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Practice Test 11 - NAPLEX

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

  1. A 55-year-old female (64 kg) is picking up a refill for lisinopril 20 mg by mouth daily. She reports starting an OTC potassium supplement (potassium gluconate 595 mg, providing 99 mg elemental potassium) twice daily for leg cramps and also uses a salt substitute at home. Current meds: lisinopril 20 mg daily and meloxicam 15 mg daily. Medical history: hypertension, arthritis. Allergies: none. Labs from yesterday: potassium 5.8 mEq/L (high), SCr 1.5 mg/dL (high). Which medication discrepancy should the pharmacist address first?
  2. A 67-year-old woman (70 kg) with nonvalvular atrial fibrillation and prior gastrointestinal bleed 2 years ago is considering anticoagulation; her creatinine clearance is 62 mL/min and she takes omeprazole. You review a pragmatic, randomized, open-label trial comparing apixaban 5 mg twice daily vs rivaroxaban 20 mg daily in patients with atrial fibrillation (median follow-up 18 months); major bleeding occurred in 2.3 vs 3.1 events per 100 patient-years (hazard ratio 0.74; 95% confidence interval 0.60–0.92; p=0.006) and stroke/systemic embolism was similar (hazard ratio 0.98; 95% confidence interval 0.78–1.23). What is the key takeaway from the study for this patient's case?
  3. In a busy chain pharmacy, a technician prints a patient's medication profile and leaves it on the counter where other customers can see it. Under HIPAA, how should the pharmacist respond to this regulatory violation?
  4. A 76-year-old female (60 kg, 158 cm) with chronic osteoarthritis pain presents for medication review due to fatigue and dark stools. Current medications: ibuprofen 600 mg PO three times daily, naproxen 500 mg PO twice daily, acetaminophen 1000 mg PO three times daily as needed, pantoprazole 40 mg PO daily, amlodipine 5 mg PO daily. Allergies: none. History: osteoarthritis, hypertension, peptic ulcer disease (remote). Labs: Hgb 9.8 g/dL (12–16), SCr 1.1 mg/dL (0.6–1.1), AST/ALT 18/16 U/L (normal). Which medication should be discontinued based on current therapy?
  5. A 28-year-old female (weight 62 kg) is brought to the emergency department for severe drowsiness after taking "a handful" of her prescribed alprazolam about 1 hour ago with alcohol. Current medications: alprazolam 1 mg by mouth three times daily as needed, sertraline 100 mg by mouth daily, ethinyl estradiol/levonorgestrel 1 tablet daily. Medical history: panic disorder. Allergies: penicillin (rash). Vitals: blood pressure 108/66 mmHg, heart rate 92 bpm, respiratory rate 8/min, oxygen saturation 90% on room air; pupils mid-size and reactive. Labs: serum creatinine 0.8 mg/dL, aspartate aminotransferase 22 U/L, alanine aminotransferase 18 U/L, ethanol level 180 mg/dL, urine toxicology positive for benzodiazepines only. Which antidote is most appropriate for this overdose?
  6. A 64-year-old man (weight 74 kg, height 170 cm) is receiving vancomycin for cellulitis. Current medications: vancomycin 1,000 mg IV every 12 hours, spironolactone 25 mg PO daily. Medical history: heart failure, chronic kidney disease. Allergies: none. Labs: SCr 1.5 mg/dL. If vancomycin clearance decreases, which pharmacokinetic parameter is expected to increase (assuming VdV_d is unchanged)?
  7. A 63-year-old male (84 kg) presents with black, tarry stools and lightheadedness for 1 day. Medical history: osteoarthritis, prior peptic ulcer disease. Current medications: naproxen 500 mg twice daily, omeprazole 20 mg daily (often missed), aspirin 81 mg daily. Allergies: none. Labs: hemoglobin 8.9 g/dL (13.5–17.5), blood urea nitrogen (BUN) 34 mg/dL (7–20), SCr 1.0 mg/dL (0.7–1.3), international normalized ratio (INR) 1.0 (0.9–1.1). Which pathophysiological mechanism explains this patient's condition?
  8. A 74-year-old woman (weight 62 kg) with chronic pain and constipation is taking oxycodone immediate-release 5 mg every 6 hours as needed (uses 3–4 doses/day) and docusate 100 mg twice daily (ineffective). She reports she skips oxycodone doses due to constipation and fear of bowel obstruction. Labs: serum creatinine 1.0 mg/dL, alanine aminotransferase 18 units/L. Social history: adequate finances; limited health literacy about bowel regimens. Allergies: none. What is the most appropriate intervention for this adherence barrier?
  9. A 63-year-old male (weight 68 kg, height 170 cm) with chronic obstructive pulmonary disease is admitted for pneumonia and started on levofloxacin 750 mg by mouth daily. Past history: chronic kidney disease stage 3. Current medications: tiotropium inhaled daily, albuterol inhaler as needed, and calcium carbonate 1000 mg by mouth three times daily with meals; allergies: none. Labs: serum creatinine 1.9 mg/dL, aspartate aminotransferase 25 U/L, alanine aminotransferase 22 U/L. Therapeutic goal: resolve infection with adequate antibiotic exposure. Which pharmacokinetic parameter is most affected in this patient if levofloxacin is taken at the same time as calcium carbonate?
