BCMTMS Practice Exam

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Board of Medication Therapy Management.

This BCMTMS practice exam is designed to help prepare you on your

goal of obtaining BCMTMS certification. Certainly, you are smart
enough to realize that if you pass this exam, you are not guaranteed to
pass the BCMTMS exam. With that stated, I have created this in an
attempt to mimic the difficulty of the questions on the exam. Best of
luck on your exam, and I hope this provides great value into your
preparation for the BCMTMS exam.

Eric Christianson, PharmD, BCPS, BCGP

Albumin 3.2 - 5 g/dl
Alkaline phosphatase
33 - 131 IU/L
(Adults: 25-60)
Adults > 61 yo: 51 - 153 IU/L
Ammonia 20 - 70 mcg/dl
Bilirubin, direct 0 - 0.3 mg/dl
Bilirubin, total 0.1 - 1.2 mg/dl

Blood Gases
Arterial Venous
pH 7.35 - 7.45 7.32 - 7.42
pCO2 35 - 45 38 - 52
pO2 70 - 100 28 - 48
HCO3 19 - 25 19 - 25
O2 Sat % 90 - 95 40 - 70
BUN 7 - 20 mg/dl

Complete blood count (CBC) Adults

Male Female
Hemoglobin (g/dl) 13.5 - 16.5 12.0 - 15.0
Hematocrit (%) 41 - 50 36 - 44
6
RBC's ( x 10 /ml) 4.5 - 5.5 4.0 - 4.9
RDW (RBC distribution width) < 14.5
MCV 80 - 100
MCH 26 - 34
MCHC % 31 - 37
Platelet count 100,000 to 450,000

Creatine kinase (CK) isoenzymes

CK-BB 0%
CK-MB (cardiac) 0 - 3.9%
CK-MM 96 - 100%
Creatine phosphokinase (CPK) 8 - 150 IU/L
Creatinine (mg/dl) 0.5 - 1.4

Electrolytes
Calcium 8.8 - 10.3 mg/dL
Calcium, ionized 2.24 - 2.46 meq/L
Chloride 95 - 107 mEq/L
Magnesium 1.6 - 2.4 mEq/L
Phosphate 2.5 - 4.5 mg/dL
Potassium 3.5 - 5.2 mEq/L
Sodium 135 - 147 mEq/L

Other
Ferritin (ng/ml) 13 - 300
Folate (ng/dl) 3.6 - 20
Glucose, fasting (mg/dl) 60 - 110
Glucose (2 hours
Up to 140
postprandial) (mg/dl)
<6% of total Hb

Hemoglobin A1c, % (as a screening test)

5.4 - Normal
-------------------------
5.5-6.4 - High risk/prediabetes; requires screening by glucose
Hemoglobin A1c criteria
-------------------------
6.5 -Diabetes, confirmed by repeating the test on a different
day
=================
In general, therapy should target a A1C level of 7% or less for
most nonpregnant adults.
Iron (mcg/dl) 65 - 150
Lactic acid (meq/L) 0.7 - 2.1
LDH (lactic dehydrogenase) 56 - 194 IU/L

Lipoproteins and triglycerides

Cholesterol, total < 200 mg/dl
HDL cholesterol 35 mg/dL. Negative risk factor: 60 mg/dL
LDL cholesterol 65 - 180 mg/dl
Normal: < 150 mg/dL.
Borderline-high: 150 to 199 mg/dL
Triglycerides
High: 200 to 499 mg/dL
Very High: >499 mg/dL

Osmolality 289 - 308 mOsm/kg

SGOT (AST) < 35 IU/L (20-48)
SGPT (ALT) <35 IU/L
Male: 300 to 1000 ng/dL
Female: < 62 ng/dL

ALT:
Male:
14-15 yr: 33-585 ng/dL
Testosterone - total (serum) 16-17 yr: 185-886 ng/dL
18-39 yr: 400-1080 ng/dL
40-59 yr: 350-890 ng/dL
> 60 yr: 350-720 ng/dL

Tanner Stage IV: 165-854 ng/dL

Tanner Stage V: 194-783 ng/dL

Thyroid Function tests

Thyroid Function Testing
Thyroid Function Measurement Normal Range
Test
Total T4 (TT4) bound and free T4 4.5 -11.5 ug/dL
Free T4 (FT4) free T4 0.8 -2.8 ng/dL
Free T4 Index estimate of free T4 1.0 -4.3 U
(FT4I) FT4I = TT4 x RT3U
Total T3 (TT3) bound and free T3 75 -200 ng/dL
Resin T3 Uptake binding capacity of 25 -35%
(RT3U) TBG
TRH TRH 5 -25 mIu/mL
TSH TSH 0.5 - 4.70 µIU/mL

