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BCACP practice questions

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Question 1Patient Care

For most nonpregnant adults with type 2 diabetes who do not have significant hypoglycemia or other limiting comorbidities, what is the generally recommended A1c goal?

  1. Less than 7.0% Correct answer.
  2. Less than 9.0%
  3. Less than 6.0%
  4. Less than 8.0%

Explanation

A goal of less than 7.0% is appropriate for most adults with type 2 diabetes because it balances microvascular benefits against hypoglycemia risk. Less stringent goals are chosen for patients with limited life expectancy, severe comorbidity, or high hypoglycemia risk.

Question 2Patient Care

Which antihypertensive class is preferred as initial therapy for a patient with chronic kidney disease and albuminuria?

  1. Thiazide diuretic
  2. Beta blocker
  3. Angiotensin-converting enzyme inhibitor Correct answer.
  4. Alpha-1 receptor blocker

Explanation

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers reduce intraglomerular pressure and albuminuria and slow CKD progression. Potassium and serum creatinine should be monitored after initiation.

Question 3Patient Care

A 58-year-old with established atherosclerotic cardiovascular disease is starting a statin. Which regimen is high-intensity statin therapy?

  1. Pravastatin 40 mg daily
  2. Atorvastatin 10 mg daily
  3. Rosuvastatin 5 mg daily
  4. Atorvastatin 40 to 80 mg daily Correct answer.

Explanation

High-intensity statin therapy lowers LDL cholesterol by at least 50% and includes atorvastatin 40 to 80 mg and rosuvastatin 20 to 40 mg. Patients with established ASCVD generally benefit from high-intensity therapy unless contraindicated.

Question 4Patient Care

A patient with a mechanical mitral valve is receiving warfarin. What INR target is recommended for thromboprophylaxis?

  1. 2.5 to 3.5 Correct answer.
  2. 1.5 to 2.0
  3. 2.0 to 3.0
  4. 3.0 to 4.0

Explanation

Mechanical mitral valves carry a higher thromboembolic risk, so a higher INR target of 2.5 to 3.5 is recommended. Mechanical aortic valves generally use a target of 2.0 to 3.0.

Question 5Patient Care

What is the preferred long-term controller medication for persistent asthma?

  1. Short-acting beta-2 agonist
  2. Oral decongestant
  3. Low-dose inhaled corticosteroid Correct answer.
  4. Long-acting beta-2 agonist alone

Explanation

Inhaled corticosteroids reduce airway inflammation and exacerbations and are the preferred controller for persistent asthma. Short-acting beta-2 agonists are relievers, and long-acting beta-2 agonists should not be used as monotherapy in asthma.

Question 6Patient Care

Which maintenance therapy is appropriate for a patient with symptomatic COPD and no asthma features?

  1. Daily oral prednisone
  2. As-needed short-acting beta-2 agonist alone
  3. Montelukast
  4. Long-acting muscarinic antagonist Correct answer.

Explanation

Long-acting bronchodilators such as long-acting muscarinic antagonists improve symptoms and quality of life in symptomatic COPD. Short-acting bronchodilators alone are used for intermittent symptoms, and daily oral corticosteroids are not appropriate maintenance therapy.

Question 7Patient Care

Which medication has been shown to reduce mortality in patients with heart failure with reduced ejection fraction?

  1. Digoxin
  2. Furosemide
  3. Amlodipine
  4. Sacubitril/valsartan Correct answer.

Explanation

Sacubitril/valsartan is an angiotensin receptor-neprilysin inhibitor that reduces mortality and hospitalization in heart failure with reduced ejection fraction. Loop diuretics relieve congestion, digoxin reduces hospitalizations, and amlodipine is mortality-neutral.

Question 8Patient Care

A patient with type 2 diabetes has an eGFR of 38 mL/min/1.73 m2 and is not taking metformin. What is the most appropriate action regarding metformin?

