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NAPLEX practice questions

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Question 1Pharmacotherapy and Pharmaceutical Care

A 58-year-old Black patient with newly diagnosed stage 1 hypertension has no other comorbidities and normal renal function. Which medication is the most appropriate initial therapy?

  1. Atenolol
  2. Spironolactone
  3. Lisinopril
  4. Chlorthalidone Correct answer.

Explanation

In Black adults without a compelling indication, a thiazide-type diuretic or a dihydropyridine calcium channel blocker is recommended as first-line therapy because these agents produce greater blood pressure reduction in this population. ACE inhibitor monotherapy is less effective here and is not preferred without a secondary indication such as proteinuric kidney disease. Beta blockers and aldosterone antagonists are not initial choices for uncomplicated hypertension.

Question 2Pharmacotherapy and Pharmaceutical Care

Which laboratory finding is the strongest contraindication to starting metformin in a patient with type 2 diabetes?

  1. eGFR of 28 mL/min Correct answer.
  2. Potassium 5.3 mEq/L
  3. ALT of 65 units/L
  4. A1c of 9.8%

Explanation

Metformin is contraindicated when the eGFR is below 30 mL/min/1.73 m2 because reduced clearance increases the risk of lactic acidosis, and the dose is also limited at eGFR 30 to 45. Mild transaminase elevation, an elevated A1c, and mild hyperkalemia do not preclude its use.

Question 3Pharmacotherapy and Pharmaceutical Care

A patient taking warfarin for atrial fibrillation has an INR of 9.0 at a routine visit and reports no bleeding. Which is the most appropriate management?

  1. Give IV vitamin K 10 mg
  2. Continue current warfarin dose
  3. Transfuse fresh frozen plasma immediately
  4. Hold warfarin and give oral vitamin K 2.5 mg Correct answer.

Explanation

For an INR above 9 without bleeding, guidelines recommend withholding warfarin and administering low-dose oral vitamin K, typically 2.5 to 5 mg. Coagulation factor replacement is reserved for serious bleeding or urgent procedures, and high-dose IV vitamin K can render the patient warfarin-resistant for days.

Question 4Pharmacotherapy and Pharmaceutical Care

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

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

Explanation

Sacubitril/valsartan is a foundational guideline-directed therapy that reduces cardiovascular death and heart failure hospitalization in HFrEF. Loop diuretics relieve congestion but do not improve survival, and digoxin reduces hospitalizations without a mortality benefit.

Question 5Pharmacotherapy and Pharmaceutical Care

Which is the preferred long-term controller medication for a patient with persistent asthma?

  1. Long-acting beta-2 agonist alone
  2. Daily oral prednisone
  3. Montelukast used alone
  4. Low-dose inhaled corticosteroid Correct answer.

Explanation

Inhaled corticosteroids are the most effective controller therapy for persistent asthma and remain the preferred foundation at every severity step. Long-acting beta-2 agonists must never be used as monotherapy in asthma because of the risk of severe exacerbation and death.

Question 6Pharmacotherapy and Pharmaceutical Care

Which regimen is appropriate first-line therapy for acute uncomplicated cystitis in a woman with normal renal function?

  1. Amoxicillin 500 mg three times daily for 7 days
  2. Ciprofloxacin 500 mg twice daily for 7 days
  3. Trimethoprim-sulfamethoxazole DS twice daily for 3 days
  4. Nitrofurantoin 100 mg twice daily for 5 days Correct answer.

Explanation

Nitrofurantoin for 5 days is a guideline-recommended first-line option for uncomplicated cystitis and causes minimal collateral damage to the microbiome. Fluoroquinolones are reserved for more serious infections because of their adverse effect burden, and amoxicillin has high resistance rates.

Question 7Pharmacotherapy and Pharmaceutical Care

How should a patient be instructed to take levothyroxine?

  1. With a multivitamin containing iron
  2. With breakfast each morning
  3. At bedtime with calcium
  4. On an empty stomach before breakfast Correct answer.

Explanation

Levothyroxine absorption is reduced by food, calcium, iron, and proton pump inhibitors, so it should be taken on an empty stomach 30 to 60 minutes before breakfast with water. Consistent timing keeps thyroid hormone concentrations stable.

