NR 566 Final Exam Advanced Pharmacology for Care of the
Family Chamberlain College of Nursing Question Bank (Latest
2026/2027 Edition) – 100% Correct Questions, Answers &
Detailed Rationales
Total Questions: 60
Time Allowed: 120 Minutes
Passing Score: 80%
Instructions: Select the BEST answer for each question based on advanced
pharmacology principles, clinical guidelines, and evidence-based prescribing practices.
SECTION 1: PHARMACOKINETICS, PHARMACODYNAMICS & PHARMACOGENOMICS
Questions 1–7
Question 1
A 78-year-old patient with a serum creatinine of 1.8 mg/dL and estimated CrCl of 32
mL/min is prescribed digoxin 0.25 mg daily for atrial fibrillation. The FNP recognizes
that age-related pharmacokinetic changes increase the risk of toxicity. Which principle
best guides the prescribing decision?
A. Decrease the dose by 50% due to reduced hepatic blood flow affecting first-pass
metabolism
B. Reduce the dose and extend the dosing interval because of decreased renal
clearance and reduced volume of distribution
C. Maintain the standard dose because digoxin is primarily metabolized by CYP3A4 and
hepatic function is preserved
D. Switch to a loading dose regimen to achieve steady state more rapidly in older adults
Correct Answer: B
,Rationale: In older adults, reduced renal clearance (decreased GFR by approximately 1
mL/min/year after age 40), decreased hepatic blood flow, and reduced lean body mass
decrease the volume of distribution for digoxin. Digoxin is primarily renally eliminated
(60–80% unchanged). The American Geriatrics Society Beers Criteria recommend
avoiding higher digoxin doses (>0.125 mg/day) in older adults due to toxicity risk. Dose
reduction and extended intervals are required when CrCl < 50 mL/min.
Question 2
A 55-year-old patient on warfarin (INR stable at 2.5) is started on TMP-SMX for a urinary
tract infection. One week later, the INR is 5.2. Which pharmacokinetic mechanism
explains this interaction?
A. TMP-SMX induces CYP2C9, increasing warfarin metabolism
B. TMP-SMX inhibits CYP2C9 and displaces warfarin from albumin, increasing free drug
concentration
C. TMP-SMX increases warfarin absorption through enhanced gastrointestinal motility
D. TMP-SMX antagonizes vitamin K synthesis in the gut, producing a pharmacodynamic
interaction only
Correct Answer: B
Rationale: Sulfamethoxazole (a component of TMP-SMX) is a potent inhibitor of
CYP2C9, the primary enzyme metabolizing S-warfarin (the more potent isomer).
Additionally, sulfonamides can displace highly protein-bound drugs like warfarin from
albumin binding sites, transiently increasing free fraction. This combination of
pharmacokinetic interactions (inhibition + displacement) significantly increases
bleeding risk. The FNP should avoid TMP-SMX in patients on warfarin or reduce
warfarin dose and monitor INR closely.
Question 3
A 62-year-old patient presents with muscle pain, weakness, and dark urine. Current
medications include simvastatin 80 mg daily, clarithromycin, and amlodipine started 2
weeks ago. Which finding is the priority concern requiring immediate attention?
,A. Statin-induced myopathy potentiated by CYP3A4 inhibition
B. Calcium channel blocker-induced peripheral edema
C. Macrolide-induced QT prolongation
D. Amlodipine-induced gingival hyperplasia
Correct Answer: A
Rationale: Both clarithromycin and amlodipine are CYP3A4 inhibitors. Simvastatin is a
CYP3A4 substrate, and concurrent use with strong inhibitors (clarithromycin) or
moderate inhibitors (amlodipine) significantly increases simvastatin plasma levels,
raising the risk of rhabdomyolysis. Dark urine indicates myoglobinuria. The priority is
immediate discontinuation of simvastatin and evaluation for rhabdomyolysis (CK levels,
renal function). FDA labeling contraindicates simvastatin with strong CYP3A4 inhibitors.
Question 4
A 45-year-old woman with estrogen receptor-positive breast cancer is prescribed
tamoxifen 20 mg daily. Genetic testing reveals she is CYP2D6 *4/*4 (poor metabolizer).
Which adjustment is most appropriate?
