Pharmacology Quiz: Medication Reconciliation

20 questions · exam conditions

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Medication ReconciliationQuestion 1 of 20

A 62-year-old male with well-controlled hypertension on lisinopril 40 mg daily presents to his primary care physician with a blood pressure of 165/95 mmHg. He reports no changes in diet, exercise, or adherence to his lisinopril. During medication reconciliation, he mentions that for the past month he has been taking an over-the-counter medication daily for his knee arthritis pain.

The patient's elevated blood pressure is most likely due to an interaction in which the over-the-counter medication is causing:

A competitive antagonism with lisinopril at the angiotensin II receptor site.

Induction of the metabolism of lisinopril, leading to lower serum concentrations.

A direct agonistic effect on alpha-adrenergic receptors, leading to vasoconstriction.

Increased sodium and water retention by inhibiting prostaglandin synthesis in the kidneys.

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Pharmacology Quiz

Pharmacology Quiz: Medication Reconciliation

Practice Medication Reconciliation in Pharmacology with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Medication Reconciliation, giving you a quick way to practice the rules, question types, and explanations that matter most for Pharmacology.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

All questions

Question 1

The patient's elevated blood pressure is most likely due to an interaction in which the over-the-counter medication is causing:

A competitive antagonism with lisinopril at the angiotensin II receptor site.
Induction of the metabolism of lisinopril, leading to lower serum concentrations.
A direct agonistic effect on alpha-adrenergic receptors, leading to vasoconstriction.
Increased sodium and water retention by inhibiting prostaglandin synthesis in the kidneys. (correct answer)

Explanation: When you encounter a previously well-controlled hypertensive patient with sudden blood pressure elevation after starting an over-the-counter medication for arthritis, think NSAIDs (nonsteroidal anti-inflammatory drugs) and their renal effects. NSAIDs like ibuprofen, naproxen, and aspirin work by inhibiting cyclooxygenase (COX) enzymes, which blocks prostaglandin synthesis. In the kidneys, prostaglandins normally promote vasodilation of renal blood vessels and enhance sodium excretion. When NSAIDs block prostaglandin production, you get vasoconstriction of renal vessels and increased sodium and water retention, leading to elevated blood pressure. This mechanism makes option D correct. Let's examine why the other options don't fit: Option A describes competitive antagonism at angiotensin II receptors - but NSAIDs don't interact with the renin-angiotensin system at the receptor level, and lisinopril is an ACE inhibitor, not an ARB. Option B suggests drug metabolism induction, but NSAIDs don't significantly induce the cytochrome P450 enzymes that metabolize lisinopril. Option C proposes direct alpha-adrenergic agonism, but NSAIDs don't have direct sympathomimetic effects on adrenergic receptors. For pharmacology exams, remember this key pattern: when you see hypertension worsening after starting NSAIDs, the mechanism is always renal - prostaglandin inhibition leads to sodium retention and vasoconstriction. This interaction is especially important in patients on ACE inhibitors or ARBs, as both drug classes depend partly on prostaglandin-mediated effects for optimal blood pressure control.

Question 2

A 75-year-old male on chronic warfarin therapy (target INR 2.0-3.0) is scheduled for an elective hip replacement. The pre-operative plan instructs him to stop warfarin 5 days before surgery and begin enoxaparin 1 mg/kg subcutaneously twice daily 3 days before surgery. The plan states he should take his last dose of enoxaparin on the morning of surgery.

Which component of this bridging plan requires intervention during the medication reconciliation process?

Warfarin should have been stopped 7 days before surgery, not 5.
The enoxaparin dose is too high and should be reduced for prophylactic bridging.
The last dose of therapeutic enoxaparin should be administered approximately 24 hours before the surgical incision. (correct answer)
Bridging therapy is not necessary for patients with a target INR of 2.0-3.0.

Explanation: For patients on therapeutic doses of LMWH (like 1 mg/kg BID), the last dose should be given at least 24 hours prior to surgery to minimize the risk of major perioperative bleeding, especially with neuraxial anesthesia. Administering a full therapeutic dose on the morning of surgery is a significant safety error. The timing of the last dose is the most critical flaw in this plan.

Question 3

An 82-year-old female resident of a skilled nursing facility is managed for major depressive disorder and insomnia with sertraline 100 mg daily and trazodone 50 mg at bedtime. After experiencing increased back pain, a new order for tramadol 50 mg every 6 hours as needed is added to her regimen. Two days later, the nursing staff reports she is agitated, confused, diaphoretic, and has developed a tremor in her lower extremities.

The patient's new symptoms are most likely the result of which drug interaction?