American Association of Clinical

Endocrinologists guidelines changed
their normal range for TSH to
0.3 - 3.04 mIU/L.
Thyroglobulin Thyroglobulin 5-25 ng/mL
Radioactive Iodine Distribution of 5 hr – 5 to 15%
Uptake (RAIU) radiolabeled iodine in 24 hr – 15 to 35%
the thyroid
Notes:
Free T4 - much more useful than total T4 (e.g. interested in unbound or active form). Total T4 not
commonly measured. Greatly affected by TBG.
Free T4 index: indirect measure of free T4. Corrects for high/low values of TBG.
Total T3: not as useful as free T3, however, may be useful in locating problems with TBG, or if looking
for problems with peripheral conversion of T4 to T3.
Resin T3 Uptake: if low, then TBG binding capacity is high. Opposite if high.
TSH: best measure to determine thyroid function.
Thyroglobulin: nonspecific test that is elevated when the thyroid gland is inflamed or enlarged.
Free T3 2.3-4.2 pg/ml
Total iron binding capacity (TIBC) 250 - 420 mcg/dl
Transferrin > 200 mg/dl
Uric acid (male) 2.0 - 8.0 mg/dl
(female) 2.0 - 7.5 mg/dl

WBC + differential
WBC (cells/ml) 4,500 - 10,000
Segmented neutrophils 54 - 62%
Band forms 3 - 5% (above 8% indicates left shift)
Basophils 0 - 1 (0 - 0.75%)
Eosinophils 0 - 3 (1 - 3%)
lymphocytes 24 - 44 (25 - 33%)
Monocytes 3 - 6 (3 - 7%)

Absolute Neutrophil Count (ANC) - Oncology

Equations:
(1) Segs and bands reported as a percentage:
WBC * ((segs / 100) + (bands / 100))

(2) Segs and bands reported in total numbers:

WBC * (segs + bands)

Neutrophils (aka polymorphonuclear cells, PMNs, granulocytes, segmented neutrophils, or segs) fight
against infection and represent a subset of the white blood count. Neutropenia by definition is an ANC
below 1800/mm3 (some sources use a lower value).

Absolute neutrophil count (ANC) of 1000-1800:

Most patients will be given chemotherapy in this range.
Risk of infection is considered low.

Mild neutropenia - Absolute neutrophil count (ANC) of 500-1000:

Carries with it a moderate risk of infection.

Absolute neutrophil count (ANC) of less than 500:

Severe neutropenia - high risk of infection. Remember that a reduced WBC is known as leukopenia.

The WBC consists of the following (differential):

Lymphocytes: 20-40%
Neutrophils: 50-60%
Basophils: 0.5-2%
Eosinophils: 1-4%
Monocytes: 2-9% (average: 4%).
ANC = Total WBC x (% "Segs" + % "Bands")
Equivalent to: WBC x ((Segs/100) + (Bands/100))

The ANC refers to the total number of neutrophil granulocytes present in the blood.

Normal value: 1500 cells/mm3.

Mild neutropenia: 1000 - <1500/mm3.
Moderate neutropenia: 500 - <1000/mm3.
Severe neutropenia: < 500/mm3.

Reference:
Ayalew Tefferi, MD, ed. Primary Hematology. Totowa, NJ: Humana Press, 2001

Labs Courtesy: GlobalRph.com

 1. A 17 year old female has tried salicylic acid and benzoyl peroxide for her mild to
moderate acne. The salicylic acid did not work. The benzoyl peroxide once daily caused
too much redness and irritation. Which of the following recommendations would be
most appropriate for management?
a. Initiate systemic minocycline
b. Initiate Tazarotene
c. Initiate topical clindamycin
d. Initiate systemic isotretinoin
Answer – topical retinoids like tazarotene, tretinoin, etc. are considered first line agents in the
management of acne. Systemic agents are usually reserved for severe cases that have not
responded to traditional therapy. Clindamycin would be an option, but likely 2nd or 3rd line
after topical retinoids.

2. A total of 13,323 study participants with Type 2 diabetes underwent randomization into
two groups. One group received aspirin 81 mg once daily and the other group received
aspirin 325 mg once daily. Comparing the 325 mg once daily group to the aspirin 81 mg
daily group, the change in heart attack rate was assessed by a 95% confidence interval
of 0.88 – 1.05, P=0.13. Which of the following is true with regards to the findings?
a. The findings indicate that there was no statistical difference between the
groups
b. The findings indicate that there was significant benefit in heart attack reduction
in the aspirin 325 mg group
c. The findings indicate that the aspirin 81 mg group had a statistically significant
reduction in heart attack compared to the aspirin 325 mg group
d. There is too little information to assess statistical significance
Answer – Given the P value is greater than 0.05, these results would not be statistically
significant in favor of the aspirin 325 mg once daily group. The is not an actual study, but a
made up example.

3. One of your patients is a caregiver for her elderly grandfather. She presents today
informing you that she is pregnant. Which of the following of her grandfather’s
medications should you educate her to be extremely careful when handling and use
protective gloves?
a. Tamsulosin
b. Nifedipine
c. Acetaminophen
d. Finasteride
Answer: Finasteride has historically been category X and women of childbearing age should avoid
touching or handling broken or crushed tablets. Tamsulosin is category B, Nifedipine is category C as
well as Acetaminophen.

