NURS 6521 Advanced Pharmacology Midterm Exam 2026 –
Complete Exam-Style Questions with Detailed Rationales | 100%
Verified – Pass Guaranteed – A+ Graded
Time Allowed: 3 Hours
Total Questions: 75 (57 Multiple-Choice, 11 Select All That Apply, 7 Case-Based)
Section I: Pharmacokinetics & Pharmacodynamics
1. A 68-year-old patient with chronic heart failure is prescribed lisinopril 10 mg daily. The
patient has a serum creatinine of 1.8 mg/dL (eGFR 38 mL/min/1.73m²) and is also
taking spironolactone 25 mg daily. The prescriber orders a basic metabolic panel in 1
week. Which pharmacokinetic parameter is most altered in this patient, and what is the
primary safety concern?
A. Decreased hepatic first-pass metabolism; risk of lisinopril accumulation and
angioedema
B. Reduced renal clearance; risk of hyperkalemia from combined ACE inhibitor and
potassium-sparing diuretic
C. Increased volume of distribution; risk of inadequate lisinopril efficacy
D. Enhanced P-glycoprotein efflux; risk of reduced spironolactone bioavailability
Correct Answer: B
Rationale: Lisinopril is renally excreted unchanged. With eGFR 38, elimination is
prolonged, increasing drug exposure. Combined with spironolactone, which antagonizes
aldosterone and reduces potassium excretion, the risk of life-threatening hyperkalemia
is substantial. First-pass metabolism (A) is irrelevant for lisinopril (not hepatically
,metabolized). Volume of distribution (C) and P-glycoprotein (D) are not primary
concerns here.
2. A patient with atrial fibrillation is prescribed warfarin. Genetic testing reveals CYP2C9
*2/*3 and VKORC1 -1639 G/A. Which pharmacogenomic implication most accurately
guides dosing?
A. Standard warfarin dosing is appropriate because pharmacogenomics does not affect
warfarin metabolism
B. Reduced initial dosing is indicated due to impaired S-warfarin metabolism and
increased warfarin sensitivity
C. Increased initial dosing is required due to rapid warfarin clearance
D. Warfarin is contraindicated; switch to apixaban regardless of CHA₂DS₂-VASc score
Correct Answer: B
Rationale: CYP2C9 *2/*3 is a poor metabolizer genotype, reducing S-warfarin clearance.
VKORC1 -1639 G/A increases sensitivity to warfarin's pharmacodynamic effect. Both
variants necessitate significantly reduced initial doses and slower titration. Warfarin is
not contraindicated (D), and standard dosing (A) or increased dosing (C) would cause
bleeding.
3. A 45-year-old patient with HIV is started on efavirenz, tenofovir disoproxil fumarate,
and emtricitabine. The patient also takes omeprazole 20 mg daily for GERD and
simvastatin 40 mg nightly for hyperlipidemia. Which drug interaction requires the most
urgent prescriber intervention?
,A. Efavirenz reduces omeprazole efficacy through CYP2C19 induction; increase
omeprazole to 40 mg
B. Tenofovir increases simvastatin levels through OATP1B1 inhibition; hold simvastatin
C. Efavirenz induces CYP3A4, reducing simvastatin efficacy and necessitating a switch
to atorvastatin or dose increase
D. Omeprazole reduces tenofovir absorption through gastric acid suppression; switch to
H2 blocker
Correct Answer: C
Rationale: Efavirenz is a potent CYP3A4 inducer and reduces simvastatin exposure by
50–60%, potentially rendering it ineffective for LDL reduction. Simvastatin is also a
CYP3A4 substrate with significant myopathy risk if levels are unpredictably altered.
Switching to atorvastatin (less CYP3A4-dependent) or pravastatin (non-CYP
metabolized) is preferred. Omeprazole-tenofovir interaction (D) is minimal with TDF
(relevant for tenofovir alafenamide). Efavirenz-omeprazole (A) is manageable.
4. A patient with epilepsy is prescribed phenytoin 300 mg daily. Serum phenytoin level is
8 mcg/mL (therapeutic 10–20 mcg/mL), but the patient is seizure-free. Albumin is 2.8
g/dL (normal 3.5–5.0). Which adjustment is most appropriate?