An additive anticholinergic effect from the combination of trazodone and tramadol.
A pharmacokinetic interaction where sertraline inhibits the metabolism of tramadol, leading to opioid toxicity.
A pharmacodynamic interaction resulting from the combined serotonergic activity of sertraline, trazodone, and tramadol. (correct answer)
An isolated adverse drug reaction to tramadol, commonly seen in elderly patients, independent of her other medications.

Explanation: The patient's clinical presentation with agitation, confusion, diaphoresis, and myoclonus (tremor) is classic for serotonin syndrome. This is a pharmacodynamic interaction caused by excessive serotonin levels. Sertraline (an SSRI), trazodone (a serotonin antagonist and reuptake inhibitor), and tramadol (a weak serotonin reuptake inhibitor) all increase serotonergic activity. Their combination puts the patient at high risk for this syndrome.

Question 4

A 68-year-old male with hypertension and osteoarthritis presents to the emergency department with abdominal pain. His reported home medications are lisinopril 20 mg daily and 'ibuprofen 800 mg three times daily as needed' from an old prescription. The admission orders include lisinopril 20 mg daily and ketorolac 15 mg IV every 6 hours for pain.

During medication reconciliation, which potential issue warrants the most immediate clarification with the prescribing physician?

The therapeutic duplication of two NSAIDs (ibuprofen and ketorolac), increasing the risk of gastrointestinal bleeding and nephrotoxicity. (correct answer)
The potential for hyperkalemia due to the concurrent administration of lisinopril and ketorolac.
The patient's home use of ibuprofen at a dose that exceeds the recommended daily maximum for over-the-counter use.
The need to switch from intravenous ketorolac to an oral pain medication to facilitate discharge planning.

Explanation: The most significant and immediate issue is the therapeutic duplication of two potent NSAIDs. Both ibuprofen and ketorolac inhibit cyclooxygenase, and their concurrent use significantly increases the risk for acute kidney injury and gastrointestinal bleeding, especially in an older adult. This risk outweighs the other potential issues.

Question 5

A patient is admitted to the hospital with acute kidney injury (AKI), with a CrCl estimated at 25 mL/min. During medication reconciliation, the pharmacist notes that the patient takes metformin 1000 mg twice daily at home, where his baseline CrCl was 70 mL/min. The admitting physician's orders continue the metformin at the same dose.

How should the pharmacist best classify and address this medication reconciliation discrepancy?

This is an unintentional discrepancy; the prescriber should be contacted to hold or dose-adjust the metformin due to the risk of lactic acidosis. (correct answer)
This is an intentional discrepancy; the prescriber likely wants to maintain glycemic control and plans to monitor lactate levels closely.
This is not a discrepancy but a continuation of therapy; no action is needed until labs show a rising lactate level.
This is a documentation error; the pharmacist should correct the order to 500 mg daily and then notify the prescriber of the change.

Explanation: This is a critical, unintentional discrepancy. Metformin is contraindicated in patients with significantly reduced renal function (e.g., eGFR < 30 mL/min) due to the increased risk of accumulation and life-threatening lactic acidosis. Continuing the home dose in the setting of AKI is a serious error. The appropriate action is to recognize it as unintentional and immediately contact the prescriber to recommend holding or appropriately adjusting the dose.

Question 6

A 65-year-old male on a stable dose of warfarin for chronic atrial fibrillation presents for a routine INR check. His INR for the past 6 months has been consistently between 2.2 and 2.8. Today, his INR is 1.4. Upon questioning during medication reconciliation, he reports no changes to his prescription medications, diet, or alcohol intake, but mentions he started taking an over-the-counter herbal supplement for 'low mood' about a month ago.

Which herbal supplement is the most likely cause of the patient's subtherapeutic INR?

Ginkgo biloba
St. John's Wort (correct answer)
Saw palmetto
Garlic

Explanation: St. John's Wort is a potent inducer of the cytochrome P450 enzyme CYP2C9, which is the primary enzyme responsible for metabolizing the more potent S-enantiomer of warfarin. Induction of this enzyme increases warfarin metabolism, leading to lower serum levels and a decreased anticoagulant effect, resulting in a subtherapeutic INR. Ginkgo and garlic can increase bleeding risk (potentiate warfarin), while saw palmetto has no significant documented interaction.

Question 7

A 72-year-old female is being discharged after a 5-day hospitalization for a pulmonary embolism. Her inpatient anticoagulation regimen consisted of enoxaparin 1 mg/kg subcutaneously every 12 hours and warfarin 5 mg daily. On the day of discharge, her INR is 1.6. The final discharge prescription list includes warfarin 5 mg daily and all of her previous home medications.

