**Advanced Pharmacology for Registered Nurses
Exam 2024: Mechanisms, Interactions, and Clinical
Decision-Making**
---
**Question 1**
A nurse is caring for a client receiving a continuous infusion of norepinephrine for septic shock. The IV
site appears pale and cool with a well-defined border. What is the priority action?
A. Apply a warm compress to the site
B. Decrease the infusion rate
C. Stop the infusion immediately and notify the provider
D. Infiltrate the site with phentolamine
💫ANSWER✔️✔️: C. Stop the infusion immediately and notify the provider
💫RATIONALE✔️✔️: Pale, cool skin with a defined border indicates norepinephrine extravasation, which
can cause ischemia and necrosis. The infusion must be stopped immediately. Phentolamine (an alpha-
adrenergic antagonist) is the antidote and should be infiltrated locally, but this requires a provider
order. The first action is stopping the infusion.
---
**Question 2**
A client with heart failure with reduced ejection fraction (HFrEF) is prescribed sacubitril/valsartan
(Entresto). The nurse should instruct the client to avoid which medication due to a serious drug
interaction?
A. Furosemide
B. Spironolactone
,C. An ACE inhibitor (e.g., lisinopril)
D. Metoprolol
💫ANSWER✔️✔️: C. An ACE inhibitor (e.g., lisinopril)
💫RATIONALE✔️✔️: Sacubitril/valsartan contains an ARB (valsartan) and a neprilysin inhibitor (sacubitril).
Concomitant use with an ACE inhibitor increases the risk of angioedema. A 36-hour washout period is
required when switching from an ACE inhibitor to Entresto. The combination is contraindicated.
---
**Question 3**
A nurse is administering IV push ondansetron (Zofran) to a client with nausea. Which finding requires
immediate action?
A. The client reports a headache
B. The client's ECG shows a QTc interval of 520 ms
C. The client reports constipation
D. The client's blood pressure is 110/70 mm Hg
💫ANSWER✔️✔️: B. The client's ECG shows a QTc interval of 520 ms
💫RATIONALE✔️✔️: Ondansetron can prolong the QT interval, increasing the risk of torsades de pointes.
A QTc >500 ms (or >60 ms above baseline) is concerning. The nurse should withhold the medication and
notify the provider. Headache and constipation are common side effects but not emergent.
---
**Question 4**
A client with tuberculosis is taking isoniazid (INH), rifampin, pyrazinamide, and ethambutol. Which
medication is most likely to cause orange-red discoloration of urine, tears, and sweat?
A. Isoniazid
B. Rifampin
C. Pyrazinamide
,D. Ethambutol
💫ANSWER✔️✔️: C. Pyrazinamide? No — rifampin.
💫RATIONALE✔️✔️: Rifampin causes orange-red discoloration of body fluids (urine, tears, sweat, saliva).
This is harmless but the client should be warned to prevent alarm. Isoniazid causes peripheral
neuropathy (vitamin B6 deficiency). Ethambutol causes optic neuritis. Pyrazinamide causes
hepatotoxicity and hyperuricemia.
---
**Question 5**
A nurse is teaching a client about newly prescribed levothyroxine. Which statement by the client
indicates correct understanding?
A. "I will take this medication with food to prevent stomach upset."
B. "I will take this medication at bedtime to help me sleep."
C. "I will take this medication on an empty stomach, 30-60 minutes before breakfast."
D. "I can stop taking this medication once my thyroid levels are normal."
💫ANSWER✔️✔️: C. "I will take this medication on an empty stomach, 30-60 minutes before breakfast."
💫RATIONALE✔️✔️: Levothyroxine is best absorbed on an empty stomach, at least 30-60 minutes before
food or other medications. It is lifelong therapy; stopping causes recurrence of hypothyroidism. Taking
at bedtime is an alternative if fasting morning dose is not possible, but morning fasting is preferred.
---
**Question 6**
A client is receiving IV heparin for a deep vein thrombosis. The nurse notes that the client's platelet
count has dropped from 250,000 to 80,000/mm³ over 3 days. What is the priority action?
A. Continue heparin and monitor platelets daily
B. Stop the heparin infusion and notify the provider
C. Administer platelet transfusion
, D. Decrease the heparin infusion rate
💫ANSWER✔️✔️: B. Stop the heparin infusion and notify the provider
💫RATIONALE✔️✔️: A drop in platelet count by >50% or an absolute count <150,000 after 5-14 days of
heparin suggests heparin-induced thrombocytopenia (HIT), a prothrombotic condition. Heparin must be
stopped immediately, and an alternative anticoagulant (argatroban, fondaparinux) started. Platelet
transfusions are contraindicated.
---
**Question 7**
A nurse is administering IV metoclopramide (Reglan) to a client with diabetic gastroparesis. Which
adverse effect requires immediate discontinuation of the medication?
A. Drowsiness
B. Diarrhea
C. Involuntary rhythmic movements of the tongue and face
D. Dry mouth
💫ANSWER✔️✔️: C. Involuntary rhythmic movements of the tongue and face
💫RATIONALE✔️✔️: These are signs of tardive dyskinesia, an irreversible movement disorder associated
with metoclopramide (a dopamine antagonist). The medication should be discontinued immediately.
Drowsiness, dry mouth, and diarrhea are common but not emergent.
---
**Question 8**
A client with a history of gout is prescribed allopurinol. The client asks, "What should I do if I have an
acute gout attack?" Which response is correct?
