NUR 164 PHARMACOLOGY MASTERY: COMPREHENSIVE
NCLEX-STYLE QUESTIONS WITH DETAILED EXPLANATIONS
1. A patient receiving IV fentanyl postoperatively has a respiratory rate
of 6 breaths per minute and is difficult to arouse. Which medication
should the nurse prepare to administer first
A. Naloxone
B. Flumazenil
C. Activated charcoal
D. Methylnaltrexone
Correct Answer: A
Explanation: Naloxone is a pure opioid antagonist that rapidly reverses
opioid-induced respiratory depression by competitively blocking mu,
kappa, and delta receptors. Flumazenil reverses benzodiazepines.
Activated charcoal is for recent oral ingestions. Methylnaltrexone treats
opioid-induced constipation without affecting analgesia or respiration.
2. A patient with type 2 diabetes is started on metformin. Which
baseline lab value is most critical to assess before the first dose
A. Hemoglobin A1c
B. Serum creatinine
C. Fasting blood glucose
D. Aspartate aminotransferase
Correct Answer: B
Explanation: Metformin is excreted unchanged by the kidneys. Impaired
renal function increases the risk of lactic acidosis, a rare but life-
threatening adverse effect. Serum creatinine is used to calculate
,estimated glomerular filtration rate. Metformin is typically avoided if
eGFR is below 30 mL/min/1.73m².
3. A nurse administers subcutaneous enoxaparin to a patient with
deep vein thrombosis. Which adverse effect would indicate a need for
immediate discontinuation and antidote administration
A. Injection site bruising
B. Thrombocytopenia with platelet count of 40,000/mcL
C. Mild headache
D. Elevated liver enzymes
Correct Answer: B
Explanation: Enoxaparin can cause heparin-induced thrombocytopenia
(HIT), an immune-mediated reaction leading to severe
thrombocytopenia and paradoxical thrombosis. A platelet count drop to
40,000/mcL with enoxaparin use requires immediate discontinuation
and alternative anticoagulation (e.g., argatroban). Protamine sulfate
partially reverses enoxaparin but is not the primary antidote for HIT.
4. Which statement by a patient prescribed losartan indicates a need
for further teaching
A. "I should avoid using salt substitutes containing potassium."
B. "This medication may cause a dry cough like lisinopril did."
C. "I need to get up slowly from sitting to prevent dizziness."
D. "I will report any swelling of my lips or face immediately."
Correct Answer: B
Explanation: Losartan is an angiotensin II receptor blocker (ARB) that
rarely causes cough compared to ACE inhibitors (e.g., lisinopril). A dry
cough is not expected with losartan, so this statement suggests
confusion between drug classes. ARBs are often substituted when ACE
inhibitor cough is intolerable.
,5. A patient on lithium for bipolar disorder has a serum level of 2.0
mEq/L and reports vomiting, diarrhea, and hand tremors. What is the
priority nursing action
A. Administer a PRN dose of haloperidol
B. Hold the next dose and prepare for possible hemodialysis
C. Increase oral fluid intake to 3 liters per day
D. Give activated charcoal with sorbitol
Correct Answer: B
Explanation: Lithium toxicity occurs above 1.5 mEq/L. A level of 2.0
mEq/L with gastrointestinal symptoms and tremors indicates moderate
toxicity. Holding lithium prevents further accumulation. Hemodialysis is
considered for levels above 2.5 mEq/L or with severe symptoms.
Charcoal does not bind lithium. Increased fluids help but are not the
priority when toxicity is already present.
6. Which medication requires the nurse to monitor for the
development of a prolonged QT interval on electrocardiogram
A. Metoprolol
B. Haloperidol
C. Pantoprazole
D. Acetaminophen
Correct Answer: B
Explanation: Haloperidol, a typical antipsychotic, is known to block
cardiac potassium channels (hERG), prolonging the QT interval and
increasing the risk of torsades de pointes. Metoprolol may cause
bradycardia but not significant QT prolongation. Pantoprazole and
acetaminophen have no known QT effects.
7. A patient accidentally takes two extra doses of carbamazepine at
home and arrives in the emergency department drowsy and ataxic.
, Which initial action should the nurse take
A. Administer flumazenil
B. Prepare for gastric lavage
C. Obtain a carbamazepine level
D. Give intravenous lipid emulsion
Correct Answer: C
Explanation: Carbamazepine overdose causes dose-dependent central
nervous system depression, ataxia, and nystagmus. A serum level guides
further management (e.g., activated charcoal, multiple doses of
charcoal, or hemodialysis). Flumazenil is not indicated. Gastric lavage is
rarely beneficial more than one hour post-ingestion. Lipid emulsion is
for local anesthetic toxicity.
8. A patient with myasthenia gravis reports worsening muscle
weakness two hours after taking pyridostigmine. The nurse notes
pinpoint pupils and excessive salivation. What is the most likely cause
A. Myasthenic crisis
B. Cholinergic crisis
C. Serotonin syndrome
D. Neuroleptic malignant syndrome
Correct Answer: B
Explanation: Pinpoint pupils (miosis), salivation, and muscle weakness
after a dose of pyridostigmine (an acetylcholinesterase inhibitor)
indicate cholinergic crisis due to excessive medication. This contrasts
with myasthenic crisis, which lacks muscarinic signs. The tensilon test
(edrophonium) can differentiate, but cholinergic crisis worsens with
more pyridostigmine.