  1. Start metformin 500 mg twice daily
  2. Do not initiate metformin; use an alternative agent Correct answer.
  3. Start metformin 1000 mg twice daily
  4. Start metformin without dose adjustment

Explanation

Metformin is not recommended for initiation when eGFR is 30 to 45 mL/min/1.73 m2 because of increased lactic acidosis risk. If a patient is already taking metformin in this range, the dose is typically reduced and renal function is monitored.

Question 9Patient Care

A PHQ-9 score of 15 falls into which depression severity category?

  1. Mild
  2. Moderate
  3. Moderately severe Correct answer.
  4. Severe

Explanation

PHQ-9 scores of 5 to 9 indicate mild depression, 10 to 14 moderate, 15 to 19 moderately severe, and 20 to 27 severe depression. A score of 15 is therefore moderately severe.

Question 10Patient Care

Which vaccine is recommended annually for most adults, including those with chronic lung disease?

  1. Influenza Correct answer.
  2. Tdap
  3. Hepatitis B
  4. Recombinant zoster

Explanation

Influenza vaccination is recommended annually for most adults, and chronic lung disease increases the risk of complications. Tdap is given every 10 years, hepatitis B is based on risk, and recombinant zoster is a two-dose series for adults 50 years and older.

Question 11Patient Care

Which regimen describes the standard initial titration of varenicline for smoking cessation?

  1. 2 mg once daily for 7 days
  2. 0.5 mg daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily Correct answer.
  3. 0.5 mg twice daily for 7 days, then 1 mg twice daily
  4. 1 mg twice daily for 12 weeks

Explanation

Varenicline is typically started at 0.5 mg daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily. This titration improves tolerability of gastrointestinal and neuropsychiatric effects.

Question 12Patient Care

A 66-year-old adult has never received any pneumococcal vaccine. Which option is recommended by the CDC for this patient?

  1. PCV20 alone Correct answer.
  2. PCV15 followed by PPSV23
  3. PPSV23 alone
  4. PCV13 alone

Explanation

Adults 65 years and older who have not received a pneumococcal conjugate vaccine can receive PCV20 or PCV21 as a single dose. If PCV15 is used, it should be followed by PPSV23.

Question 13Patient Care

Which patient with nonvalvular atrial fibrillation meets criteria for apixaban dose reduction to 2.5 mg twice daily?

  1. Age 84 years, weight 70 kg, serum creatinine 1.0 mg/dL
  2. Age 84 years, weight 58 kg, serum creatinine 1.7 mg/dL Correct answer.
  3. Age 79 years, weight 62 kg, serum creatinine 1.4 mg/dL
  4. Age 76 years, weight 55 kg, serum creatinine 1.2 mg/dL

Explanation

Apixaban is reduced to 2.5 mg twice daily when at least two of the following are present: age 80 years or older, weight 60 kg or less, and serum creatinine 1.5 mg/dL or higher. The first patient meets all three criteria.

Question 14Patient Care

A conscious patient with diabetes has hypoglycemia and can swallow. What is the best initial treatment?

  1. Give a high-fat meal
  2. Give 15 to 20 g of fast-acting oral carbohydrate Correct answer.
  3. Administer subcutaneous insulin
  4. Give intramuscular glucagon

Explanation

For a conscious patient who can swallow, the initial treatment is 15 to 20 g of fast-acting carbohydrate, followed by rechecking glucose in about 15 minutes. Glucagon is reserved for patients who cannot take oral therapy or have severe hypoglycemia.

Question 15Patient Care

How should levothyroxine be taken to maximize absorption?

  1. With breakfast
  2. With coffee and a multivitamin
  3. At bedtime with calcium carbonate
  4. 30 to 60 minutes before breakfast with water Correct answer.

Explanation

Levothyroxine should be taken on an empty stomach with water, typically 30 to 60 minutes before breakfast. Calcium, iron, and other products can reduce absorption and should be separated by several hours.

Question 16Patient Care

A patient repeatedly misses evening medication doses. Which intervention is most appropriate first?