  10. A 74-year-old woman (63 kg) taking lithium for bipolar disorder presents with tremor and nausea. Current medications: lithium carbonate 300 mg three times daily, ibuprofen 600 mg three times daily started 1 week ago for back pain, and sertraline 50 mg daily. Labs: lithium level 1.9 mEq/L (reference 0.6–1.2), serum creatinine 1.3 mg/dL (reference 0.6–1.3). Allergy: none known. The ibuprofen was recommended by a clinic staff member without checking for interactions. Which medication error needs to be reported?
  11. In a hospital oncology ward, a 55-year-old female (70 kg) is receiving cyclophosphamide 1,000 mg IV today; current meds include ondansetron, aprepitant, and normal saline maintenance fluids; allergy: none known. After administration, the nurse asks how to dispose of used tubing, empty IV bags, and PPE due to hazardous drug contamination. How should this medication be disposed of safely?
  12. A 71-year-old male (70 kg, 170 cm) is hospitalized for acute decompensated heart failure and receives IV furosemide 80 mg twice daily. Current medications: furosemide IV, potassium chloride 20 mEq PO daily, enoxaparin 40 mg SC daily. Allergies: none. Labs this morning: Na 128 mEq/L (135–145), K 3.8 mEq/L (3.5–5.0), SCr 1.0 mg/dL (0.6–1.3). Vitals: BP 110/70 mmHg, HR 88 bpm. Which lab result suggests a need for intervention?
  13. An open-label randomized trial compares two oral antibiotics for uncomplicated UTI. Clinicians know the assigned drug and are more likely to order follow-up urine cultures for patients receiving the older antibiotic, leading to more documented treatment failures in that group. What type of bias could affect the validity of this study?
  14. A 27-year-old female (weight 62 kg) picks up insulin glargine (Lantus) pens from a retail pharmacy for newly diagnosed type 1 diabetes. She reports that her in-use pen has been kept in the refrigerator door and she sometimes leaves it on the kitchen counter for several hours. Which recommendation ensures optimal stability for insulin glargine pens once opened, given standard storage guidance (controlled room temperature 20–25°C [68–77°F] allowed)?
  15. A 54-year-old male (110 kg) with chronic low back pain and depression presents with excessive daytime sleepiness, slowed breathing noted by his spouse, and several near-falls over the past week. Medical history: obstructive sleep apnea (uses CPAP inconsistently), depression, and chronic pain; allergy: none. Current medications: oxycodone IR 10 mg PO every 6 hours PRN (using 4 doses/day), gabapentin 600 mg PO TID (increased from 300 mg TID 2 weeks ago), and lorazepam 1 mg PO nightly (started 1 week ago for insomnia). Labs: SCr 1.0 mg/dL, AST/ALT WNL; no recent hospitalization. What is the most likely cause of this patient's symptoms?
  16. A 62-year-old female (71 kg) presents for a new antibiotic. Current medications: dofetilide 500 mcg by mouth twice daily, levothyroxine 100 mcg daily. Allergies: none. Medical history: atrial fibrillation. Labs: serum creatinine 0.9 mg/dL, potassium 4.2 mEq/L. New prescription: ciprofloxacin 500 mg by mouth twice daily for 7 days. Which action should the pharmacist take to ensure patient safety?
  17. A 61-year-old woman (weight 68 kg, height 165 cm) with seizures is taking valproic acid. Current medications: divalproex sodium 1,000 mg/day in divided doses, aspirin 81 mg PO daily. Medical history: epilepsy, coronary artery disease. Allergies: none. Labs: albumin 2.5 g/dL (low), total valproic acid level 55 mcg/mL (typical goal 50–100 mcg/mL), AST/ALT normal. Which pharmacokinetic parameter should be monitored during therapy?
  18. A budget impact model evaluated adding a new inhaled triple therapy for COPD to a health plan with 50,000 covered lives. The eligible population was estimated at 600 patients (mean age 68 years; 55% male; frequent exacerbators). The model projected that 30% would switch to triple therapy, increasing pharmacy costs by $540,000 annually, while reducing COPD-related hospitalizations by 18 events per year (average cost $12,000 each). What does the budget impact model suggest for the healthcare system over 1 year?
  19. A 56-year-old woman (74 kg) with hypothyroidism switched from one manufacturer of levothyroxine 100 mcg by mouth daily to another due to a formulary change 6 weeks ago. She now reports palpitations, anxiety, and weight loss. Current medications: levothyroxine 100 mcg daily (new manufacturer), calcium carbonate 500 mg twice daily. Medical history: hypothyroidism. Allergies: none. Labs: thyroid-stimulating hormone (TSH) 0.05 mIU/L (low; reference 0.4–4.0), free T4 elevated. Which monitoring parameter is critical for this patient on levothyroxine after a product change?
  20. A 34-year-old female requests emergency contraception and asks that no information be shared with her spouse. Later, a man claiming to be her husband calls and demands to know what she purchased and whether she is pregnant. There is no authorization on file, and the patient has not agreed to share information. What is the best way to handle this confidentiality issue consistent with HIPAA and professional ethics?

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