Upon reviewing the discharge medication list as part of the medication reconciliation process, which of the following represents the most critical, time-sensitive intervention for the pharmacist to make?

Contact the prescriber to recommend adding a prescription for bridging anticoagulation with a low-molecular-weight heparin. (correct answer)
Advise the prescriber that the warfarin dose is likely subtherapeutic and a higher dose should be prescribed.
Ensure that a follow-up appointment for an INR check within 3-5 days is scheduled before the patient leaves.
Screen for interactions between warfarin and the patient's home medications, particularly any herbal supplements.

Explanation: The most critical issue is the lack of bridging anticoagulation. Warfarin has a slow onset of action, and a therapeutic INR (typically 2.0-3.0) will not be reached for several days. An INR of 1.6 is subtherapeutic. Discharging the patient on warfarin alone without a bridging agent like enoxaparin creates a high risk for thrombosis. This is a critical omission that requires immediate correction.

Question 8

A 55-year-old renal transplant recipient, who is immunologically stable on tacrolimus 2 mg twice daily, is admitted with community-acquired pneumonia. The initial plan is to use a respiratory fluoroquinolone, but a review of his records shows a history of significant QTc interval prolongation with moxifloxacin. Consequently, the physician writes an order for clarithromycin 500 mg twice daily.

As the pharmacist reviewing this order, what is the most urgent potential drug interaction that must be addressed?

Clarithromycin is a potent CYP3A4 inhibitor and will significantly increase serum tacrolimus concentrations, leading to a high risk of toxicity. (correct answer)
Clarithromycin also carries a risk of QTc prolongation, which may be unsafe given the patient's prior history with moxifloxacin.
There is a pharmacodynamic interaction where clarithromycin may antagonize the immunosuppressive effects of tacrolimus, risking graft rejection.
Tacrolimus can increase the risk of C. difficile-associated diarrhea when administered concurrently with broad-spectrum antibiotics like clarithromycin.

Explanation: Tacrolimus is a calcineurin inhibitor with a narrow therapeutic index, and it is primarily metabolized by CYP3A4. Clarithromycin is a potent inhibitor of CYP3A4. Co-administration will lead to a rapid and significant increase in tacrolimus levels, placing the patient at high risk for severe nephrotoxicity and neurotoxicity. This interaction is more immediate and life-threatening than the other concerns.

Question 9

A 67-year-old male with atrial fibrillation, heart failure, and gout is admitted for a COPD exacerbation. His home medications include warfarin, digoxin 0.125 mg daily, and allopurinol. On admission, he is started on prednisone, levofloxacin, and scheduled ipratropium/albuterol nebulizers. The lab results show a digoxin level of 1.1 ng/mL and an INR of 2.4.

When screening for potential drug interactions upon admission, which of the following requires the most urgent management?

Levofloxacin can increase the INR in patients on warfarin.
Prednisone can cause fluid retention, worsening his heart failure.
Levofloxacin can decrease the renal clearance of digoxin.
Albuterol can cause hypokalemia, increasing the risk of digoxin toxicity. (correct answer)

Explanation: While all listed points are valid concerns, the interaction between albuterol and digoxin is the most urgent. High doses of beta-2 agonists like albuterol can cause a significant intracellular shift of potassium, leading to hypokalemia. Hypokalemia markedly sensitizes the myocardium to digoxin, increasing the risk of life-threatening arrhythmias even with a therapeutic digoxin level. This acute risk requires immediate monitoring and possible potassium supplementation.

Question 10

A 58-year-old female with a history of severe persistent asthma requiring high-dose inhaled corticosteroids and a long-acting beta-agonist is newly diagnosed with hypertension. Her asthma is currently well-controlled. Her primary care physician initiates therapy with carvedilol 6.25 mg twice daily.

The initiation of carvedilol in this patient represents what type of medication-related problem?

A drug-drug interaction, as carvedilol may reduce the efficacy of her asthma medications.
A drug-disease interaction, as non-selective beta-blockers are relatively contraindicated in patients with severe asthma. (correct answer)
A therapeutic duplication, because both carvedilol and her beta-agonist act on beta-adrenergic receptors.
An adverse drug reaction, as carvedilol is likely to cause immediate bronchospasm upon first dose.

Explanation: This is a classic drug-disease interaction. Carvedilol is a non-selective beta-blocker (blocks β1 and β2 receptors). Blocking β2 receptors in the lungs can cause bronchoconstriction and antagonize the effects of beta-agonists, potentially leading to a severe asthma exacerbation. While it also represents a pharmacodynamic drug-drug interaction (A), the more fundamental problem is using this class of drug in this specific disease state.