A. Increase phenytoin to 400 mg daily to achieve therapeutic total level
B. Calculate corrected phenytoin level; the patient likely has adequate free phenytoin
despite low albumin
C. Add valproic acid to enhance phenytoin protein binding
D. Discontinue phenytoin because subtherapeutic levels indicate treatment failure
, Correct Answer: B
Rationale: Phenytoin is highly protein-bound (90%). Hypoalbuminemia reduces total
phenytoin but increases the free (active) fraction. The corrected level = measured level /
[(0.2 × albumin) + 0.1] = 8 / [(0.2 × 2.8) + 0.1] = .66 = 12.1 mcg/mL, which is
therapeutic. Increasing the dose (A) would cause toxicity. Valproic acid (C) displaces
phenytoin from albumin, complicating binding. Discontinuation (D) is inappropriate if
seizure-free.
5. A patient with metastatic breast cancer receives doxorubicin. The prescriber notes
the patient is a CYP2D6 ultrarapid metabolizer and also takes paroxetine. Which
pharmacogenomic and pharmacokinetic consideration is most relevant?
A. Paroxetine inhibits CYP2D6, potentially reducing doxorubicin efficacy
B. CYP2D6 ultrarapid metabolism increases doxorubicin cardiotoxicity risk
C. Doxorubicin is primarily metabolized by CYP3A4; CYP2D6 status is irrelevant
D. Paroxetine induces doxorubicin metabolism through CYP1A2
Correct Answer: C
Rationale: Doxorubicin undergoes extensive reduction by carbonyl reductases and
CYP3A4/CYP2C8-mediated metabolism; CYP2D6 plays a minimal role. Paroxetine is a
potent CYP2D6 inhibitor but does not significantly affect doxorubicin. The distractor
tests whether the examinee knows doxorubicin's metabolic pathway versus tamoxifen
(which is CYP2D6-dependent).
6. Which factors increase the risk of drug toxicity in geriatric patients through
pharmacokinetic alterations? (Select All That Apply)
Complete Exam-Style Questions with Detailed Rationales | 100%
Verified – Pass Guaranteed – A+ Graded
Time Allowed: 3 Hours
Total Questions: 75 (57 Multiple-Choice, 11 Select All That Apply, 7 Case-Based)
Section I: Pharmacokinetics & Pharmacodynamics
1. A 68-year-old patient with chronic heart failure is prescribed lisinopril 10 mg daily. The
patient has a serum creatinine of 1.8 mg/dL (eGFR 38 mL/min/1.73m²) and is also
taking spironolactone 25 mg daily. The prescriber orders a basic metabolic panel in 1
week. Which pharmacokinetic parameter is most altered in this patient, and what is the
primary safety concern?
A. Decreased hepatic first-pass metabolism; risk of lisinopril accumulation and
angioedema
B. Reduced renal clearance; risk of hyperkalemia from combined ACE inhibitor and
potassium-sparing diuretic
C. Increased volume of distribution; risk of inadequate lisinopril efficacy
D. Enhanced P-glycoprotein efflux; risk of reduced spironolactone bioavailability
Correct Answer: B
Rationale: Lisinopril is renally excreted unchanged. With eGFR 38, elimination is
prolonged, increasing drug exposure. Combined with spironolactone, which antagonizes
aldosterone and reduces potassium excretion, the risk of life-threatening hyperkalemia
is substantial. First-pass metabolism (A) is irrelevant for lisinopril (not hepatically
,metabolized). Volume of distribution (C) and P-glycoprotein (D) are not primary
concerns here.
2. A patient with atrial fibrillation is prescribed warfarin. Genetic testing reveals CYP2C9
*2/*3 and VKORC1 -1639 G/A. Which pharmacogenomic implication most accurately
guides dosing?
A. Standard warfarin dosing is appropriate because pharmacogenomics does not affect
warfarin metabolism
B. Reduced initial dosing is indicated due to impaired S-warfarin metabolism and
increased warfarin sensitivity
C. Increased initial dosing is required due to rapid warfarin clearance
D. Warfarin is contraindicated; switch to apixaban regardless of CHA₂DS₂-VASc score
Correct Answer: B
Rationale: CYP2C9 *2/*3 is a poor metabolizer genotype, reducing S-warfarin clearance.