Question 8Pharmacotherapy and Pharmaceutical Care

Which vaccine is recommended annually for all adults aged 50 years and older?

  1. Human papillomavirus vaccine
  2. Inactivated influenza vaccine Correct answer.
  3. Measles-mumps-rubella vaccine
  4. Tetanus-diphtheria-pertussis vaccine

Explanation

Annual influenza vaccination is recommended for everyone 6 months and older, including adults 50 and older, ideally before the start of each flu season. Tdap is a one-time dose with tetanus boosters every 10 years, and MMR and HPV vaccines are not administered annually.

Question 9Pharmacotherapy and Pharmaceutical Care

An 82-year-old patient with atrial fibrillation weighs 58 kg and has a serum creatinine of 1.6 mg/dL. Which apixaban regimen is appropriate for stroke prevention?

  1. 5 mg twice daily
  2. 2.5 mg once daily
  3. 2.5 mg twice daily Correct answer.
  4. 10 mg twice daily

Explanation

Apixaban is reduced to 2.5 mg twice daily when at least two of three criteria are met: age 80 years or older, weight 60 kg or less, and serum creatinine 1.5 mg/dL or higher. This patient meets all three, so the reduced dose is required to limit bleeding risk.

Question 10Pharmacotherapy and Pharmaceutical Care

Which add-on therapy is most appropriate for a patient with type 2 diabetes, heart failure with reduced ejection fraction, and an eGFR of 35 mL/min/1.73 m2?

  1. Glyburide
  2. Sitagliptin
  3. Dapagliflozin Correct answer.
  4. Pioglitazone

Explanation

SGLT2 inhibitors such as dapagliflozin reduce heart failure hospitalizations and slow CKD progression, and they can be continued at a reduced eGFR in this setting. Pioglitazone causes fluid retention and is avoided in heart failure, while sulfonylureas and DPP-4 inhibitors offer no cardiovascular or renal benefit.

Question 11Pharmacotherapy and Pharmaceutical Care

Which is the first-line pharmacologic treatment for convulsive status epilepticus in a patient with an established IV line?

  1. Lorazepam 4 mg IV Correct answer.
  2. Phenytoin 20 mg/kg IV
  3. Valproic acid 40 mg/kg IV
  4. Levetiracetam 60 mg/kg IV

Explanation

A benzodiazepine such as IV lorazepam is the first-line agent for convulsive status epilepticus. Phenytoin, levetiracetam, and valproate are second-line options given when seizures persist after adequate benzodiazepine therapy.

Question 12Pharmacotherapy and Pharmaceutical Care

A patient is being switched from phenelzine to sertraline. How long must phenelzine be discontinued before sertraline is started?

  1. 3 days
  2. 24 hours
  3. 7 days
  4. 14 days Correct answer.

Explanation

At least 14 days must elapse after stopping an MAOI before an SSRI is started because of the risk of serotonin syndrome. When switching in the opposite direction, the SSRI is also generally tapered off for about 2 weeks before the MAOI is begun.

Question 13Pharmacotherapy and Pharmaceutical Care

Which intervention is appropriate prophylaxis for opioid-induced constipation in a patient starting long-term morphine?

  1. Scheduled senna with as-needed escalation Correct answer.
  2. Increased dietary fiber as the sole measure
  3. Bisacodyl only after 5 days without a bowel movement
  4. Methylnaltrexone as first-line prophylaxis

Explanation

A scheduled stimulant laxative such as senna is recommended for prophylaxis of opioid-induced constipation, with additional agents added as needed. Peripherally acting mu-opioid receptor antagonists are reserved for patients who fail conventional laxative therapy.

Question 14Pharmacotherapy and Pharmaceutical Care

Which regimen represents high-intensity statin therapy?

  1. Simvastatin 40 mg daily
  2. Rosuvastatin 5 mg daily
  3. Pravastatin 40 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 daily. Simvastatin 40 mg, pravastatin 40 mg, and rosuvastatin 5 to 10 mg are moderate-intensity regimens.

Question 15Pharmacotherapy and Pharmaceutical Care

A patient with type 2 diabetes has a urine albumin-to-creatinine ratio of 600 mg/g, a blood pressure of 138/84 mm Hg, and an eGFR of 55 mL/min/1.73 m2. Which addition is most likely to slow progression of kidney disease?