A. "Take an extra dose of allopurinol during the attack."
B. "Allopurinol is not for acute attacks; you will need a separate medication like colchicine or NSAIDs."
C. "Stop taking allopurinol during the attack."
Exam 2024: Mechanisms, Interactions, and Clinical
Decision-Making**
---
**Question 1**
A nurse is caring for a client receiving a continuous infusion of norepinephrine for septic shock. The IV
site appears pale and cool with a well-defined border. What is the priority action?
A. Apply a warm compress to the site
B. Decrease the infusion rate
C. Stop the infusion immediately and notify the provider
D. Infiltrate the site with phentolamine
💫ANSWER✔️✔️: C. Stop the infusion immediately and notify the provider
💫RATIONALE✔️✔️: Pale, cool skin with a defined border indicates norepinephrine extravasation, which
can cause ischemia and necrosis. The infusion must be stopped immediately. Phentolamine (an alpha-
adrenergic antagonist) is the antidote and should be infiltrated locally, but this requires a provider
order. The first action is stopping the infusion.
---
**Question 2**
A client with heart failure with reduced ejection fraction (HFrEF) is prescribed sacubitril/valsartan
(Entresto). The nurse should instruct the client to avoid which medication due to a serious drug
interaction?
A. Furosemide
B. Spironolactone
,C. An ACE inhibitor (e.g., lisinopril)
D. Metoprolol
💫ANSWER✔️✔️: C. An ACE inhibitor (e.g., lisinopril)
💫RATIONALE✔️✔️: Sacubitril/valsartan contains an ARB (valsartan) and a neprilysin inhibitor (sacubitril).
Concomitant use with an ACE inhibitor increases the risk of angioedema. A 36-hour washout period is
required when switching from an ACE inhibitor to Entresto. The combination is contraindicated.
---
**Question 3**
A nurse is administering IV push ondansetron (Zofran) to a client with nausea. Which finding requires
immediate action?
A. The client reports a headache
B. The client's ECG shows a QTc interval of 520 ms
C. The client reports constipation
D. The client's blood pressure is 110/70 mm Hg
💫ANSWER✔️✔️: B. The client's ECG shows a QTc interval of 520 ms
💫RATIONALE✔️✔️: Ondansetron can prolong the QT interval, increasing the risk of torsades de pointes.
A QTc >500 ms (or >60 ms above baseline) is concerning. The nurse should withhold the medication and
notify the provider. Headache and constipation are common side effects but not emergent.
---
**Question 4**
A client with tuberculosis is taking isoniazid (INH), rifampin, pyrazinamide, and ethambutol. Which
medication is most likely to cause orange-red discoloration of urine, tears, and sweat?
A. Isoniazid
B. Rifampin
C. Pyrazinamide
,D. Ethambutol
💫ANSWER✔️✔️: C. Pyrazinamide? No — rifampin.
💫RATIONALE✔️✔️: Rifampin causes orange-red discoloration of body fluids (urine, tears, sweat, saliva).
This is harmless but the client should be warned to prevent alarm. Isoniazid causes peripheral
neuropathy (vitamin B6 deficiency). Ethambutol causes optic neuritis. Pyrazinamide causes
hepatotoxicity and hyperuricemia.
---
**Question 5**
A nurse is teaching a client about newly prescribed levothyroxine. Which statement by the client
indicates correct understanding?
A. "I will take this medication with food to prevent stomach upset."
B. "I will take this medication at bedtime to help me sleep."
C. "I will take this medication on an empty stomach, 30-60 minutes before breakfast."
D. "I can stop taking this medication once my thyroid levels are normal."
💫ANSWER✔️✔️: C. "I will take this medication on an empty stomach, 30-60 minutes before breakfast."
💫RATIONALE✔️✔️: Levothyroxine is best absorbed on an empty stomach, at least 30-60 minutes before
food or other medications. It is lifelong therapy; stopping causes recurrence of hypothyroidism. Taking
at bedtime is an alternative if fasting morning dose is not possible, but morning fasting is preferred.
---
**Question 6**
A client is receiving IV heparin for a deep vein thrombosis. The nurse notes that the client's platelet
count has dropped from 250,000 to 80,000/mm³ over 3 days. What is the priority action?
A. Continue heparin and monitor platelets daily
B. Stop the heparin infusion and notify the provider
C. Administer platelet transfusion
, D. Decrease the heparin infusion rate
💫ANSWER✔️✔️: B. Stop the heparin infusion and notify the provider
💫RATIONALE✔️✔️: A drop in platelet count by >50% or an absolute count <150,000 after 5-14 days of
heparin suggests heparin-induced thrombocytopenia (HIT), a prothrombotic condition. Heparin must be
stopped immediately, and an alternative anticoagulant (argatroban, fondaparinux) started. Platelet
transfusions are contraindicated.
---
**Question 7**
A nurse is administering IV metoclopramide (Reglan) to a client with diabetic gastroparesis. Which
adverse effect requires immediate discontinuation of the medication?
A. Drowsiness
B. Diarrhea
C. Involuntary rhythmic movements of the tongue and face
D. Dry mouth
💫ANSWER✔️✔️: C. Involuntary rhythmic movements of the tongue and face
💫RATIONALE✔️✔️: These are signs of tardive dyskinesia, an irreversible movement disorder associated
with metoclopramide (a dopamine antagonist). The medication should be discontinued immediately.
Drowsiness, dry mouth, and diarrhea are common but not emergent.
---
**Question 8**
A client with a history of gout is prescribed allopurinol. The client asks, "What should I do if I have an
acute gout attack?" Which response is correct?
A. "Take an extra dose of allopurinol during the attack."
B. "Allopurinol is not for acute attacks; you will need a separate medication like colchicine or NSAIDs."
C. "Stop taking allopurinol during the attack."