  1. Use a pill organizer with phone reminders Correct answer.
  2. Discontinue the medications
  3. Add a second medication
  4. Increase the dose of each medication

Explanation

The first step is to identify and address the adherence barrier with practical supports such as pill organizers, reminders, and simplified dosing. Dose escalation or adding medications does not solve missed doses.

Question 17Patient Care

Which instruction is correct for oral alendronate therapy?

  1. Take with breakfast and lie down for 30 minutes
  2. Take at bedtime with calcium carbonate
  3. Take with milk to reduce esophageal irritation
  4. Take on an empty stomach with water and remain upright for 30 minutes Correct answer.

Explanation

Oral bisphosphonates such as alendronate should be taken on an empty stomach with plain water, and the patient should remain upright for at least 30 minutes. This reduces esophageal irritation and improves absorption.

Question 18Patient Care

Which medication is appropriate for initial treatment of an acute gout flare in a patient with normal renal function and no contraindications?

  1. Naproxen Correct answer.
  2. Probenecid
  3. High-dose allopurinol
  4. Febuxostat

Explanation

Acute gout flares are treated with anti-inflammatory therapy such as an NSAID, colchicine, or systemic corticosteroid. Urate-lowering drugs are not used alone to treat an acute flare.

Question 19Patient Care

A patient with heart failure is started on furosemide. Which laboratory parameter should be monitored most closely?

  1. Serum sodium only
  2. Serum glucose only
  3. Liver enzymes
  4. Serum potassium and renal function Correct answer.

Explanation

Loop diuretics can cause hypokalemia, hyponatremia, and worsening renal function, so potassium and renal function should be monitored closely. Glucose and liver enzymes are not the primary monitoring parameters for furosemide.

Question 20Patient Care

Which counseling point is appropriate when starting empagliflozin in a patient with type 2 diabetes and heart failure?

  1. Take it with a large meal to prevent hypoglycemia
  2. Stop the drug if blood pressure decreases
  3. Expect rapid weight gain
  4. Maintain hydration and report genital irritation Correct answer.

Explanation

SGLT2 inhibitors can cause volume depletion and genital mycotic infections, so patients should maintain hydration and report genital irritation. These agents reduce heart failure hospitalization and slow CKD progression.

Question 21Patient Care

In a patient with CKD and anemia, what should be corrected before initiating an erythropoiesis-stimulating agent?

  1. Hyperkalemia
  2. Iron deficiency Correct answer.
  3. Vitamin B12 deficiency only
  4. Hyperuricemia

Explanation

Adequate iron stores are needed for an erythropoiesis-stimulating agent to be effective, so iron deficiency should be evaluated and corrected first. Starting an ESA without adequate iron can lead to poor response and unnecessary dose escalation.

Question 22Patient Care

Which antihypertensive is preferred for treatment of chronic hypertension in pregnancy?

  1. Labetalol Correct answer.
  2. Losartan
  3. Spironolactone
  4. Lisinopril

Explanation

Labetalol, nifedipine, and methyldopa are preferred antihypertensives in pregnancy. ACE inhibitors and angiotensin receptor blockers are contraindicated because of fetal toxicity.

Question 23Patient Care

A patient with asthma has symptoms more than 2 days per week but not daily, with no nighttime awakenings. How is this classified?

  1. Severe persistent asthma
  2. Mild persistent asthma Correct answer.
  3. Intermittent asthma
  4. Moderate persistent asthma

Explanation

Asthma with symptoms more than 2 days per week but not daily is classified as mild persistent. Intermittent asthma causes symptoms 2 days per week or less.

Question 24Patient Care

A patient taking warfarin for atrial fibrillation needs analgesia for chronic osteoarthritis. Which option is the safest initial choice?

  1. Aspirin
  2. Naproxen
  3. Acetaminophen Correct answer.
  4. Ibuprofen

Explanation

Acetaminophen is preferred initially because NSAIDs and aspirin increase bleeding risk and gastrointestinal injury in patients taking warfarin. If high-dose acetaminophen is used, INR should be monitored because it can potentiate warfarin.

Question 25Patient Care

Which laboratory test is used to monitor warfarin therapy?