A. Continue tamoxifen; CYP2D6 genotype does not affect efficacy
B. Increase tamoxifen to 40 mg daily to overcome poor metabolism
C. Switch to an aromatase inhibitor (anastrozole) as an alternative
D. Switch to toremifene, which does not require CYP2D6 activation
Correct Answer: D
Rationale: Tamoxifen is a prodrug requiring CYP2D6-mediated conversion to endoxifen
(30–100 times more potent antiestrogen). CYP2D6 poor metabolizers (*4/*4) produce
minimal endoxifen, significantly reducing tamoxifen efficacy. Clinical Pharmacogenetics
Implementation Consortium (CPIC) guidelines recommend considering alternative
endocrine therapy in CYP2D6 poor metabolizers. Toremifene and aromatase inhibitors
do not require CYP2D6 activation; however, aromatase inhibitors are only for
postmenopausal women. For premenopausal women, toremifene is the preferred
alternative.
, Question 5
Which factors contribute to altered drug disposition in neonates? Select all that apply.
A. Reduced glomerular filtration rate requiring extended dosing intervals for renally
cleared drugs
B. Immature hepatic enzyme systems, particularly CYP450 activity, affecting phase I
metabolism
C. Increased body water content leading to increased volume of distribution for
water-soluble drugs
D. Higher plasma protein binding increasing free drug concentration of highly bound
medications
E. Increased blood-brain barrier permeability allowing greater CNS penetration of drugs
Correct Answers: A, B, C, E
Rationale: Neonates have reduced GFR (approximately 30–50% of adult values),
immature hepatic enzyme systems (CYP450 activity develops over months), increased
total body water (75–80% vs. 60% in adults), and incomplete blood-brain barrier
development. However, neonates have LOWER plasma protein binding (due to
decreased albumin and fetal albumin with lower binding affinity), which INCREASES free
drug concentration—not higher protein binding. Therefore, D is incorrect.
Question 6
A patient asks how long it will take for their new antidepressant to reach steady-state
concentration. The medication has a half-life of 24 hours. Which response is most
accurate?
A. Approximately 24 hours
B. Approximately 2–3 days
C. Approximately 5 days
D. Approximately 2 weeks
Correct Answer: C
Rationale: Steady state is achieved after approximately 4–5 half-lives (97% of
steady-state concentration). With a 24-hour half-life, steady state is reached in 4–5
Family Chamberlain College of Nursing Question Bank (Latest
2026/2027 Edition) – 100% Correct Questions, Answers &
Detailed Rationales
Total Questions: 60
Time Allowed: 120 Minutes
Passing Score: 80%
Instructions: Select the BEST answer for each question based on advanced
pharmacology principles, clinical guidelines, and evidence-based prescribing practices.
SECTION 1: PHARMACOKINETICS, PHARMACODYNAMICS & PHARMACOGENOMICS
Questions 1–7
Question 1
A 78-year-old patient with a serum creatinine of 1.8 mg/dL and estimated CrCl of 32
mL/min is prescribed digoxin 0.25 mg daily for atrial fibrillation. The FNP recognizes
that age-related pharmacokinetic changes increase the risk of toxicity. Which principle
best guides the prescribing decision?
A. Decrease the dose by 50% due to reduced hepatic blood flow affecting first-pass
metabolism
B. Reduce the dose and extend the dosing interval because of decreased renal
clearance and reduced volume of distribution
C. Maintain the standard dose because digoxin is primarily metabolized by CYP3A4 and
hepatic function is preserved
D. Switch to a loading dose regimen to achieve steady state more rapidly in older adults
Correct Answer: B
,Rationale: In older adults, reduced renal clearance (decreased GFR by approximately 1
mL/min/year after age 40), decreased hepatic blood flow, and reduced lean body mass
decrease the volume of distribution for digoxin. Digoxin is primarily renally eliminated
(60–80% unchanged). The American Geriatrics Society Beers Criteria recommend
avoiding higher digoxin doses (>0.125 mg/day) in older adults due to toxicity risk. Dose
reduction and extended intervals are required when CrCl < 50 mL/min.
Question 2
A 55-year-old patient on warfarin (INR stable at 2.5) is started on TMP-SMX for a urinary
tract infection. One week later, the INR is 5.2. Which pharmacokinetic mechanism
explains this interaction?