  1. Amlodipine
  2. Furosemide
  3. Lisinopril Correct answer.
  4. Sodium bicarbonate

Explanation

An ACE inhibitor reduces intraglomerular pressure and albuminuria and slows CKD progression in patients with diabetes and significant albuminuria. Blood pressure and potassium should be monitored after initiation, and the dose may be titrated to the maximum tolerated.

Question 16Pharmacotherapy and Pharmaceutical Care

Which regimen is approved for HIV pre-exposure prophylaxis in a sexually active adult without HIV infection?

  1. Efavirenz plus tenofovir DF daily
  2. Emtricitabine/tenofovir DF daily Correct answer.
  3. Zidovudine/lamivudine daily
  4. Raltegravir daily

Explanation

Daily emtricitabine/tenofovir disoproxil, or the tenofovir alafenamide combination, is an approved oral PrEP regimen, and long-acting injectable cabotegravir is an alternative. HIV status must be confirmed negative before and during PrEP because of the risk of selecting resistant virus.

Question 17Pharmacotherapy and Pharmaceutical Care

A patient receiving chemotherapy for breast cancer presents with a temperature of 38.5 degrees C and an absolute neutrophil count of 400 cells/mm3. Which empiric antibiotic is most appropriate?

  1. Trimethoprim-sulfamethoxazole
  2. Cefepime Correct answer.
  3. Metronidazole
  4. Vancomycin alone

Explanation

Febrile neutropenia requires prompt empiric coverage with an antipseudomonal beta-lactam such as cefepime, piperacillin-tazobactam, or meropenem. Vancomycin is added only for specific indications such as suspected catheter infection, MRSA colonization, or hemodynamic instability.

Question 18Pharmacotherapy and Pharmaceutical Care

Which medication is considered potentially inappropriate for an 80-year-old patient with chronic insomnia?

  1. Ramelteon
  2. Melatonin
  3. Cognitive behavioral therapy for insomnia
  4. Diphenhydramine Correct answer.

Explanation

First-generation antihistamines such as diphenhydramine are strongly anticholinergic and cause confusion, falls, and urinary retention in older adults, so the Beers criteria advise avoiding them. Nonpharmacologic therapy is preferred first-line for insomnia in this population.

Question 19Pharmacotherapy and Pharmaceutical Care

A drug has an elimination half-life of 12 hours and is given without a loading dose. Approximately how long will it take to reach steady state?

  1. 60 hours Correct answer.
  2. 120 hours
  3. 24 hours
  4. 12 hours

Explanation

Steady state is generally reached after about 4 to 5 half-lives, which for a 12-hour half-life is roughly 48 to 60 hours. A loading dose can achieve therapeutic concentrations sooner when a rapid effect is needed.

Question 20Pharmacotherapy and Pharmaceutical Care

A patient stabilized on warfarin is started on trimethoprim-sulfamethoxazole for a urinary tract infection. Which effect is most likely?

  1. No change in INR because the drugs do not interact
  2. Reduced warfarin absorption leading to subtherapeutic INR
  3. Decreased INR through enzyme induction
  4. Increased INR through inhibition of CYP2C9 Correct answer.

Explanation

Trimethoprim-sulfamethoxazole inhibits CYP2C9, which metabolizes the more potent S-warfarin enantiomer, and it can also displace warfarin from albumin, so the INR rises. Close INR monitoring with a preemptive dose reduction is usually needed.

Question 21Pharmacotherapy and Pharmaceutical Care

A patient with heart failure is being transitioned from lisinopril 20 mg daily to sacubitril/valsartan. What is the minimum time lisinopril must be withheld before the first dose?

  1. 7 days
  2. No washout is required
  3. 12 hours
  4. 36 hours Correct answer.

Explanation

A 36-hour washout is required when switching from an ACE inhibitor to sacubitril/valsartan because simultaneous neprilysin and ACE inhibition markedly increases the risk of angioedema. The same interval applies when switching back from sacubitril/valsartan to an ACE inhibitor.

Question 22Pharmacotherapy and Pharmaceutical Care

For a serious MRSA infection, which vancomycin exposure target is currently recommended to balance efficacy and safety?