  1. aPTT
  2. D-dimer
  3. Platelet count
  4. INR Correct answer.

Explanation

The INR standardizes prothrombin time and is used to monitor warfarin anticoagulation. aPTT is used primarily to monitor unfractionated heparin, not warfarin.

Question 26Patient Care

A 62-year-old man with a history of myocardial infarction is not currently taking lipid-lowering therapy. His LDL-C is 145 mg/dL. Which medication is most appropriate to start?

  1. Ezetimibe 10 mg once daily
  2. Atorvastatin 80 mg once daily Correct answer.
  3. Gemfibrozil 600 mg twice daily
  4. Pravastatin 10 mg once daily

Explanation

Established clinical ASCVD calls for high-intensity statin therapy, defined as atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg, which lowers LDL-C by at least 50%. Lower-intensity agents and non-statin drugs do not provide comparable event reduction as initial monotherapy.

Question 27Patient Care

A patient is prescribed insulin glargine pens. Which statement about storing unopened pens is correct?

  1. They should be kept in direct sunlight to prevent crystallization.
  2. They should be refrigerated at 2 to 8 degrees C until the expiration date. Correct answer.
  3. They may be kept at room temperature for up to 6 months before first use.
  4. They should be placed in the freezer until the day they are first used.

Explanation

Unopened insulin pens and vials are stored at 2 to 8 degrees C until the labeled expiration date, and freezing permanently destroys the hormone. Room-temperature limits of about 28 days apply only after a pen or vial is first used.

Question 28Patient Care

A patient is starting omeprazole for gastroesophageal reflux disease. Which instruction is correct?

  1. Take it at bedtime with a full glass of milk.
  2. Take it 30 to 60 minutes before the first meal of the day. Correct answer.
  3. Take it only when heartburn occurs.
  4. Take it immediately after the largest meal of the day.

Explanation

Proton pump inhibitors covalently bind pumps that are activated by a meal, so dosing 30 to 60 minutes before breakfast produces maximal acid suppression. Scheduled rather than as-needed dosing is required for mucosal healing.

Question 29Patient Care

Which patient should be offered a naloxone prescription?

  1. A patient taking 90 morphine milligram equivalents daily plus a benzodiazepine Correct answer.
  2. A patient taking oxycodone 5 mg once daily for 3 days after a dental extraction
  3. A patient taking naproxen 500 mg twice daily for osteoarthritis
  4. A patient using topical lidocaine patches for chronic back pain

Explanation

Naloxone should be offered to patients receiving 50 morphine milligram equivalents or more per day, those using benzodiazepines concurrently, and those with prior overdose or substance use disorder. These factors substantially raise the risk of fatal respiratory depression.

Question 30Patient Care

At what age does the USPSTF recommend beginning colorectal cancer screening in average-risk adults?

  1. 45 years Correct answer.
  2. 55 years
  3. 60 years
  4. 40 years

Explanation

The USPSTF recommends starting colorectal cancer screening at age 45 for average-risk adults and continuing through age 75, reflecting rising incidence in younger adults. Earlier initiation is reserved for defined high-risk groups.

Question 31Patient Care

Which laboratory monitoring is recommended for a patient on long-term metformin therapy?

  1. Serum lithium level
  2. Vitamin B12 level Correct answer.
  3. Liver function tests every 3 months
  4. Serum amylase every 6 months

Explanation

Long-term metformin use interferes with calcium-dependent vitamin B12 absorption in the ileum, so periodic B12 measurement is advised, particularly when anemia or peripheral neuropathy appears. Metformin does not require routine pancreatic or hepatic monitoring.

Question 32Patient Care

Which counseling point is correct for a patient starting subcutaneous insulin injections?

  1. Rotate injection sites within the same body region to prevent lipohypertrophy. Correct answer.
  2. Massage the site vigorously after injection to speed absorption.
  3. Inject into the same site each time for consistent absorption.
  4. Reuse pen needles for up to one week to reduce cost.