A. TMP-SMX induces CYP2C9, increasing warfarin metabolism
B. TMP-SMX inhibits CYP2C9 and displaces warfarin from albumin, increasing free drug
concentration
C. TMP-SMX increases warfarin absorption through enhanced gastrointestinal motility
D. TMP-SMX antagonizes vitamin K synthesis in the gut, producing a pharmacodynamic
interaction only
Correct Answer: B
Rationale: Sulfamethoxazole (a component of TMP-SMX) is a potent inhibitor of
CYP2C9, the primary enzyme metabolizing S-warfarin (the more potent isomer).
Additionally, sulfonamides can displace highly protein-bound drugs like warfarin from
albumin binding sites, transiently increasing free fraction. This combination of
pharmacokinetic interactions (inhibition + displacement) significantly increases
bleeding risk. The FNP should avoid TMP-SMX in patients on warfarin or reduce
warfarin dose and monitor INR closely.
Question 3
A 62-year-old patient presents with muscle pain, weakness, and dark urine. Current
medications include simvastatin 80 mg daily, clarithromycin, and amlodipine started 2
weeks ago. Which finding is the priority concern requiring immediate attention?
,A. Statin-induced myopathy potentiated by CYP3A4 inhibition
B. Calcium channel blocker-induced peripheral edema
C. Macrolide-induced QT prolongation
D. Amlodipine-induced gingival hyperplasia
Correct Answer: A
Rationale: Both clarithromycin and amlodipine are CYP3A4 inhibitors. Simvastatin is a
CYP3A4 substrate, and concurrent use with strong inhibitors (clarithromycin) or
moderate inhibitors (amlodipine) significantly increases simvastatin plasma levels,
raising the risk of rhabdomyolysis. Dark urine indicates myoglobinuria. The priority is
immediate discontinuation of simvastatin and evaluation for rhabdomyolysis (CK levels,
renal function). FDA labeling contraindicates simvastatin with strong CYP3A4 inhibitors.
Question 4
A 45-year-old woman with estrogen receptor-positive breast cancer is prescribed
tamoxifen 20 mg daily. Genetic testing reveals she is CYP2D6 *4/*4 (poor metabolizer).
Which adjustment is most appropriate?
A. Continue tamoxifen; CYP2D6 genotype does not affect efficacy
B. Increase tamoxifen to 40 mg daily to overcome poor metabolism
C. Switch to an aromatase inhibitor (anastrozole) as an alternative
D. Switch to toremifene, which does not require CYP2D6 activation
Correct Answer: D
Rationale: Tamoxifen is a prodrug requiring CYP2D6-mediated conversion to endoxifen
(30–100 times more potent antiestrogen). CYP2D6 poor metabolizers (*4/*4) produce
minimal endoxifen, significantly reducing tamoxifen efficacy. Clinical Pharmacogenetics
Implementation Consortium (CPIC) guidelines recommend considering alternative
endocrine therapy in CYP2D6 poor metabolizers. Toremifene and aromatase inhibitors
do not require CYP2D6 activation; however, aromatase inhibitors are only for
postmenopausal women. For premenopausal women, toremifene is the preferred
alternative.
, Question 5
Which factors contribute to altered drug disposition in neonates? Select all that apply.
A. Reduced glomerular filtration rate requiring extended dosing intervals for renally
cleared drugs
B. Immature hepatic enzyme systems, particularly CYP450 activity, affecting phase I
metabolism
C. Increased body water content leading to increased volume of distribution for
water-soluble drugs
D. Higher plasma protein binding increasing free drug concentration of highly bound
medications
E. Increased blood-brain barrier permeability allowing greater CNS penetration of drugs
Correct Answers: A, B, C, E
Rationale: Neonates have reduced GFR (approximately 30–50% of adult values),
immature hepatic enzyme systems (CYP450 activity develops over months), increased
total body water (75–80% vs. 60% in adults), and incomplete blood-brain barrier
development. However, neonates have LOWER plasma protein binding (due to
decreased albumin and fetal albumin with lower binding affinity), which INCREASES free
drug concentration—not higher protein binding. Therefore, D is incorrect.
Question 6
A patient asks how long it will take for their new antidepressant to reach steady-state
concentration. The medication has a half-life of 24 hours. Which response is most
accurate?
A. Approximately 24 hours
B. Approximately 2–3 days
C. Approximately 5 days
D. Approximately 2 weeks
Correct Answer: C
Rationale: Steady state is achieved after approximately 4–5 half-lives (97% of
steady-state concentration). With a 24-hour half-life, steady state is reached in 4–5
