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Practice Test 10 - NAPLEX

20 questions. Answer them in any order, then submit to see your score and every explanation.

  1. A 58-year-old man (92 kg, 178 cm) presents for medication reconciliation after hospital discharge for an acute coronary syndrome with drug-eluting stent placement 10 days ago. Current medications: aspirin 81 mg daily, clopidogrel 75 mg daily, omeprazole 20 mg daily, atorvastatin 80 mg nightly, metoprolol succinate 50 mg daily, lisinopril 10 mg daily, nitroglycerin 0.4 mg SL as needed. PMH: GERD, HTN, HLD. Labs: SCr 1.0 mg/dL; AST/ALT within normal limits. Allergies: none. Which drug-related problem needs immediate attention?
  2. A 56-year-old male (84 kg) with chronic hepatitis C (treated, stable) comes for medication reconciliation. Current prescriptions: acetaminophen 1000 mg by mouth three times daily as needed for pain (from PCP) and hydrocodone/acetaminophen 5/325 mg, 1–2 tablets by mouth every 6 hours as needed (from dentist). OTC: acetaminophen 500 mg tablets, "2 tablets when pain is bad." Medical history: chronic liver disease, osteoarthritis. Allergies: none. Labs: AST 78 U/L (high), ALT 85 U/L (high), total bilirubin 1.8 mg/dL (high), INR 1.3 (slightly high). Which action should the pharmacist take to optimize this patient's medication regimen?
  3. A 45-year-old Black woman (78 kg) presents for follow-up after an acute coronary syndrome treated with percutaneous coronary intervention and drug-eluting stent placement 2 days ago. Current medications include aspirin 81 mg orally daily, clopidogrel 75 mg orally daily, metoprolol succinate 50 mg orally daily, and rosuvastatin 20 mg orally nightly; allergy: penicillin (rash). Labs: hemoglobin 12.8 g/dL, platelets 240,000/mm3^3, serum creatinine 0.9 mg/dL (estimated creatinine clearance 88 mL/min), alanine aminotransferase 18 units/L. Pharmacogenomic test shows CYP2C19 *2/*2 (poor metabolizer). Which action should the pharmacist take considering the patient's pharmacogenomic profile?
  4. A 74-year-old man (73 kg) with chronic pain is started on transdermal fentanyl 25 mcg/hour every 72 hours. Two days later his daughter reports he is very sleepy and difficult to arouse. Current medications: fentanyl patch 25 mcg/hour (new), clonazepam 0.5 mg twice daily, acetaminophen 650 mg three times daily. Medical history: anxiety, chronic back pain. Allergies: none. Vitals at home: respiratory rate 8/min. Which action should the pharmacist take to address this adverse event?
  5. A 65-year-old man (84 kg) with chronic hepatitis C (treated, cured) and atrial fibrillation is taking rivaroxaban 20 mg PO daily with dinner. He is newly prescribed clarithromycin 500 mg PO BID for 7 days for sinusitis. Current medications: rivaroxaban 20 mg daily, clarithromycin 500 mg BID, metoprolol succinate 50 mg daily. Labs: SCr 1.0 mg/dL, AST 55 U/L (high; normal 10–40), ALT 62 U/L (high; normal 7–56); allergies: none. Which secondary resource would best verify the interaction risk (CYP3A4/P-gp inhibition) and recommended action?
  6. A 57-year-old woman (weight 73 kg, height 167 cm) with stage 5 chronic kidney disease on hemodialysis is receiving counseling on protein intake. Dietary preference: enjoys salads and fruit; limits salt. Medications: epoetin alfa, sevelamer, and a renal multivitamin. Labs: albumin 3.0 g/dL (normal 3.5–5.0), phosphorus 5.9 mg/dL, potassium 5.2 mEq/L. What is the best recommendation for managing this patient's nutrient intake?
  7. A 33-year-old male (76 kg) with mild hyperlipidemia (low-density lipoprotein cholesterol 148 mg/dL, alanine aminotransferase 24 U/L) is invited to participate in a Phase I trial of lipidoran, a new oral lipid-lowering agent, involving intensive blood sampling for pharmacokinetics and frequent safety labs. The study team explains foreseeable risks, potential benefits, alternatives, confidentiality, compensation for injury, and that participation is voluntary with the right to withdraw at any time before the patient signs consent. What ethical consideration is central to this trial phase?
  8. A 52-year-old man (weight 86 kg) with hypertension on amlodipine 10 mg daily has an average home blood pressure of 148/92 mmHg. A randomized controlled trial compared adding chlorthalidone 12.5–25 mg daily vs hydrochlorothiazide 25–50 mg daily for 12 weeks; mean systolic blood pressure reduction was -16.5 vs -12.0 mmHg (between-group difference -4.5 mmHg, 95% CI -6.8 to -2.2; p<0.001), with higher hypokalemia in the chlorthalidone group (6% vs 2%). Based on the study, which treatment is most appropriate for this patient?
  9. A 73-year-old woman (68 kg) with osteoporosis is considering denosumab. In a trial, new vertebral fracture occurred in 2.3% with denosumab vs 7.2% with placebo over 3 years (RR =0.32=0.32, 95% CI 0.260.26 to 0.410.41, p<0.001p<0.001). Which statistical finding is most crucial for assessing drug efficacy for fracture prevention?