Explanation

Rotating sites within one anatomical region prevents lipohypertrophy and scarring, which cause erratic insulin absorption. Needles are single-use, and massaging the site makes absorption unpredictable.

Question 33Patient Care

A 55-year-old with hypertension and no other comorbidities is being treated. Which blood pressure goal is recommended by the 2017 ACC/AHA guideline?

  1. Less than 130/80 mm Hg Correct answer.
  2. Less than 150/90 mm Hg
  3. Less than 140/90 mm Hg
  4. Less than 120/70 mm Hg

Explanation

The 2017 ACC/AHA guideline defines hypertension as 130/80 mm Hg or higher and recommends a treatment target below 130/80 for most adults, including those with diabetes or ASCVD. A threshold of 150/90 is reserved for selected older adults with limited life expectancy.

Question 34Patient Care

A patient started lisinopril 4 weeks ago and reports a persistent dry, nonproductive cough. Blood pressure is at goal and there is no evidence of volume overload. What is the most appropriate action?

  1. Discontinue lisinopril and start losartan. Correct answer.
  2. Reduce the lisinopril dose by half.
  3. Add benzonatate to suppress the cough.
  4. Continue lisinopril and reassess in 3 months.

Explanation

ACE inhibitor cough is mediated by bradykinin accumulation and typically resolves within weeks of switching to an ARB, which preserves renin-angiotensin blockade without raising bradykinin. Dose reduction and cough suppressants do not reliably relieve it.

Question 35Patient Care

Which regimen is preferred as initial therapy for a 52-year-old Black patient with newly diagnosed stage 2 hypertension and no other comorbidities?

  1. Lisinopril 20 mg daily as monotherapy
  2. Amlodipine 5 mg plus chlorthalidone 12.5 mg daily Correct answer.
  3. Losartan 50 mg plus spironolactone 25 mg daily
  4. Atenolol 50 mg daily as monotherapy

Explanation

Black adults generally have a greater blood pressure response to calcium channel blockers and thiazide-type diuretics than to ACE inhibitors as monotherapy, and stage 2 hypertension warrants starting two agents. Beta blockers and aldosterone antagonists are not initial choices here.

Question 36Patient Care

What is a reasonable hemoglobin A1c goal for a 78-year-old woman with type 2 diabetes, mild cognitive impairment, and three other chronic conditions?

  1. Less than 6.5%
  2. Less than 6.0%
  3. Less than 8.0% Correct answer.
  4. Less than 7.0%

Explanation

Guidelines recommend a less stringent goal such as below 8.0% for older adults with multiple comorbidities, cognitive or functional impairment, or limited life expectancy because the harms of hypoglycemia outweigh tight control. A goal below 7.0% applies to most nonpregnant adults without these features.

Question 37Patient Care

A patient with major depressive disorder starts sertraline 50 mg daily. At what point should the response to therapy be formally assessed?

  1. After 6 months
  2. After 4 to 8 weeks of adherent therapy Correct answer.
  3. After 3 days
  4. After 1 week

Explanation

Antidepressants need 4 to 8 weeks at a therapeutic dose before full response can be judged; earlier visits focus on adherence, adverse effects, and safety. Six months corresponds to the continuation phase rather than initial response assessment.

Question 38Patient Care

A patient with gout is beginning allopurinol. Which medication should be co-prescribed to prevent flares?

  1. Colchicine 0.6 mg once or twice daily Correct answer.
  2. Probenecid
  3. Prednisone 40 mg daily for 6 weeks
  4. Febuxostat

Explanation

Initiating urate-lowering therapy shifts serum urate and can precipitate flares, so low-dose colchicine or an NSAID is given prophylactically for at least 3 to 6 months. A second urate-lowering drug is not a substitute for anti-inflammatory prophylaxis.

Question 39Patient Care

A patient with CKD stage 3 starts lisinopril. Two weeks later serum creatinine has risen from 1.4 to 1.7 mg/dL and potassium is 4.8 mEq/L. What is the most appropriate action?