  1. AUC24/MIC of 800 to 1000
  2. AUC24/MIC of 400 to 600 Correct answer.
  3. AUC24/MIC of 100 to 200
  4. AUC24/MIC greater than 1500

Explanation

Consensus guidelines recommend an AUC24/MIC ratio of 400 to 600 for serious MRSA infection, assuming an MIC of 1 mg/L. This target preserves efficacy while reducing nephrotoxicity compared with trough-only monitoring above 15 to 20 mg/L.

Question 23Pharmacotherapy and Pharmaceutical Care

Which antiepileptic drug is preferred for a patient with generalized epilepsy who is planning pregnancy?

  1. Phenytoin
  2. Topiramate
  3. Lamotrigine Correct answer.
  4. Valproate

Explanation

Lamotrigine and levetiracetam have the lowest rates of major congenital malformations and are preferred whenever seizure control allows in pregnancy. Valproate carries the highest risk of neural tube defects and neurodevelopmental impairment and should be avoided in patients who may become pregnant.

Question 24Pharmacotherapy and Pharmaceutical Care

A kidney transplant recipient taking tacrolimus and mycophenolate develops tremor and a rising serum creatinine; the tacrolimus trough is 28 ng/mL. Which action is most appropriate?

  1. Hold tacrolimus and evaluate for nephrotoxicity Correct answer.
  2. Add diltiazem to improve levels
  3. Continue the current regimen and recheck in one week
  4. Increase the tacrolimus dose

Explanation

Tremor with acute kidney injury and a supratherapeutic trough indicates calcineurin inhibitor toxicity, so the drug should be held or reduced while renal function and levels are reassessed. Diltiazem inhibits CYP3A4 and would raise tacrolimus concentrations further.

Question 25Pharmacotherapy and Pharmaceutical Care

A patient with newly diagnosed Burkitt lymphoma and a uric acid of 12 mg/dL is beginning chemotherapy. Which agent is preferred for rapid control of hyperuricemia?

  1. Rasburicase Correct answer.
  2. Febuxostat
  3. Allopurinol
  4. Sodium bicarbonate alone

Explanation

Rasburicase is a recombinant urate oxidase that rapidly degrades uric acid already present in plasma and is preferred for high-risk tumor lysis syndrome. Allopurinol and febuxostat block formation of new uric acid but do not lower existing levels.

Question 26Pharmacotherapy and Pharmaceutical Care

A 24-year-old with mild persistent asthma uses albuterol two or three times weekly and wakes with symptoms twice a month. Which pharmacologic therapy is preferred as the initial controller?

  1. Long-acting beta-2 agonist used alone
  2. Short-acting beta-2 agonist taken twice daily
  3. Daily oral prednisone
  4. Low-dose inhaled corticosteroid Correct answer.

Explanation

Mild persistent asthma is treated with a daily anti-inflammatory controller, and low-dose inhaled corticosteroid is the preferred agent for all severity steps. Monotherapy with a long-acting beta-2 agonist is not appropriate in asthma because of the risk of exacerbation and death. Short-acting bronchodilators provide symptom relief but do not alter airway inflammation.

Question 27Pharmacotherapy and Pharmaceutical Care

A patient with chronic obstructive pulmonary disease is started on tiotropium. Blockade of which receptor class accounts for this drug's bronchodilating effect?

  1. Beta-2 adrenergic receptors
  2. Muscarinic M3 receptors Correct answer.
  3. Histamine H1 receptors
  4. Leukotriene receptors

Explanation

Tiotropium is a long-acting muscarinic antagonist that blocks M3 receptors on airway smooth muscle, reducing vagally mediated bronchoconstriction. Long-acting beta-2 agonists act on a different receptor and are a separate maintenance class. Leukotriene and histamine receptor blockers do not provide bronchodilation in COPD.

Question 28Pharmacotherapy and Pharmaceutical Care

A patient taking warfarin for a mechanical mitral valve has an intracranial hemorrhage with an INR of 6.5. Which therapy is most appropriate for urgent reversal?

  1. Protamine sulfate plus fresh frozen plasma
  2. Idarucizumab plus oral vitamin K
  3. Oral vitamin K alone
  4. Intravenous vitamin K plus four-factor prothrombin complex concentrate Correct answer.