  10. A 61-year-old female (weight 74 kg) reports she is "allergic to sulfa" because she developed a rash with sulfamethoxazole/trimethoprim years ago. She is now prescribed hydrochlorothiazide 25 mg daily for hypertension. Medical history: hypertension and osteopenia. Current medications: calcium carbonate 600 mg twice daily and vitamin D3 1000 units daily. Labs: serum creatinine 0.9 mg/dL, potassium 4.1 mEq/L, alanine aminotransferase 21 U/L, aspartate aminotransferase 19 U/L. Documented allergies: "sulfonamide antibiotic—rash." What is the most significant allergy-related concern for this patient?
  11. A 72-year-old male (weight 78 kg) with atrial fibrillation, chronic kidney disease stage 3, and hyperlipidemia tests positive for COVID-19 and is prescribed nirmatrelvir/ritonavir (Paxlovid) under EUA. Current medications: apixaban 5 mg by mouth twice daily, atorvastatin 40 mg by mouth nightly, amlodipine 10 mg by mouth daily. Labs: serum creatinine 1.7 mg/dL (baseline 1.6), estimated creatinine clearance 42 mL/min. How should the pharmacist manage a potential interaction with an EUA drug?
  12. A 64-year-old male (weight 78 kg) with chronic atrial fibrillation presents for anticoagulation follow-up. Medical history includes atrial fibrillation and hypertension; allergies: none. Current medications: warfarin 5 mg by mouth daily, amiodarone 200 mg by mouth daily, hydrochlorothiazide 25 mg by mouth daily. Labs: international normalized ratio (INR) 5.2 (high; goal 2–3), aspartate aminotransferase 26 U/L, serum creatinine 0.9 mg/dL. What is the most significant error in this patient's medication regimen?
  13. A 56-year-old female (74 kg) with bipolar disorder is maintained on lithium carbonate 300 mg PO three times daily. Current medications: lithium, levothyroxine 75 mcg PO daily, naproxen 220 mg PO twice daily as needed (started 1 week ago for knee pain). Allergies: none. Labs today: lithium level 1.6 mEq/L (therapeutic 0.6–1.2), SCr 1.3 mg/dL (0.6–1.2), sodium 134 mEq/L (135–145), thyroid-stimulating hormone (TSH) 6.8 mIU/L (0.4–4.0). Vital signs: BP 118/70 mmHg, HR 60 bpm. Which parameter indicates the need for a dose adjustment?
  14. A 66-year-old female (70 kg, 162 cm) with hypertension takes lisinopril 20 mg by mouth once daily and potassium chloride 20 mEq by mouth once daily for prior hypokalemia on diuretics. Lisinopril is on shortage and will be changed to another ACE inhibitor. What is the pharmacist's best action to reduce risk during this shortage-driven change?
  15. A 28-year-old woman (64 kg) with chronic pain is prescribed a transdermal scopolamine patch for motion sickness prevention before a cruise. Current medications: scopolamine 1 mg patch behind the ear every 72 hours as needed, sertraline 50 mg daily. Pertinent values: no glaucoma history reported. Allergies: none. What is the most important counseling point for this device?
  16. A 27-year-old female (weight 65 kg) is admitted for diabetic ketoacidosis and is started on an insulin infusion after initial fluid resuscitation. Labs: SCr 0.9 mg/dL, Na 130 mEq/L, K 4.8 mEq/L, glucose 520 mg/dL. Regular insulin is prepared as 100 units in 100 mL (1 unit/mL), and the order is to start at 0.1 unit/kg/hr. Calculate the infusion rate in mL/hr.
  17. A 63-year-old female (weight 68 kg) presents for a comprehensive medication review and brings in two inhalers that she uses daily. She reports taking fluticasone/salmeterol 250/50 mcg 1 inhalation twice daily, tiotropium 18 mcg 1 inhalation once daily, and two rescue inhalers: albuterol HFA 2 puffs every 4–6 hours as needed and levalbuterol HFA 2 puffs every 4–6 hours as needed; she states she alternates them "so they don't stop working." Labs: serum creatinine 0.9 mg/dL, alanine aminotransferase 24 U/L. Medical history: chronic obstructive pulmonary disease. Allergies: none. What is the most significant duplication in therapy present?
  18. A 70-year-old male (weight 92 kg, height 178 cm) with heart failure and atrial fibrillation is on digoxin 0.25 mg by mouth daily, furosemide 40 mg by mouth twice daily, and carvedilol 25 mg by mouth twice daily; allergies: none. He reports nausea and yellow-green vision changes. Labs: serum creatinine 1.6 mg/dL, potassium 3.0 mEq/L (low), aspartate aminotransferase 30 U/L, alanine aminotransferase 26 U/L, digoxin level 2.4 ng/mL (typical goal 0.5–0.9 ng/mL in heart failure). Therapeutic goal: symptom control of heart failure and rate control while avoiding toxicity. Which pharmacodynamic effect is responsible for the patient's symptoms?
  19. A 70-year-old man (78 kg) is picking up a new prescription after a transient ischemic attack. Current medications: atorvastatin 40 mg daily and lisinopril 20 mg daily. New prescription: clopidogrel 75 mg daily. Allergy: aspirin (angioedema). The pharmacy profile shows an active prescription for omeprazole 40 mg daily continued from prior therapy. No intervention is made. Which medication error needs to be reported?
  20. At 11:00, 360 mL remains; rate is 150 mL/h. Finish time?

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