  1. Add spironolactone to help control the potassium.
  2. Continue lisinopril and recheck creatinine and potassium in 1 to 2 weeks. Correct answer.
  3. Halve the lisinopril dose now and repeat labs in 6 months.
  4. Discontinue lisinopril and start amlodipine.

Explanation

A creatinine rise of up to about 30% after ACE inhibitor initiation reflects reduced intraglomerular pressure and is expected, so therapy continues with repeat labs. Larger rises or progressive hyperkalemia would prompt dose adjustment or discontinuation.

Question 40Patient Care

Which contraceptive is most appropriate for a 38-year-old woman who smokes 15 cigarettes daily and has migraine with aura?

  1. Levonorgestrel 52-mg intrauterine device Correct answer.
  2. Combined oral contraceptive containing ethinyl estradiol and levonorgestrel
  3. Combined transdermal contraceptive patch
  4. Combined contraceptive vaginal ring

Explanation

Combined hormonal contraceptives are CDC category 4, meaning contraindicated, for women aged 35 or older who smoke and for migraine with aura, because of elevated venous thromboembolism and stroke risk. A progestin-only intrauterine device avoids estrogen exposure.

Question 41Patient Care

A 60-year-old adult reports having had herpes zoster 2 years ago and asks about vaccination. Which recommendation is correct?

  1. Defer vaccination until age 65.
  2. Give recombinant zoster vaccine in 2 doses, 2 to 6 months apart. Correct answer.
  3. Zoster vaccine is not indicated because prior infection confers lifelong immunity.
  4. Give live attenuated zoster vaccine as a single dose.

Explanation

Recombinant zoster vaccine is recommended for all adults aged 50 and older, including those with prior herpes zoster, and is given as two doses 2 to 6 months apart. Prior infection does not guarantee durable immunity.

Question 42Patient Care

A patient with type 2 diabetes taking empagliflozin develops acute gastroenteritis with vomiting and poor oral intake. What is the most appropriate advice?

  1. Continue empagliflozin but stop all fluid intake.
  2. Double the empagliflozin dose to compensate for missed calories.
  3. Hold empagliflozin until eating and drinking normally for 24 to 48 hours. Correct answer.
  4. Continue empagliflozin and add a sulfonylurea.

Explanation

SGLT2 inhibitors are temporarily withheld during acute illness with reduced intake because they can precipitate euglycemic diabetic ketoacidosis. Therapy is restarted once oral intake has been normal for roughly 24 to 48 hours.

Question 43Patient Care

A patient with moderate persistent allergic rhinitis has inadequate relief from oral loratadine. Which agent is most appropriate to add?

  1. Oral prednisone for 4 weeks
  2. Oxymetazoline nasal spray twice daily for 3 weeks
  3. Oral montelukast as monotherapy
  4. Fluticasone intranasal spray once daily Correct answer.

Explanation

Intranasal corticosteroids are the most effective single drug class for moderate-to-severe allergic rhinitis and are the standard add-on when an oral antihistamine is insufficient. Systemic steroids and prolonged topical decongestants are not appropriate long-term therapy.

Question 44Patient Care

A patient taking sertraline who was recently started on linezolid develops agitation, diaphoresis, hyperreflexia, and inducible clonus. Temperature is 38.6 degrees C. What is the most likely diagnosis?

  1. Neuroleptic malignant syndrome
  2. Serotonin syndrome Correct answer.
  3. Acute dystonic reaction
  4. Anticholinergic toxicity

Explanation

The triad of mental status change, autonomic instability, and neuromuscular hyperactivity such as clonus and hyperreflexia after serotonergic drugs identifies serotonin syndrome. Linezolid is a weak MAO inhibitor and can precipitate it in patients taking SSRIs.

Question 45Patient Care

A patient stable on warfarin with an INR of 2.5 is prescribed trimethoprim-sulfamethoxazole for a urinary tract infection. What is the most appropriate management?

  1. Select an alternative antibiotic or reduce the warfarin dose with an INR check in 3 to 5 days. Correct answer.
  2. Double the warfarin dose to offset antibiotic effects.
  3. Continue both drugs unchanged and recheck the INR in 4 weeks.
  4. Stop warfarin permanently and start aspirin.

