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Practice Test 6 - NAPLEX

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

  1. A 52-year-old male (weight 90 kg) with chronic hepatitis C and cirrhosis is being treated for anxiety with lorazepam, but due to excessive sedation the team plans to use a reduced dose. Medical history: cirrhosis (Child-Pugh class C), anxiety. Current medications: spironolactone 100 mg daily, furosemide 40 mg daily, lactulose 20 g three times daily. Labs: AST 110 U/L (normal 10–40), ALT 95 U/L (normal 7–56), total bilirubin 3.2 mg/dL (normal 0.2–1.2), albumin 2.6 g/dL (normal 3.5–5.0). If the usual lorazepam dose is 1 mg by mouth every 8 hours and the plan is to reduce the total daily dose by 50% due to hepatic impairment, determine the appropriate total daily dose for this patient.
  2. A 74-year-old woman (60 kg) is admitted for medication reconciliation after a fall. PMH: atrial fibrillation, CKD stage 3, osteoarthritis, depression. Home meds: warfarin 5 mg PO daily, amiodarone 200 mg PO daily, sertraline 50 mg PO daily, ibuprofen 600 mg PO three times daily, acetaminophen 1,000 mg PO three times daily PRN. Labs: INR 4.6 (goal 2–3), SCr 1.6 mg/dL (eGFR 32 mL/min/1.73 m2^2), AST/ALT WNL. Allergies: none. Which drug-related problem needs immediate attention?
  3. A 66-year-old female hospitalized with COVID-19 pneumonia is started on remdesivir under EUA. Past medical history includes type 2 diabetes and nonalcoholic fatty liver disease. Current medications: insulin glargine, insulin lispro, lisinopril 10 mg daily. Baseline labs: alanine aminotransferase (ALT) 92 U/L (normal 7–56), aspartate aminotransferase (AST) 78 U/L (normal 10–40), serum creatinine 0.9 mg/dL. What is the most important safety monitoring parameter for this EUA medication?
  4. A 57-year-old female (62 kg, 160 cm) with hyperlipidemia is started on high-intensity atorvastatin 80 mg PO nightly after an ischemic stroke. Current medications: atorvastatin 80 mg nightly, clopidogrel 75 mg daily, amlodipine 5 mg daily. Allergies: none. Baseline labs: AST 38 U/L (10–40), ALT 41 U/L (7–56), CK 110 U/L (30–200), SCr 0.9 mg/dL (0.6–1.3). Vitals: BP 132/78 mmHg, HR 70 bpm. Which lab value should be monitored for this medication?
  5. A 60-year-old female (74 kg, 162 cm) presents with acute bacterial sinusitis and is prescribed an antibiotic. Current medications: dofetilide 500 mcg orally twice daily, hydrochlorothiazide 25 mg daily. Medical history: atrial fibrillation (on dofetilide). Allergies: penicillin (rash). Labs: SCr 0.9 mg/dL, potassium 3.6 mEq/L. Which medication is contraindicated for this patient?
  6. In a community pharmacy, the pharmacist delegates to a technician the task of preparing will-call bags and organizing them by pickup time while the pharmacist handles immunizations. The technician is also answering phones and processing returns, and the will-call area becomes disorganized, increasing wait times. The pharmacist wants to improve workflow without increasing staffing. Which strategy best improves delegation effectiveness in this scenario?
  7. A 63-year-old man (weight 75 kg) is being treated for acute decompensated heart failure and is receiving multiple IV medications through a single peripheral IV line. Past medical history includes heart failure with reduced ejection fraction and atrial fibrillation; allergies: none. Current medications/orders: furosemide 40 mg IV twice daily, amiodarone infusion, and a heparin infusion for anticoagulation. Labs: serum creatinine 1.1 mg/dL, potassium 3.8 mEq/L, magnesium 1.9 mg/dL, INR 1.1, AST/ALT within normal limits. The nurse asks to Y-site piggyback furosemide into the amiodarone line to save IV access. Which action should the pharmacist take to ensure safety?
  8. A 58-year-old man (92 kg) presents to the pharmacy for counseling on insulin storage. Chief complaint: fasting blood glucose has increased over the past week. Medical history includes type 2 diabetes and hypertension. Current medications: insulin glargine 30 units subcutaneously nightly (started 3 months ago; current pen in use for 10 days), metformin 1000 mg orally twice daily (5 years), lisinopril 20 mg orally daily (4 years). Labs: serum creatinine 1.0 mg/dL (normal 0.6–1.3), fasting glucose 186 mg/dL (normal 70–99). He reports keeping his in-use insulin glargine pen in the refrigerator door and sometimes leaving it on the kitchen counter near a sunny window. Which of the following storage instructions is correct for insulin glargine pens in use?
  9. A 36-year-old male (90 kg) presents after being found in a garage with a running car; he has headache, dizziness, and nausea. Current medications: none. Labs: carboxyhemoglobin 24% (normal <2% nonsmoker), serum creatinine 0.9 mg/dL, aspartate aminotransferase 22 units/L, alanine aminotransferase 20 units/L. Allergies: none. History: no chronic illness; exposure occurred about 1 hour ago. What is the most important initial action for this exposure?