VKORC1 -1639 G/A increases sensitivity to warfarin's pharmacodynamic effect. Both
variants necessitate significantly reduced initial doses and slower titration. Warfarin is
not contraindicated (D), and standard dosing (A) or increased dosing (C) would cause
bleeding.
3. A 45-year-old patient with HIV is started on efavirenz, tenofovir disoproxil fumarate,
and emtricitabine. The patient also takes omeprazole 20 mg daily for GERD and
simvastatin 40 mg nightly for hyperlipidemia. Which drug interaction requires the most
urgent prescriber intervention?
,A. Efavirenz reduces omeprazole efficacy through CYP2C19 induction; increase
omeprazole to 40 mg
B. Tenofovir increases simvastatin levels through OATP1B1 inhibition; hold simvastatin
C. Efavirenz induces CYP3A4, reducing simvastatin efficacy and necessitating a switch
to atorvastatin or dose increase
D. Omeprazole reduces tenofovir absorption through gastric acid suppression; switch to
H2 blocker
Correct Answer: C
Rationale: Efavirenz is a potent CYP3A4 inducer and reduces simvastatin exposure by
50–60%, potentially rendering it ineffective for LDL reduction. Simvastatin is also a
CYP3A4 substrate with significant myopathy risk if levels are unpredictably altered.
Switching to atorvastatin (less CYP3A4-dependent) or pravastatin (non-CYP
metabolized) is preferred. Omeprazole-tenofovir interaction (D) is minimal with TDF
(relevant for tenofovir alafenamide). Efavirenz-omeprazole (A) is manageable.
4. A patient with epilepsy is prescribed phenytoin 300 mg daily. Serum phenytoin level is
8 mcg/mL (therapeutic 10–20 mcg/mL), but the patient is seizure-free. Albumin is 2.8
g/dL (normal 3.5–5.0). Which adjustment is most appropriate?
A. Increase phenytoin to 400 mg daily to achieve therapeutic total level
B. Calculate corrected phenytoin level; the patient likely has adequate free phenytoin
despite low albumin
C. Add valproic acid to enhance phenytoin protein binding
D. Discontinue phenytoin because subtherapeutic levels indicate treatment failure
, Correct Answer: B
Rationale: Phenytoin is highly protein-bound (90%). Hypoalbuminemia reduces total
phenytoin but increases the free (active) fraction. The corrected level = measured level /
[(0.2 × albumin) + 0.1] = 8 / [(0.2 × 2.8) + 0.1] = .66 = 12.1 mcg/mL, which is
therapeutic. Increasing the dose (A) would cause toxicity. Valproic acid (C) displaces
phenytoin from albumin, complicating binding. Discontinuation (D) is inappropriate if
seizure-free.
5. A patient with metastatic breast cancer receives doxorubicin. The prescriber notes
the patient is a CYP2D6 ultrarapid metabolizer and also takes paroxetine. Which
pharmacogenomic and pharmacokinetic consideration is most relevant?
A. Paroxetine inhibits CYP2D6, potentially reducing doxorubicin efficacy
B. CYP2D6 ultrarapid metabolism increases doxorubicin cardiotoxicity risk
C. Doxorubicin is primarily metabolized by CYP3A4; CYP2D6 status is irrelevant
D. Paroxetine induces doxorubicin metabolism through CYP1A2
Correct Answer: C
Rationale: Doxorubicin undergoes extensive reduction by carbonyl reductases and
CYP3A4/CYP2C8-mediated metabolism; CYP2D6 plays a minimal role. Paroxetine is a
potent CYP2D6 inhibitor but does not significantly affect doxorubicin. The distractor
tests whether the examinee knows doxorubicin's metabolic pathway versus tamoxifen
(which is CYP2D6-dependent).
6. Which factors increase the risk of drug toxicity in geriatric patients through
pharmacokinetic alterations? (Select All That Apply)
