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Practice Test 9 - NAPLEX

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

  1. A 40-year-old male (weight 88 kg) with epilepsy requests an early refill and reports excessive sleepiness. Medical history includes seizure disorder; allergies: none. Current medications: carbamazepine immediate-release 200 mg by mouth three times daily, carbamazepine extended-release 200 mg by mouth twice daily. Labs: sodium 130 mEq/L (low), serum creatinine 0.9 mg/dL, alanine aminotransferase 22 U/L. What adjustment should be made to avoid duplication?
  2. A 34-year-old female (weight 58 kg) with moderate persistent asthma reports poor adherence because she forgets multiple daily doses. Current medications: albuterol HFA 90 mcg/actuation, 2 puffs every 4–6 hours as needed; budesonide nebulizer suspension 0.5 mg/2 mL twice daily (often missed); and montelukast 10 mg tablet nightly. Labs: SCr 0.7 mg/dL (0.6–1.3), AST 18 U/L (10–40), ALT 16 U/L (7–56), Na 140 mEq/L (135–145), K 4.1 mEq/L (3.5–5.0). She prefers a device that is portable and reduces administration time while maintaining effective inhaled corticosteroid delivery. What is the optimal drug delivery system for this patient?
  3. A 72-year-old man (weight 80 kg) with heart failure is evaluating Drug C vs Drug D for reducing hospitalizations. In a head-to-head trial, hospitalization occurred in 22% with Drug C vs 28% with Drug D over 1 year; RR =0.79=0.79 (95% CI 0.600.60 to 1.041.04), p=0.09p=0.09. What is the clinical significance of the study's p-value in determining therapy?
  4. A 74-year-old female (weight 60 kg, height 160 cm) is discharged with a new prescription for levofloxacin 750 mg by mouth once daily for 7 days for pyelonephritis. Current medications: lisinopril 10 mg by mouth daily and calcium carbonate 500 mg by mouth twice daily; allergies: none known. Labs at discharge: serum creatinine 2.2 mg/dL (0.6–1.3) with estimated creatinine clearance 22 mL/min, aspartate aminotransferase 20 units/L (10–40). The discharge summary includes no renal dose adjustment instructions. What is the most critical error in this scenario?
  5. A 64-year-old man (86 kg) with type 2 diabetes and chronic kidney disease stage 3a reports he has been rationing empagliflozin 10 mg daily (taking it every other day) because he cannot afford the 220monthlycostafterlosinghisjob.Currentmedications:empagliflozin10mgdaily(nonadherentduetocost),metformin500mgtwicedaily(adherent),glipizide10mgdaily(adherent),losartan100mgdaily(adherent).Labs:hemoglobinA1c8.9220 monthly cost after losing his job. Current medications: empagliflozin 10 mg daily (nonadherent due to cost), metformin 500 mg twice daily (adherent), glipizide 10 mg daily (adherent), losartan 100 mg daily (adherent). Labs: hemoglobin A1c 8.9%, serum creatinine 1.5 mg/dL (estimated glomerular filtration rate ~52 mL/min/1.73 m^2$), potassium 4.4 mEq/L, alanine aminotransferase 21 U/L; no known drug allergies; he has limited transportation but can receive mail. What is the most appropriate intervention for this adherence barrier?
  6. A 52-year-old man (88 kg) presents with severe right first metatarsophalangeal joint pain, redness, and swelling that started overnight. Medical history: hypertension, chronic kidney disease stage 3. Current medications: hydrochlorothiazide 25 mg daily, losartan 50 mg daily. Allergies: none. Labs: uric acid 9.8 mg/dL (normal 3.5–7.2), SCr 1.9 mg/dL, eGFR 40 mL/min/1.73 m2m^2, potassium 4.3 mEq/L. Which condition is most consistent with this patient's symptoms?
  7. A dentist writes for lisdexamfetamine for ADHD. The pharmacist should:
  8. A 69-year-old man (86 kg, 174 cm) with type 2 diabetes is started on insulin glargine due to persistent hyperglycemia despite oral therapy. Current medications: metformin 1000 mg PO BID, empagliflozin 10 mg PO daily. Allergies: none. Labs: A1c 10.2%, fasting SMBG averages 220 mg/dL, eGFR 70 mL/min/1.73 m². What is the most appropriate initial dose for insulin glargine in this patient?
  9. A pharmacist reviews a high-alert medication MUE for insulin safety in a 72-year-old female (weight 64 kg) with type 2 diabetes and stage 3 chronic kidney disease. Home meds: insulin glargine 30 units nightly (often takes 30–40 units based on bedtime glucose), insulin lispro 10 units with meals (skips when not eating), and glyburide 5 mg daily; labs: A1c 7.1% (goal individualized 7–8%), SCr 1.6 mg/dL (0.6–1.2), eGFR 32 mL/min/1.73 m2^2 (>60). She reports 3 episodes of morning glucose <60 mg/dL (70–99) in the past 2 weeks. Which medication change is most appropriate to improve therapeutic outcomes?