Explanation

Life-threatening warfarin-associated bleeding requires rapid replacement of functional vitamin K-dependent clotting factors together with intravenous vitamin K. Four-factor prothrombin complex concentrate corrects the INR faster and with less volume than plasma. Protamine and idarucizumab reverse different anticoagulants.

Question 29Pharmacotherapy and Pharmaceutical Care

Below which estimated glomerular filtration rate should metformin not be initiated because of the risk of lactic acidosis?

  1. 30 mL/min/1.73 m2 Correct answer.
  2. 45 mL/min/1.73 m2
  3. 60 mL/min/1.73 m2
  4. 90 mL/min/1.73 m2

Explanation

Metformin is contraindicated when the eGFR is below 30 mL/min/1.73 m2 because reduced clearance allows drug accumulation and lactic acidosis. Initiation is not recommended between 30 and 45 mL/min/1.73 m2, and the dose should be limited in that range if already in use. Higher eGFR values do not preclude therapy.

Question 30Pharmacotherapy and Pharmaceutical Care

A 55-year-old has a first episode of nonsevere Clostridioides difficile infection. Which treatment is appropriate?

  1. Intravenous vancomycin
  2. Oral rifaximin
  3. Oral metronidazole
  4. Oral vancomycin Correct answer.

Explanation

Oral vancomycin (or fidaxomicin) is recommended for an initial episode of C. difficile infection because it achieves high intracolonic concentrations. Metronidazole is now reserved for situations where preferred agents are unavailable. Intravenous vancomycin does not reach the colonic lumen in adequate amounts, and rifaximin is used for recurrence suppression rather than primary therapy.

Question 31Pharmacotherapy and Pharmaceutical Care

A patient with type 1 diabetes is alert and diaphoretic with a capillary glucose of 52 mg/dL. Which intervention is most appropriate?

  1. Give intramuscular glucagon
  2. Inject subcutaneous insulin glargine
  3. Give 15 g of fast-acting oral carbohydrate Correct answer.
  4. Give 50 mL of 50% dextrose intravenously

Explanation

A conscious patient who can swallow should be treated with the rule of 15: 15 g of rapid-acting oral carbohydrate, rechecking glucose in 15 minutes and repeating if still low. Glucagon and intravenous dextrose are reserved for patients who cannot take oral intake or have no intravenous access. Giving insulin would worsen the hypoglycemia.

Question 32Pharmacotherapy and Pharmaceutical Care

Which counseling point is correct for a patient beginning alendronate for postmenopausal osteoporosis?

  1. Take together with a calcium supplement to improve absorption
  2. Take with a full glass of water and stay upright for at least 30 minutes Correct answer.
  3. Take at bedtime with a light snack
  4. Crush the tablet and mix it into applesauce

Explanation

Oral bisphosphonates are poorly absorbed and can cause esophageal irritation, so they must be taken on an empty stomach with a full glass of plain water while remaining upright for at least 30 minutes. Food, calcium, and other medications markedly reduce absorption and must be separated by at least 30 to 60 minutes. Crushing the tablet increases mucosal injury risk.

Question 33Pharmacotherapy and Pharmaceutical Care

A patient is found unresponsive with pinpoint pupils and a respiratory rate of 6 breaths/min after suspected heroin use. Which medication should be given?

  1. Intravenous acetylcysteine
  2. Intravenous atropine
  3. Intravenous naloxone Correct answer.
  4. Intravenous flumazenil

Explanation

The triad of depressed consciousness, pinpoint pupils, and respiratory depression indicates opioid toxicity, which is reversed with the competitive opioid antagonist naloxone. Naloxone is titrated to restore adequate respiration rather than full wakefulness. The other agents reverse benzodiazepines, cholinergic excess, and acetaminophen toxicity, respectively.

Question 34Pharmacotherapy and Pharmaceutical Care

A patient with a duodenal ulcer has confirmed Helicobacter pylori infection and a documented penicillin allergy, with no prior macrolide exposure. Which eradication regimen is most appropriate?