Question 11

Which herbal supplement is the most likely cause of the patient's subtherapeutic INR?

Ginkgo biloba
St. John's Wort (correct answer)
Saw palmetto
Garlic

Question 12

A pharmacist identifies a discrepancy during admission medication reconciliation: the patient's home medication is apixaban 5 mg twice daily, but the admission order is for rivaroxaban 20 mg once daily. Both medications are appropriate for the patient's diagnosis of atrial fibrillation.

What is the most appropriate first step for the pharmacist to take to resolve this discrepancy?

Change the order to apixaban 5 mg twice daily to match the home regimen and ensure continuity of care.
Document the discrepancy in the chart and dispense the rivaroxaban as ordered by the physician.
Ask the patient which medication they would prefer to take while in the hospital.
Contact the prescriber to verify whether the change was intentional, for example, due to hospital formulary. (correct answer)

Explanation: Pharmacists cannot unilaterally change a physician's order. The discrepancy could be an error, or it could be an intentional change (e.g., due to formulary restrictions, a new contraindication, or provider preference). The only way to know is to communicate with the prescriber. This first step clarifies intent, ensures patient safety, and allows for correction if the change was indeed an error.

Question 13

A 70-year-old female is being treated for a urinary tract infection with ciprofloxacin. Her past medical history is significant for depression, for which she takes citalopram 40 mg daily. Three days into her antibiotic course, she is brought to the emergency department with palpitations. An ECG reveals a prolonged QTc interval of 510 ms.

The patient's presentation is most likely due to a pharmacodynamic interaction between citalopram and ciprofloxacin, which results in:

Antagonism of cardiac potassium channels by ciprofloxacin alone.
Inhibition of citalopram metabolism by ciprofloxacin.
An increased risk of serotonin syndrome.
An additive effect on QT interval prolongation. (correct answer)

Explanation: When you encounter a question about drug interactions causing cardiac effects, first determine whether it's a pharmacokinetic interaction (affecting drug levels) or pharmacodynamic interaction (affecting drug effects at the target). The question stem explicitly tells you this is a pharmacodynamic interaction. Both citalopram (an SSRI) and ciprofloxacin (a fluoroquinolone antibiotic) are known to independently prolong the QT interval by blocking cardiac potassium channels, specifically the hERG channel. When used together, their effects are additive - meaning each drug contributes its own QT-prolonging effect, resulting in a combined effect greater than either drug alone. This additive pharmacodynamic interaction explains the patient's prolonged QTc of 510 ms and subsequent palpitations. Looking at the wrong answers: Option A is incorrect because ciprofloxacin doesn't act alone here - both drugs contribute to potassium channel blockade. Option B describes a pharmacokinetic interaction involving drug metabolism, but the question specifically states this is a pharmacodynamic interaction, and ciprofloxacin doesn't significantly inhibit the CYP enzymes that metabolize citalopram. Option C is wrong because serotonin syndrome results from excessive serotonergic activity, not QT prolongation, and ciprofloxacin doesn't affect serotonin pathways. The correct answer is D - the additive effect occurs because both drugs independently block the same cardiac ion channels. Study tip: Remember that QT prolongation is a class effect of both SSRIs and fluoroquinolones. When you see these drug classes combined with cardiac symptoms, think additive pharmacodynamic effects rather than metabolic interactions.

Question 14

The patient's elevated blood pressure is most likely due to an interaction in which the over-the-counter medication is causing:

A competitive antagonism with lisinopril at the angiotensin II receptor site.
Induction of the metabolism of lisinopril, leading to lower serum concentrations.
A direct agonistic effect on alpha-adrenergic receptors, leading to vasoconstriction.
Increased sodium and water retention by inhibiting prostaglandin synthesis in the kidneys. (correct answer)

Question 15

A patient is admitted with a new diagnosis of heart failure. The physician's admission orders include lisinopril 10 mg daily. The medication reconciliation reveals the patient is taking losartan 50 mg daily at home. Which of the following describes the relationship between these two medications and the necessary intervention?

Therapeutic duplication; both are RAAS inhibitors and should not be used concurrently. One must be discontinued. (correct answer)
Pharmacokinetic interaction; losartan will inhibit the conversion of lisinopril to its active form, requiring a dose increase.
Intentional combination therapy; the ARB and ACE inhibitor work synergistically to improve heart failure outcomes.
Drug-class conversion; no intervention is needed as this is a standard switch between equivalent therapies.