Explanation

Trimethoprim-sulfamethoxazole inhibits CYP2C9 and displaces warfarin from albumin, raising the INR and bleeding risk within days, so an alternative agent or close INR-guided dose reduction is needed. Aspirin is not an acceptable substitute for anticoagulation in atrial fibrillation.

Question 46Patient Care

A patient with type 2 diabetes on metformin has an eGFR of 35 mL/min/1.73 m2 and is scheduled for an arterial contrast study. What is the most appropriate action?

  1. Stop metformin permanently and start a sulfonylurea on the morning of the procedure.
  2. Continue metformin without interruption because the eGFR is above 30.
  3. Increase the metformin dose to offset contrast-induced hyperglycemia.
  4. Withhold metformin at the time of contrast and restart only after renal function is confirmed stable at 48 hours. Correct answer.

Explanation

For patients with eGFR 30 to 59 receiving iodinated contrast, metformin is held at the time of the procedure and restarted 48 hours later only after renal function is rechecked and stable. Permanent discontinuation is unnecessary if function remains unchanged.

Question 47Patient Care

A patient with heart failure with reduced ejection fraction on sacubitril/valsartan, spironolactone, and furosemide has a potassium of 5.8 mEq/L and an eGFR of 40 mL/min/1.73 m2. Which action is most appropriate?

  1. Stop furosemide and start potassium chloride supplementation.
  2. Hold spironolactone, review dietary potassium and other medications, and recheck potassium promptly. Correct answer.
  3. Continue all three drugs unchanged and repeat potassium in 4 weeks.
  4. Increase the spironolactone dose to promote potassium excretion.

Explanation

Spironolactone contributes most to potassium retention in this regimen, so it is withheld while diet and contributing medications are reviewed and potassium is rechecked promptly. Other guideline-directed drugs are continued when feasible, with a potassium binder or dose adjustment added as needed.

Question 48Patient Care

A woman with hypothyroidism maintained on levothyroxine 100 mcg daily reports a positive pregnancy test. What is the recommended approach to her levothyroxine?

  1. Decrease the dose by 25% to protect the fetus.
  2. Keep the dose unchanged and check TSH at 20 weeks.
  3. Stop levothyroxine until the second trimester.
  4. Increase the dose by about 20% to 30% and check TSH every 4 weeks. Correct answer.

Explanation

Thyroid hormone requirements rise by roughly 20% to 30% early in pregnancy, often managed by adding two tablets weekly, with TSH checked every 4 weeks through mid-gestation. Untreated maternal hypothyroidism increases miscarriage and neurodevelopmental risk.

Question 49Patient Care

A 76-year-old with type 2 diabetes and CKD stage 4 (eGFR 25 mL/min/1.73 m2) has had two episodes of hypoglycemia while taking glyburide. Which change is most appropriate?

  1. Continue glyburide at the current dose and add a bedtime snack.
  2. Add metformin to lower the sulfonylurea requirement.
  3. Discontinue glyburide and start linagliptin or low-dose basal insulin. Correct answer.
  4. Switch glyburide to chlorpropamide at an equivalent dose.

Explanation

Glyburide's active metabolites accumulate in renal impairment and cause prolonged hypoglycemia, so it should be avoided in advanced CKD. Linagliptin requires no renal dose adjustment, and basal insulin titrated cautiously is a reasonable alternative.

Question 50Patient Care

A 72-year-old with Parkinson disease on carbidopa-levodopa develops nausea from acute gastroenteritis. Which antiemetic is most appropriate?

  1. Prochlorperazine
  2. Promethazine
  3. Metoclopramide
  4. Ondansetron Correct answer.

Explanation

Metoclopramide, prochlorperazine, and promethazine block dopamine receptors and can precipitate or worsen parkinsonism. Ondansetron acts on 5-HT3 receptors without dopaminergic antagonism and is the preferred antiemetic in this setting.