  10. A 38-year-old female (weight 58 kg) presents with severe diarrhea and muscle cramps. Medical history: irritable bowel syndrome; no renal or hepatic dysfunction. Current medications: dicyclomine 20 mg PO four times daily as needed. Labs: serum sodium 134 mEq/L (135–145), glucose 80 mg/dL (70–100), BUN 10 mg/dL (7–20). What is the calculated osmolarity of this patient's serum using Osm=2×Na+glucose18+BUN2.8\text{Osm} = 2\times\text{Na} + \frac{\text{glucose}}{18} + \frac{\text{BUN}}{2.8}?
  11. Dose is 100 mg/m2/day divided q8h. BSA 1.5 m2. Vial 25 mg/mL. mL/dose?
  12. A 27-year-old woman (59 kg) presents to the pharmacy requesting emergency contraception after missing 2 birth control pills. Current medications: ethinyl estradiol/norgestimate 1 tablet PO daily, carbamazepine 400 mg PO twice daily (stable), and folic acid 1 mg PO daily; she admits she sometimes misses pills and has unprotected intercourse. Labs: none; allergies: none; PMH: epilepsy. Which factor is contributing to the therapeutic failure of her contraception?
  13. A 40-year-old woman (62 kg) with asthma reports worsening control and increased nighttime symptoms over the last month. Current medications: budesonide/formoterol 160/4.5 two inhalations twice daily, albuterol HFA PRN, and a new propranolol 40 mg PO twice daily started 4 weeks ago for performance anxiety; she is adherent to inhalers. Vitals: HR 58 bpm, wheezing on exam; labs: none; allergies: none; PMH: asthma. Which medication change is most likely responsible for the patient's new symptoms?
  14. A 71-year-old male (weight 76 kg) is taking digoxin 0.25 mg by mouth daily for atrial fibrillation rate control and reports nausea, loss of appetite, and yellow-tinged vision. Current medications: digoxin 0.25 mg daily, furosemide 40 mg daily, metoprolol succinate 50 mg daily, potassium chloride 20 mEq daily. Labs: serum creatinine 1.8 mg/dL, potassium 3.1 mEq/L (low). Allergies: none. Medical history: atrial fibrillation, heart failure with reduced ejection fraction, chronic kidney disease. Which monitoring parameter should be prioritized?
  15. A cost-effectiveness analysis compared two smoking cessation strategies in adults (mean age 46 years; 51% female) with COPD: Strategy 1 (varenicline + counseling) vs Strategy 2 (nicotine patch + counseling). Over 1 year, Strategy 1 cost $820 and produced 0.78 QALYs; Strategy 2 cost $620 and produced 0.77 QALYs. Which treatment is most cost-effective at a willingness-to-pay threshold of $50,000 per QALY?
  16. A 35-year-old man (weight 90 kg) with chronic plaque psoriasis is considering starting adalimumab. A randomized, double-blind trial compared adalimumab vs placebo for 16 weeks; 75% improvement in Psoriasis Area and Severity Index occurred in 71% vs 7% (p<0.001), but the trial excluded patients with active infection and those with untreated latent tuberculosis. What is the key takeaway from the study for this patient's case?
  17. A 33-year-old woman (72 kg) with type 1 diabetes is using a rapid-acting insulin pen and reports occasional "wet" injections and higher post-meal glucose. Current medications: insulin aspart via pen per carbohydrate counting, insulin degludec 18 units daily. Pertinent values: postprandial glucose often 220–260 mg/dL. Allergies: none. What is the most important counseling point for this device?
  18. A 72-year-old female (60 kg, 160 cm) with heart failure is seen in clinic for dizziness and muscle cramps 1 week after increasing furosemide from 20 mg to 40 mg PO daily. Current medications: furosemide 40 mg daily, lisinopril 20 mg daily, metoprolol succinate 50 mg daily, potassium chloride 10 mEq daily. Allergies: sulfonamides (hives). Labs: Na 132 mEq/L (135–145), K 3.1 mEq/L (3.5–5.0), Mg 1.6 mg/dL (1.7–2.2), SCr 1.1 mg/dL (0.6–1.3). Vitals: BP 98/62 mmHg, HR 64 bpm. Which lab result suggests a need for intervention?
  19. A pharmacy-based IRB-approved study evaluates adherence to a new hepatitis C antiviral. Study tablets are stored in a back room, and a staff member takes photos of participant pill bottles with visible names and uploads them to a shared team chat that includes non-study employees. What is the primary ethical concern in this study?
  20. A 73-year-old woman (weight 63 kg) with overactive bladder reports dry mouth and constipation on oxybutynin immediate-release tablets and frequently forgets her midday dose. Medical history: overactive bladder, constipation; allergies: none. Current medications (forms/routes): oxybutynin 5 mg tablet by mouth three times daily, polyethylene glycol powder by mouth daily as needed. Labs: serum creatinine 1.0 mg/dL, AST/ALT within normal limits. What adjustment is needed for this patient's medication regimen to reduce anticholinergic adverse effects and improve adherence?

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