Explanation: Lisinopril is an ACE inhibitor and losartan is an angiotensin II receptor blocker (ARB). Both act on the renin-angiotensin-aldosterone system (RAAS). Using them together (therapeutic duplication) is contraindicated as it does not provide additional benefit and significantly increases the risk of adverse effects like hyperkalemia, hypotension, and acute kidney injury. The pharmacist must contact the prescriber to clarify which agent should be continued and ensure the other is discontinued.

Question 16

A pharmacist is performing an admission medication reconciliation for a 78-year-old patient with dementia who was brought to the hospital by his daughter. The patient is unable to recall his medications, and the bottles he brought from home appear to contain a mix of different pills in the same containers. His daughter provides a handwritten list but is unsure of the dosages.

To obtain the Best Possible Medication History (BPMH) in this scenario, which of the following actions should the pharmacist prioritize?

Use a pill identification tool to identify the mixed pills from the patient's bottles.
Call the patient's outpatient community pharmacy to obtain a fill history for the last 6-12 months. (correct answer)
Rely on the daughter's handwritten list as she is the primary caregiver and most likely to be accurate.
Consult the patient's electronic health record for the medication list from his last hospital discharge summary.

Explanation: While all sources provide some information, the most reliable and comprehensive source in this complex situation is the patient's outpatient pharmacy fill history. This will provide drug names, strengths, dosages, fill dates, and quantities, which is crucial for constructing an accurate BPMH. Pill identification (A) is useful but doesn't confirm adherence or dosage. The daughter's list (C) is a good starting point but she admits uncertainty. The last discharge summary (D) may be outdated.

Question 17

A patient's electronic health record lists a 'penicillin allergy' with the reaction described as 'severe rash and hives as a child.' The patient is now admitted with a serious infection, and the culture results indicate the most effective antibiotic would be piperacillin-tazobactam. The physician places an order for meropenem instead, citing the penicillin allergy.

During medication review, what is the most appropriate action for the pharmacist to take?

Approve the meropenem order, as it is a safe and effective alternative in patients with a penicillin allergy.
Recommend switching to a third-generation cephalosporin like ceftriaxone, which has a lower cross-reactivity risk than piperacillin-tazobactam.
Contact the physician to further clarify the nature of the childhood allergic reaction and discuss the low cross-reactivity between penicillins and carbapenems. (correct answer)
Cancel the meropenem order and enter an order for piperacillin-tazobactam, as a childhood rash is not a true contraindication.

Explanation: The best action is to gather more information. A history of a non-anaphylactic rash in childhood has a very low probability of representing a true, current IgE-mediated allergy. However, the pharmacist cannot unilaterally decide this. The most appropriate step is to engage the prescriber, clarify the allergy history, and discuss the risks/benefits. Broad-spectrum agents like meropenem should be avoided if a narrower-spectrum, first-line agent could be used safely. This promotes antimicrobial stewardship while ensuring patient safety.

Question 18

When screening for potential drug interactions upon admission, which of the following requires the most urgent management?

Levofloxacin can increase the INR in patients on warfarin.
Prednisone can cause fluid retention, worsening his heart failure.
Levofloxacin can decrease the renal clearance of digoxin.
Albuterol can cause hypokalemia, increasing the risk of digoxin toxicity. (correct answer)

Question 19

During medication reconciliation for a newly admitted 68-year-old male with hypertension, the pharmacist notes that the patient's handwritten home medication list includes 'Hydralazine 25 mg TID'. The initial physician order set, however, contains an order for 'Hydroxyzine 25 mg TID'.

If this look-alike/sound-alike discrepancy is not identified and corrected, what is the most likely clinical consequence for the patient?

Severe hypotension due to the potent vasodilatory effects of hydroxyzine.
Worsening anxiety, as the patient will be receiving an antihypertensive instead of an anxiolytic.
Uncontrolled hypertension due to the omission of his antihypertensive and administration of an antihistamine. (correct answer)
Significant sedation and anticholinergic effects from the administration of hydralazine.

Explanation: This is a classic look-alike/sound-alike (LASA) error. Hydralazine is a vasodilator used for hypertension. Hydroxyzine is a first-generation antihistamine with sedative and anxiolytic properties. If the error is not caught, the patient will not receive his prescribed antihypertensive (hydralazine), leading to uncontrolled hypertension. He will instead receive an antihistamine (hydroxyzine), which does not treat hypertension.

Question 20

The patient's presentation is most likely due to a pharmacodynamic interaction between citalopram and ciprofloxacin, which results in:

Antagonism of cardiac potassium channels by ciprofloxacin alone.
Inhibition of citalopram metabolism by ciprofloxacin.
An increased risk of serotonin syndrome.
An additive effect on QT interval prolongation. (correct answer)