9. Which pair of medications, when taken together, creates a high risk
for serotonin syndrome
NCLEX-STYLE QUESTIONS WITH DETAILED EXPLANATIONS
1. A patient receiving IV fentanyl postoperatively has a respiratory rate
of 6 breaths per minute and is difficult to arouse. Which medication
should the nurse prepare to administer first
A. Naloxone
B. Flumazenil
C. Activated charcoal
D. Methylnaltrexone
Correct Answer: A
Explanation: Naloxone is a pure opioid antagonist that rapidly reverses
opioid-induced respiratory depression by competitively blocking mu,
kappa, and delta receptors. Flumazenil reverses benzodiazepines.
Activated charcoal is for recent oral ingestions. Methylnaltrexone treats
opioid-induced constipation without affecting analgesia or respiration.
2. A patient with type 2 diabetes is started on metformin. Which
baseline lab value is most critical to assess before the first dose
A. Hemoglobin A1c
B. Serum creatinine
C. Fasting blood glucose
D. Aspartate aminotransferase
Correct Answer: B
Explanation: Metformin is excreted unchanged by the kidneys. Impaired
renal function increases the risk of lactic acidosis, a rare but life-
threatening adverse effect. Serum creatinine is used to calculate
,estimated glomerular filtration rate. Metformin is typically avoided if
eGFR is below 30 mL/min/1.73m².
3. A nurse administers subcutaneous enoxaparin to a patient with
deep vein thrombosis. Which adverse effect would indicate a need for
immediate discontinuation and antidote administration
A. Injection site bruising
B. Thrombocytopenia with platelet count of 40,000/mcL
C. Mild headache
D. Elevated liver enzymes
Correct Answer: B
Explanation: Enoxaparin can cause heparin-induced thrombocytopenia
(HIT), an immune-mediated reaction leading to severe
thrombocytopenia and paradoxical thrombosis. A platelet count drop to
40,000/mcL with enoxaparin use requires immediate discontinuation
and alternative anticoagulation (e.g., argatroban). Protamine sulfate
partially reverses enoxaparin but is not the primary antidote for HIT.
4. Which statement by a patient prescribed losartan indicates a need
for further teaching
A. "I should avoid using salt substitutes containing potassium."
B. "This medication may cause a dry cough like lisinopril did."
C. "I need to get up slowly from sitting to prevent dizziness."
D. "I will report any swelling of my lips or face immediately."
Correct Answer: B
Explanation: Losartan is an angiotensin II receptor blocker (ARB) that
rarely causes cough compared to ACE inhibitors (e.g., lisinopril). A dry
cough is not expected with losartan, so this statement suggests
confusion between drug classes. ARBs are often substituted when ACE
inhibitor cough is intolerable.
,5. A patient on lithium for bipolar disorder has a serum level of 2.0
mEq/L and reports vomiting, diarrhea, and hand tremors. What is the
priority nursing action
A. Administer a PRN dose of haloperidol
B. Hold the next dose and prepare for possible hemodialysis
C. Increase oral fluid intake to 3 liters per day
D. Give activated charcoal with sorbitol
Correct Answer: B
Explanation: Lithium toxicity occurs above 1.5 mEq/L. A level of 2.0
mEq/L with gastrointestinal symptoms and tremors indicates moderate
toxicity. Holding lithium prevents further accumulation. Hemodialysis is
considered for levels above 2.5 mEq/L or with severe symptoms.
Charcoal does not bind lithium. Increased fluids help but are not the
priority when toxicity is already present.
6. Which medication requires the nurse to monitor for the
development of a prolonged QT interval on electrocardiogram
A. Metoprolol
B. Haloperidol
C. Pantoprazole
D. Acetaminophen
Correct Answer: B
Explanation: Haloperidol, a typical antipsychotic, is known to block
cardiac potassium channels (hERG), prolonging the QT interval and
increasing the risk of torsades de pointes. Metoprolol may cause
bradycardia but not significant QT prolongation. Pantoprazole and
acetaminophen have no known QT effects.
7. A patient accidentally takes two extra doses of carbamazepine at
home and arrives in the emergency department drowsy and ataxic.
, Which initial action should the nurse take
A. Administer flumazenil
B. Prepare for gastric lavage
C. Obtain a carbamazepine level
D. Give intravenous lipid emulsion
Correct Answer: C
Explanation: Carbamazepine overdose causes dose-dependent central
nervous system depression, ataxia, and nystagmus. A serum level guides
further management (e.g., activated charcoal, multiple doses of
charcoal, or hemodialysis). Flumazenil is not indicated. Gastric lavage is
rarely beneficial more than one hour post-ingestion. Lipid emulsion is
for local anesthetic toxicity.
8. A patient with myasthenia gravis reports worsening muscle
weakness two hours after taking pyridostigmine. The nurse notes
pinpoint pupils and excessive salivation. What is the most likely cause
A. Myasthenic crisis
B. Cholinergic crisis
C. Serotonin syndrome
D. Neuroleptic malignant syndrome
Correct Answer: B
Explanation: Pinpoint pupils (miosis), salivation, and muscle weakness
after a dose of pyridostigmine (an acetylcholinesterase inhibitor)
indicate cholinergic crisis due to excessive medication. This contrasts
with myasthenic crisis, which lacks muscarinic signs. The tensilon test
(edrophonium) can differentiate, but cholinergic crisis worsens with
more pyridostigmine.
9. Which pair of medications, when taken together, creates a high risk
for serotonin syndrome
