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Practice Test 2 - NAPLEX

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

  1. A 61-year-old man (weight 76 kg) is seen for follow-up after starting spironolactone for heart failure with reduced ejection fraction 3 months ago. Medical history includes heart failure with reduced ejection fraction (ejection fraction 30%), hypertension, and chronic kidney disease stage 3. Current medications: sacubitril/valsartan 49 mg/51 mg by mouth twice daily, carvedilol 25 mg by mouth twice daily, spironolactone 25 mg by mouth daily, furosemide 40 mg by mouth daily, and potassium chloride 20 mEq by mouth daily. Pertinent labs today: serum potassium 5.7 mEq/L (3.5–5.0), serum creatinine 1.8 mg/dL (0.6–1.3). Allergies: none. What is the most significant error in this patient's medication regimen?
  2. A pharmacoeconomic analysis compared a new long-acting insulin (Insulin X) to standard basal insulin in 1,000 patients (median age 58 years; 49% female) with type 2 diabetes and chronic kidney disease stage 3. Over 1 year, severe hypoglycemia occurred in 6% with Insulin X vs 9% with standard insulin (relative risk 0.67; 95% CI 0.48 to 0.94; p = 0.02). Annual drug costs were $3,600 (Insulin X) vs $2,400 (standard), and each severe hypoglycemia event was estimated to cost $4,000 in medical care. How do the confidence intervals affect the interpretation of the study?
  3. A 66-year-old male (weight 78 kg) with chronic kidney disease stage 3 is admitted for pneumonia and develops hypomagnesemia after diuretic therapy. Labs: SCr 2.0 mg/dL, Na 140 mEq/L, K 3.6 mEq/L, Mg 1.3 mg/dL. The provider orders magnesium sulfate 1 g IV in 50 mL to infuse over 2 hours. Determine the mL/hr rate for the medication infusion.
  4. A 74-year-old man (weight 78 kg) with heart failure with reduced ejection fraction (left ventricular ejection fraction 30%) is stable on carvedilol, lisinopril, and spironolactone; blood pressure is 118/70 mmHg and estimated glomerular filtration rate is 48 mL/min/1.73 m2^2. A randomized, double-blind trial evaluated adding dapagliflozin 10 mg daily vs placebo in patients with heart failure with reduced ejection fraction (with or without diabetes) for a median 18 months; the primary composite (cardiovascular death or worsening heart failure) occurred in 16.3% vs 21.2% (hazard ratio 0.74, 95% CI 0.65–0.85; p<0.001). What is the clinical significance of the study's findings for this patient?
  5. In a comparative effectiveness trial, 420 adults (mean age 62 years; 52% female) with type 2 diabetes and established cardiovascular disease were randomized to Drug A vs Drug B for 24 weeks. The primary outcome (hemoglobin A1c reduction) was −1.1% with Drug A vs −0.9% with Drug B (mean difference −0.2%, 95% CI −0.35 to −0.05; p = 0.01). A cost analysis estimated total 24-week medication costs of $2,400 (Drug A) vs $1,800 (Drug B). What does the p-value indicate about the study results?
  6. A hospital pharmacist prepares an IV admixture containing carmustine. After the preparation is complete, the pharmacist has a used syringe with an attached needle and the empty vial. According to USP <800> standards, what is the proper method of disposal for the used syringe and needle?
  7. A meta-analysis of 12 trials (n = 18,500; mean age 63 years; 47% female) evaluated a high-intensity statin vs moderate-intensity statin for major cardiovascular events. The pooled hazard ratio was 0.92 (95% CI 0.84 to 1.01; p = 0.07). Annual medication costs were $120 (moderate) vs $240 (high). What is the primary conclusion from the meta-analysis?
  8. In a hospital pharmacy, a pharmacist delegates to a technician the task of preparing a medication history worksheet for admitted patients. The pharmacist later learns the technician used outdated forms and did not include a section for OTC products, leading to incomplete histories. The technician reports they did not know a newer form existed. Which strategy best improves delegation effectiveness in this scenario?
  9. A 73-year-old man (weight 80 kg, height 175 cm) is treated with dabigatran for atrial fibrillation. Current medications: dabigatran 150 mg PO twice daily, verapamil ER 240 mg PO daily. Medical history: atrial fibrillation, chronic kidney disease. Allergies: none. Labs: SCr 2.0 mg/dL. Which factor is most likely to affect the drug's clearance in this patient?
  10. A 3-year-old male (14 kg) requires an oral suspension of propranolol 4 mg/mL, total volume 75 mL. You have propranolol HCl powder available and will QS with a vehicle. Using a balance and graduated cylinder, how many milligrams of propranolol HCl are needed?