  1. Doxycycline, rifabutin, and amoxicillin
  2. Amoxicillin, clarithromycin, and a proton pump inhibitor
  3. Bismuth, metronidazole, tetracycline, and a proton pump inhibitor Correct answer.
  4. Amoxicillin, levofloxacin, and a proton pump inhibitor

Explanation

Bismuth quadruple therapy avoids penicillin and is a recommended first-line regimen for H. pylori eradication, particularly when penicillin cannot be used. Clarithromycin-based triple therapy requires amoxicillin or metronidazole and would not be suitable here without modification. Rifabutin-containing regimens are reserved for refractory cases.

Question 35Pharmacotherapy and Pharmaceutical Care

A healthy 45-year-old with no antibiotic use in the past month and no drug allergies has acute bacterial rhinosinusitis that has not improved after 10 days. Which antibiotic is recommended first-line?

  1. Levofloxacin
  2. Amoxicillin-clavulanate Correct answer.
  3. Trimethoprim-sulfamethoxazole
  4. Azithromycin

Explanation

Amoxicillin-clavulanate is the recommended empiric choice for acute bacterial rhinosinusitis because it covers the common pathogens, including beta-lactamase-producing organisms, and limits fluoroquinolone exposure. Macrolides and trimethoprim-sulfamethoxazole have high rates of pneumococcal resistance. Fluoroquinolones are reserved for patients who fail first-line therapy or have specific risk factors.

Question 36Pharmacotherapy and Pharmaceutical Care

A patient with nephrotic syndrome and severe hypoalbuminemia (albumin 2.0 g/dL) has a total phenytoin concentration of 8 mcg/mL. How should this result be interpreted?

  1. Increase the dose because the total level is subtherapeutic
  2. Take no action because total levels are unaffected by albumin
  3. Reduce the dose because the level reflects toxicity
  4. Measure free phenytoin because total levels underestimate active drug Correct answer.

Explanation

Phenytoin is highly protein bound, so hypoalbuminemia lowers the total concentration while the pharmacologically active free fraction may remain therapeutic. A free (unbound) level, or a corrected total level using the Sheiner-Tozer equation, should guide dosing in this situation. Adjusting the dose based on the total level alone risks overdosing the patient.

Question 37Pharmacotherapy and Pharmaceutical Care

A patient stabilized on lithium carbonate is started on hydrochlorothiazide for hypertension. What effect should be anticipated?

  1. Lithium concentrations will remain unchanged but renal function will decline
  2. Lithium concentrations will fall and the dose will need to be increased
  3. Lithium concentrations will rise only if dietary sodium increases
  4. Lithium concentrations will rise, increasing the risk of toxicity Correct answer.

Explanation

Thiazides cause sodium and volume depletion, which increases proximal tubular reabsorption of lithium and reduces its renal clearance. Serum lithium concentrations can rise substantially within days, producing tremor, ataxia, and confusion. The combination requires avoidance or close monitoring with a preemptive dose reduction.

Question 38Pharmacotherapy and Pharmaceutical Care

A patient taking digoxin and furosemide reports nausea, anorexia, and yellow-tinged visual changes. The serum potassium is 3.0 mEq/L. What best explains these findings?

  1. Hyponatremia has displaced digoxin from tissue binding sites
  2. Hypokalemia has increased myocardial sensitivity to digoxin Correct answer.
  3. Hyperkalemia has reduced renal digoxin clearance
  4. Hypocalcemia has increased intestinal digoxin absorption

Explanation

Digoxin binds the sodium-potassium ATPase, and its effect is enhanced when extracellular potassium is low, so hypokalemia promotes toxicity even at therapeutic digoxin concentrations. Loop diuretics are a common cause of the hypokalemia that precipitates this interaction. Potassium repletion and digoxin level measurement are the immediate priorities.

Question 39Pharmacotherapy and Pharmaceutical Care

Which supplement is routinely co-prescribed with low-dose weekly methotrexate in rheumatoid arthritis?

  1. Calcium carbonate 500 mg twice daily
  2. Vitamin B12 monthly
  3. Pyridoxine 50 mg daily
  4. Folic acid 1 mg daily Correct answer.

Explanation

Folic acid supplementation reduces methotrexate-related stomatitis, nausea, and transaminase elevation without compromising the anti-inflammatory effect. It is given daily except on the methotrexate day in most regimens. Pyridoxine is paired with isoniazid, and calcium has no role in methotrexate tolerance.

