) Decreased triglyceride levels
Correct Answer: B – Empagliflozin (SGLT2 inhibitor) reduces CV mortality and HF hospitalization in
HFrEF regardless of diabetes status.
2. A patient on verapamil presents with constipation, bradycardia, and ankle edema. Which effect is
most concerning?
A) Constipation
B) Bradycardia
C) Ankle edema
D) Headache
Correct Answer: B – Verapamil (non-dihydropyridine CCB) causes bradycardia and heart block;
constipation is common but not life-threatening.
3. A patient with bipolar disorder on lithium develops a new tremor, polyuria, and weight gain.
Lithium level is 1.2 mEq/L. What is the most appropriate next step?
A) Increase lithium dose
B) Add valproate
C) Check renal function and thyroid studies
D) Switch to carbamazepine
Correct Answer: C – Lithium at 1.2 mEq/L may be therapeutic but polyuria suggests nephrogenic DI;
weight gain suggests hypothyroidism.
,4. Which medication is most appropriate for a patient with cirrhosis and acute variceal bleeding?
A) Propranolol
B) Octreotide
C) Spironolactone
D) Lactulose
Correct Answer: B – Octreotide (somatostatin analog) reduces portal pressure and is used with
endoscopic therapy for acute variceal bleeding.
5. A patient on warfarin has an INR of 1.8 (goal 2-3). The patient reports eating large amounts of
spinach daily. What is the most likely cause?
A) Warfarin resistance
B) Vitamin K excess from spinach
C) Malabsorption
D) Drug interaction with aspirin
Correct Answer: B – Spinach is high in vitamin K, which antagonizes warfarin and lowers INR.
6. A patient with myasthenia gravis is prescribed azithromycin for pneumonia. What is the risk?
A) No significant risk
B) Worsening of myasthenia gravis
C) Serotonin syndrome
D) QT prolongation only
Correct Answer: B – Macrolides (azithromycin, erythromycin) can worsen myasthenia gravis symptoms.
7. Which drug is first-line for trigeminal neuralgia?
A) Gabapentin
B) Carbamazepine
C) Pregabalin
D) Amitriptyline
Correct Answer: B – Carbamazepine is first-line for trigeminal neuralgia; oxcarbazepine is an
alternative.
8. A patient on digoxin has a potassium of 3.1 mEq/L and reports nausea and yellow vision. What is
the priority?
,A) Give potassium chloride IV
B) Hold digoxin and check digoxin level
C) Administer digoxin immune fab
D) Give magnesium sulfate
Correct Answer: B – Hypokalemia + nausea + yellow vision = digoxin toxicity; hold digoxin, check
level, then replete potassium.
9. A patient with Parkinson's disease on carbidopa/levodopa develops sudden confusion, rigidity,
and fever. What is the most likely diagnosis?
A) Serotonin syndrome
B) Neuroleptic malignant syndrome
C) Parkinson's disease progression
D) Levodopa toxicity
Correct Answer: B – Abrupt withdrawal of levodopa can cause NMS-like syndrome (rigidity, fever,
autonomic instability).
10. Which antidepressant is most likely to cause hyponatremia (SIADH) in older adults?
A) Bupropion
B) Sertraline
C) Mirtazapine
D) Trazodone
Correct Answer: B – SSRIs (especially sertraline, fluoxetine) cause SIADH more often than other
antidepressants in older adults.
11. A patient with gout and CKD stage 4 needs urate-lowering therapy. Which drug is preferred?
A) Allopurinol
B) Febuxostat
C) Probenecid
D) Colchicine
Correct Answer: A – Allopurinol is preferred (dose adjust for renal function); febuxostat is alternative;
probenecid ineffective in CKD.
12. A patient on metformin and sitagliptin presents with severe epigastric pain radiating to the
back, with elevated lipase. Which drug is most likely causative?
A) Metformin
, B) Sitagliptin
C) Both
D) Neither
Correct Answer: B – DPP-4 inhibitors (sitagliptin, linagliptin) have a rare association with acute
pancreatitis.
13. A patient on amiodarone develops a new-onset gray-blue skin discoloration on sun-exposed
areas. What should the nurse advise?
A) Stop amiodarone immediately
B) Use sun protection; discoloration may partially reverse after stopping
C) Apply topical steroids
D) It is a sign of amiodarone toxicity requiring hospitalization
Correct Answer: B – Blue-gray skin discoloration is a cosmetic side effect of chronic amiodarone; sun
protection helps.
14. Which medication is used to reverse the neuromuscular blockade of rocuronium?
A) Neostigmine
B) Sugammadex
C) Atropine
D) Edrophonium
Correct Answer: B – Sugammadex encapsulates rocuronium and vecuronium, providing rapid reversal.
15. A patient with schizophrenia on clozapine has a white blood cell count of 2,500/mm³. What is
the priority?
A) Continue clozapine and repeat CBC in 1 week
B) Stop clozapine immediately and initiate infection precautions
C) Add filgrastim (G-CSF)
D) Reduce clozapine dose by 50%
Correct Answer: B – WBC <3,000/mm³ or ANC <1,500/mm³ requires clozapine discontinuation per
REMS protocol.
16. Which drug is most effective for reducing mortality in heart failure with reduced ejection
fraction?
A) Furosemide
B) Digoxin