  11. A 74-year-old male (weight 76 kg) presents for a comprehensive medication review after a hospital discharge. Medical history: heart failure with reduced ejection fraction, hypertension, hyperlipidemia, benign prostatic hyperplasia (BPH). Allergies: none. Current medications: sacubitril/valsartan 49 mg/51 mg by mouth twice daily (new), lisinopril 20 mg by mouth daily (home med), furosemide 40 mg by mouth daily, metoprolol succinate 100 mg by mouth daily, atorvastatin 40 mg by mouth nightly, and tamsulosin 0.4 mg by mouth nightly. Pertinent labs: SCr 1.2 mg/dL (0.6–1.3), potassium 4.8 mEq/L (3.5–5.0), AST 26 U/L (10–40), ALT 22 U/L (7–56). Which medication should be discontinued based on current indications?
  12. A 64-year-old female (weight 62 kg) comes to urgent care for easy bruising and bleeding gums for 2 days. Current medications: warfarin 5 mg by mouth daily (stable for months), trimethoprim-sulfamethoxazole double strength 1 tablet by mouth twice daily started 4 days ago for urinary tract infection, and levothyroxine 75 mcg by mouth daily. Labs: international normalized ratio (INR) 6.8 (goal 2–3), serum creatinine 0.9 mg/dL; liver function tests within normal limits; allergies: penicillin (rash); medical history: atrial fibrillation, hypothyroidism. What is the best management strategy for this adverse reaction?
  13. A 70-year-old male (weight 80 kg) is discharged with nitrofurantoin oral suspension compounded by the hospital pharmacy (nonsterile, water-containing oral preparation) and labeled to refrigerate at 2–8°C (36–46°F). He asks how long it is good for. What action should the pharmacist take regarding this storage issue?
  14. A 62-year-old man (86 kg) with COPD is on chronic theophylline ER 300 mg PO BID and presents with new atrial fibrillation; cardiology starts ciprofloxacin 500 mg PO BID for suspected infectious exacerbation. Current medications: theophylline ER 300 mg BID, tiotropium daily, albuterol PRN, ciprofloxacin 500 mg BID. Labs: SCr 1.0 mg/dL, AST/ALT normal; allergies: none. Which secondary resource would best verify whether ciprofloxacin increases theophylline concentrations and recommend monitoring or dose changes?
  15. A 63-year-old male (88 kg) with type 2 diabetes is started on empagliflozin 10 mg by mouth daily 2 weeks ago. He now reports painful urination, increased urinary frequency, and genital itching. Current medications: metformin 1000 mg by mouth twice daily, empagliflozin 10 mg by mouth daily, lisinopril 10 mg by mouth daily, atorvastatin 20 mg by mouth nightly. Allergies: none known. Medical history: type 2 diabetes, hypertension, hyperlipidemia. Labs today: serum creatinine 1.0 mg/dL (normal), glucose 168 mg/dL (high). Which action should the pharmacist take to address this adverse event?
  16. A 2-month-old male infant (weight 5 kg) is prescribed acetaminophen 15 mg/kg per dose by mouth every 6 hours as needed for fever. Medical history: none significant; current medications: none. Allergies: none known. Labs: not applicable. Acetaminophen liquid concentration is 160 mg/5 mL. What volume (mL) should be administered per dose?
  17. A 34-year-old man (weight 120 kg, height 175 cm; body mass index 39.2 kg/m2^2) asks for a non-drug plan to reduce his risk of developing diabetes. Medical history: prediabetes; allergies: none. Current medications: none. Labs/vitals: hemoglobin A1c 6.2%, fasting glucose 118 mg/dL, blood pressure 130/84 mmHg. Lifestyle: drinks sugar-sweetened beverages daily, eats late at night, no exercise, sleeps 6 hours/night. What non-drug intervention should be prioritized for this patient?
  18. A 34-year-old male (82 kg) with generalized anxiety disorder is started on propranolol 20 mg PO TID for performance anxiety. He has a history of asthma controlled with albuterol HFA 2 puffs q4–6h PRN; allergies: none. Vitals today: HR 58 bpm, BP 112/70 mmHg; labs: SCr 0.9 mg/dL (0.6–1.3). Which mechanism of action explains the most clinically important risk in this patient?
  19. A 58-year-old male (weight 92 kg) requests a comprehensive medication review due to dizziness and falls. Medical history: type 2 diabetes, hypertension, benign prostatic hyperplasia, chronic low back pain, and insomnia. Current medications: metformin 1000 mg twice daily, glipizide 10 mg twice daily, lisinopril 40 mg daily, amlodipine 10 mg daily, tamsulosin 0.4 mg nightly, cyclobenzaprine 10 mg three times daily as needed, and zolpidem 10 mg nightly. Labs: serum creatinine 1.0 mg/dL, alanine aminotransferase 35 U/L, aspartate aminotransferase 30 U/L, hemoglobin A1c 6.4%. Allergies: "codeine—nausea." Which medication on the list is most likely causing the patient's symptoms?
  20. A pharmacist-led MUE evaluates nephrotoxicity risk in a 55-year-old male (weight 95 kg) receiving IV antibiotics for MRSA bacteremia. Current therapy: vancomycin 1.5 g IV every 12 hours (day 4), piperacillin-tazobactam 4.5 g IV every 6 hours (day 4), and home ibuprofen 600 mg three times daily as needed (received twice daily inpatient); baseline SCr was 0.9 mg/dL (0.6–1.2) and is now 1.6 mg/dL. Vancomycin AUC is estimated high, and urine output is decreasing. The goal is to minimize kidney injury while maintaining effective MRSA treatment. What is the best approach to optimize this patient's therapy?

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