Question 40Pharmacotherapy and Pharmaceutical Care

Six days after starting unfractionated heparin, a patient's platelet count falls from 250,000 to 90,000/mcL and a new deep vein thrombosis is found. What is the most appropriate management?

  1. Continue heparin and monitor platelet counts every other day
  2. Stop heparin and transfuse platelets
  3. Stop heparin and start argatroban Correct answer.
  4. Stop heparin and start warfarin alone

Explanation

This presentation is consistent with heparin-induced thrombocytopenia, a prothrombotic disorder requiring immediate discontinuation of all heparin products and initiation of a non-heparin anticoagulant such as argatroban. Warfarin must not be started alone during the acute phase because it can worsen thrombosis. Platelet transfusion is avoided unless bleeding is life-threatening.

Question 41Pharmacotherapy and Pharmaceutical Care

Which counseling statement is most appropriate for a patient starting oral ferrous sulfate for iron-deficiency anemia?

  1. Take on an empty stomach with a source of vitamin C Correct answer.
  2. Take with an antacid to prevent nausea
  3. Take with milk to reduce stomach upset
  4. Take at the same time as levothyroxine

Explanation

Ferrous iron is absorbed best in an acidic environment on an empty stomach, and vitamin C enhances absorption by keeping iron in the reduced ferrous state. Calcium-containing foods, antacids, and levothyroxine all reduce absorption and should be separated by at least two hours. Milk is particularly problematic because of its calcium content.

Question 42Pharmacotherapy and Pharmaceutical Care

A patient taking sertraline is started on tramadol and two days later develops agitation, inducible clonus, hyperreflexia, and a temperature of 38.9 degrees C. What is the most appropriate next step?

  1. Give benztropine for extrapyramidal symptoms
  2. Stop the serotonergic medications and provide supportive care Correct answer.
  3. Increase the sertraline dose to stabilize mood
  4. Give dantrolene and bromocriptine

Explanation

The combination of a serotonergic agent, neuromuscular hyperactivity with clonus and hyperreflexia, and autonomic instability indicates serotonin syndrome. Management is withdrawal of the offending agents plus supportive care, with benzodiazepines for agitation and cooling measures for hyperthermia. Dantrolene and bromocriptine are used for neuroleptic malignant syndrome.

Question 43Pharmacotherapy and Pharmaceutical Care

Which baseline laboratory and anthropometric monitoring is required when olanzapine is initiated?

  1. Pulmonary function tests and arterial blood gases
  2. Weight, fasting glucose, and a lipid panel Correct answer.
  3. Renal ultrasound and urinary catecholamines
  4. Serum ceruloplasmin and 24-hour urinary copper

Explanation

Second-generation antipsychotics such as olanzapine carry a substantial risk of weight gain, dyslipidemia, and hyperglycemia, so weight or BMI, waist circumference, blood pressure, fasting glucose, and lipids should be obtained at baseline and monitored periodically. These parameters guide the choice of antipsychotic and the need for metabolic intervention. The other tests do not assess antipsychotic risk.

Question 44Pharmacotherapy and Pharmaceutical Care

A woman using a combined oral contraceptive is beginning rifampin as part of tuberculosis therapy. What counseling is appropriate?

  1. No change is needed because rifampin does not affect contraceptive efficacy
  2. Stop hormonal contraception permanently and use only barrier methods
  3. Double the contraceptive dose for the duration of therapy
  4. Add a barrier method during therapy and for 4 weeks afterward Correct answer.

Explanation

Rifampin is a potent inducer of CYP3A4 and increases hepatic metabolism of contraceptive steroids, which can lead to breakthrough ovulation and contraceptive failure. An additional barrier method is advised during rifampin therapy and for about four weeks after it ends, while enzyme induction resolves. Doubling the dose is not a reliable solution.

Question 45Pharmacotherapy and Pharmaceutical Care

A patient who wants to quit smoking has no contraindications to pharmacotherapy and prefers a single agent with the highest demonstrated monotherapy efficacy. Which agent is most appropriate?