  10. A 27-year-old male (weight 80 kg) started lisdexamfetamine (Schedule II) 50 mg orally each morning for attention-deficit/hyperactivity disorder 2 months ago. He reports palpitations and decreased appetite; he also takes pseudoephedrine 60 mg twice daily for congestion and drinks 3–4 energy drinks/day. Allergies: none. Medical history: ADHD, seasonal allergies; no substance use disorder history. Vitals today: blood pressure 152/94 mmHg, heart rate 112 bpm. Labs: serum creatinine 0.9 mg/dL (0.6–1.3). What is the best recommendation for this patient's therapy?
  11. A 64-year-old female (weight 60 kg, height 158 cm) with chronic obstructive pulmonary disease is started on theophylline for persistent symptoms. Current medications: theophylline extended-release 300 mg by mouth every 12 hours, albuterol inhaler as needed. She reports quitting smoking 10 days ago (previously 1 pack/day). Labs: serum creatinine 0.8 mg/dL, aspartate aminotransferase 24 U/L, alanine aminotransferase 21 U/L; theophylline level 18 mcg/mL (goal 10–20 mcg/mL) with nausea and insomnia. Allergies: none. Therapeutic goal: symptom control with theophylline in goal range and minimal adverse effects. Which pharmacokinetic parameter is most affected in this patient?
  12. A 59-year-old male (90 kg) with type 2 diabetes is prescribed dulaglutide 1.5 mg subcutaneously weekly, but the plan prefers semaglutide (weekly) and does not cover dulaglutide. Current medications: metformin 1000 mg twice daily, insulin glargine 20 units nightly; allergies: none. Labs/vitals: A1C 9.1%, eGFR 85 mL/min/1.73 m2^2, blood pressure 136/82 mmHg; history: no pancreatitis. What formulary substitution should be made for this medication?
  13. A 63-year-old male (90 kg, 175 cm) with type 2 diabetes and CKD stage 3 is started on trimethoprim-sulfamethoxazole DS 1 tablet PO twice daily for cellulitis. Current medications: metformin 500 mg PO twice daily, lisinopril 40 mg PO daily, atorvastatin 40 mg PO nightly. Allergies: none. Baseline labs: SCr 2.0 mg/dL (0.6–1.3), eGFR 35 mL/min/1.73 m², K 4.8 mEq/L (3.5–5.0), AST 26 U/L (10–40), ALT 24 U/L (7–56). Vitals: BP 136/80 mmHg, HR 76 bpm. Which lab value should be monitored for this medication?
  14. A 24-year-old male (72 kg) with acne vulgaris is prescribed tretinoin 0.05% cream nightly, but the formulary only covers adapalene 0.1% gel. Current medications: benzoyl peroxide wash daily; allergies: none. Vitals: unremarkable; no pregnancy considerations. What formulary substitution should be made for this medication?
  15. A 72-year-old man (weight 65 kg) with Parkinson disease and aspiration risk has a percutaneous endoscopic gastrostomy (PEG) tube for medications and nutrition. Treatment goal is continued symptom control; current medications include carbidopa/levodopa immediate-release 25/100 mg by mouth three times daily, sertraline 50 mg by mouth daily, and omeprazole 20 mg by mouth daily. Allergies: none. Which administration route/dosage form is most appropriate to deliver carbidopa/levodopa through the PEG tube?
  16. A hospital performs medication reconciliation for a 71-year-old male (weight 88 kg) transferred from a skilled nursing facility for altered mental status and falls. Facility MAR lists: diphenhydramine 50 mg nightly for sleep (scheduled), oxybutynin ER 10 mg daily, sertraline 100 mg daily, and metoprolol succinate 50 mg daily; adherence is documented as consistent. Labs: sodium 138 mEq/L (135–145), serum creatinine 1.0 mg/dL (0.6–1.2), glucose 102 mg/dL (70–99). The goal is to reduce fall risk and anticholinergic burden during transition of care. Which medication change is most appropriate to improve therapeutic outcomes?
  17. In a retail pharmacy, an experienced technician is asked by the pharmacist to train a newly hired technician on the workflow for processing prior authorizations. The experienced technician is also scheduled to manage the drive-thru during peak hours, and training is rushed with no checklist. After a week, the new technician submits incomplete prior authorization requests, causing delays. Which strategy best improves delegation effectiveness in this scenario?
  18. A 34-year-old man (76 kg) presents with a written prescription for alprazolam 1 mg tablets: take 1 tablet by mouth three times daily as needed for anxiety; quantity #180; refills: 3. Current medications: sertraline 100 mg daily. Allergies: none. Medical history: generalized anxiety disorder. Labs: not available. Which regulatory requirement applies to this prescription?
  19. A 26-year-old female requests a compounded lidocaine oral rinse at 2% w/v for short-term mucosal pain relief. Prepare a total of 250 mL using purified water and a suitable flavoring agent; the prescriber requests alcohol-free formulation. Using a balance and graduated cylinder, how many grams of lidocaine HCl are required to prepare 250 mL of a 2% w/v solution?
  20. In a hospital pharmacy, a 64-year-old female (73 kg) is ordered a continuous infusion of norepinephrine for septic shock; the unit stocks both norepinephrine 4 mg/250 mL and 8 mg/250 mL premixed bags. Current meds: piperacillin-tazobactam, vancomycin, acetaminophen PRN. Labs: SCr 1.9 mg/dL, AST/ALT 60/55 U/L (elevated), INR 1.2, A1c 6.0%; allergies: none. The risk is selecting the wrong premix concentration leading to hypotension or severe hypertension/ischemia. What is the best practice for handling this high-alert medication?

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