  1. Bupropion SR started 1 week before the quit date
  2. Clonidine titrated to 0.2 mg twice daily
  3. Varenicline titrated to 1 mg twice daily Correct answer.
  4. Nicotine gum used as needed

Explanation

Varenicline, a partial nicotinic acetylcholine receptor agonist, produces the highest quit rates among single first-line agents in comparative trials. Nicotine replacement and bupropion are also first-line but somewhat less effective as monotherapy. Clonidine is a second-line option used when first-line agents fail.

Question 46Pharmacotherapy and Pharmaceutical Care

A patient receiving gentamicin 5 mg/kg once daily has serum concentrations monitored. Which pharmacokinetic target best correlates with bactericidal efficacy for this dosing strategy?

  1. A peak concentration to MIC ratio of at least 8 to 10 Correct answer.
  2. Time above the MIC exceeding 40 percent of the dosing interval
  3. An area under the curve to MIC ratio of 400 to 600
  4. A trough concentration maintained above 2 mcg/mL

Explanation

Aminoglycosides show concentration-dependent killing, so extended-interval dosing aims for a high peak-to-MIC ratio with a low or undetectable trough to limit nephrotoxicity and ototoxicity. The peak-to-MIC ratio target is generally 8 to 10. Time above MIC and AUC-to-MIC targets describe beta-lactam and vancomycin pharmacodynamics, respectively.

Question 47Pharmacotherapy and Pharmaceutical Care

A patient at 34 weeks of gestation with severe preeclampsia is receiving magnesium sulfate for seizure prophylaxis. Which finding signals magnesium toxicity that requires immediate intervention?

  1. Respiratory rate of 16 breaths per minute
  2. Blood pressure of 150/95 mm Hg
  3. Urine output of 40 mL per hour
  4. Loss of deep tendon reflexes Correct answer.

Explanation

Magnesium toxicity progresses from loss of deep tendon reflexes to respiratory depression, cardiac conduction abnormalities, and cardiac arrest. Reflexes disappear at roughly 9 to 12 mEq/L, so their loss mandates stopping the infusion and, if needed, administering intravenous calcium gluconate. Urine output and respiratory rate should be monitored but are normal at these values.

Question 48Pharmacotherapy and Pharmaceutical Care

A patient on long-term prednisone 20 mg daily is admitted with hypotension that does not respond to intravenous fluids. Which intervention is indicated?

  1. Double the oral prednisone dose
  2. Start intravenous levothyroxine
  3. Give oral fludrocortisone 0.1 mg
  4. Give intravenous hydrocortisone 100 mg Correct answer.

Explanation

Chronic glucocorticoid therapy suppresses the hypothalamic-pituitary-adrenal axis, and acute illness can precipitate adrenal crisis with vasopressor-refractory hypotension. Immediate high-dose intravenous hydrocortisone provides both glucocorticoid and salt-retaining mineralocorticoid activity. Oral therapy is inadequate in a patient who may have impaired absorption and needs rapid onset.

Question 49Pharmacotherapy and Pharmaceutical Care

A patient admitted with alcohol withdrawal has tremor, diaphoresis, and a glucose of 60 mg/dL. In which sequence should treatment be provided?

  1. Dextrose first, then thiamine 30 minutes later
  2. Naltrexone 50 mg orally before any other therapy
  3. Thiamine 100 mg intravenously before dextrose administration Correct answer.
  4. Haloperidol 5 mg intramuscularly for agitation

Explanation

Thiamine should be given before or with glucose in patients at risk for Wernicke encephalopathy, because a glucose load can precipitate or worsen the deficiency-related neurologic injury. Benzodiazepines are the mainstay for withdrawal symptoms. Antipsychotics lower the seizure threshold and are avoided as monotherapy.

Question 50Pharmacotherapy and Pharmaceutical Care

A patient has a serum potassium of 7.2 mEq/L with widening of the QRS complex on the electrocardiogram. Which medication should be administered first?

  1. Oral sodium polystyrene sulfonate
  2. Intravenous calcium gluconate Correct answer.
  3. Intravenous furosemide
  4. Intravenous regular insulin with dextrose

Explanation

Membrane stabilization with intravenous calcium is the immediate priority whenever hyperkalemia produces electrocardiographic changes, because it antagonizes the cardiotoxic effects of potassium within minutes. Insulin with dextrose and other measures shift or remove potassium but do not protect the myocardium as rapidly. Calcium does not lower the serum potassium itself.