4. A patient reports to you that their pen device for their exenatide doesn’t seem to be
working correctly. The patient brought it in and you also agree that it does not appear
 to be working correctly. Which of the following forms would be useful for the patient to
report this issue to MedWatch?
a. 3500B
b. 106
c. 224
d. 3500A
Answer – 3500B is for consumers to report issues in relation to medications. Plain 3500 is for
healthcare professionals. Both are voluntary. 3500A is for distributors, manufacturers, and
investigators. 3500A is mandatory. 106 is a DEA form that is used to report significant loss. 224
is another DEA form used for registration.

5. A 68 year old has a history of HFrEF. The attending physician would like to put him on
digoxin to help with this. He does not have atrial fibrillation. Which of the following is
correct with regard to the use of digoxin in CHF?
a. Much like atrial fibrillation, a loading dose can be used in CHF to improve
symptoms quickly
b. Target concentrations in CHF are generally lower than compared to atrial
fibrillation
c. Primary symptoms of digoxin toxicity include rash, hearing loss, and renal failure
d. Digoxin has the potential to raise potassium levels and this is why we need to
monitor this closely
Answer – A loading dose in CHF is generally not appropriate, while you might see it done in
atrial fibrillation. B is the only correct statement as we don’t get as aggressive with target
concentrations in CHF. Signs of digoxin toxicity include GI upset, weight loss, drop in pulse, CNS
changes, and visual problems. In the setting of hypokalemia or hypomagnesemia, we do get
concerned about an increased risk of arrhythmias. Digoxin itself does not cause hyperkalemia.

6. 75 research subjects were placed on extended release guanfacine for management of

ADHD. The Clinical Global Impression-Improvement scale was utilized to assess
response to the medication. Which type of variable would this scale be considered?
a. Nominal
b. Ordinal
c. Ratio
d. Continuous
Answer – Psych related scales are often subjective, but they do have an order that indicates a
patient being “better” or “worse” clinically. These scales are ordinal data.

7. A patient is inquiring about the use of medroxyprogesterone acetate injection as a

means for birth control. Which of the following would be a potential risk with its use?
a. Hepatic encephalopathy
b. Loss of bone mineral density
c. Risk of aplastic anemia
d. Atrial fibrillation risk
Answer – Medroxyprogesterone acetate increases the risk of reduced bone mineral density. It
is recommended to try to avoid use of this for no more than 2 years.

8. One of you patients has been experiencing confusion, feels like his heart is racing, and is
excessively sweating. His past medical history includes a history of anxiety, alcohol
abuse (has recently been trying to stop), obesity, hypertension, and insomnia. His
medications include hydralazine which was increased a couple of weeks ago, lorazepam
0.5 mg as needed, and trazodone as night for sleep. Which of the following is most likely
the cause of his symptoms?
a. Hydralazine
b. Lorazepam
c. Trazodone
d. Alcohol cessation
Answer – these symptoms are likely indicative of alcohol withdrawal. The tachycardia,
sweating, and CNS changes would likely not be due to any one medication. He should follow up
with his primary care provider for further follow up and assessment of symptoms.

9. For a pharmacist to bill incident-to billing codes, which of the following would not be
necessary?
a. Patient must first be seen by a physician for an evaluation
b. The service must be medically appropriate to be given in a provider’s office or
clinic
c. The patient must receive greater than 80% of their prescriptions at one
pharmacy
d. Services must be within the pharmacist’s scope of practice
Answer – All of the above are true except billing incident-to would not depend upon where the
patient gets their prescriptions filled.

10. A 55 year old male has cardiovascular disease. Which of the following would not be
considered a modifiable risk factor?
a. Age
b. Smoking
c. Dyslipidemia
d. Hypertension
Answer – there isn’t much we can do about age. Medication therapy and lifestyle changes
could all help alter his modifiable risk factors like smoking, elevated cholesterol, and
hypertension.

11. Which of the following is agencies responsible for the approval of biologic agents?
a. DMEPA
b. MERP
c. NIH
d. CBER
Answer – CBER is the center for biologics evaluation and research and it is responsible for
approval of biologics and biosimilars. DMEPA (Division of Medication Error Prevention and
Analysis) reviews med error reports etc. MERP is the ISMP medication error reporting program.
NIH is the National Institute of Health which primarily works on clinical trials and is taxpayer
funded.

12. One of your patients has recently been diagnosed with severe cluster headaches. He
takes triptans as needed, but is frequently using them several times per week. Which of
the following would be the most appropriate initial intervention for prevention?
a. Scheduled acetaminophen
b. Verapamil
c. Nadolol
d. Lamotrigine
Answer – for prevention of cluster headaches, calcium channel blockers (non-dihydropyridine)
are the usual medication of choice. Triptans and oxygen therapy are the usual treatments of
choice for acute management.

13. A concerned mother comes in with her 16 year old daughter who has itching, redness, in
the creases of the skin, particularly behind the knees and inside the elbow area. She has
not seen a primary care provider yet, but states that she knows that it is dermatitis. It is
not bleeding and does not look infected. She states her daughter has had a couple of
flares in the past, but cannot recall what was done. Which of the following would be
most appropriate to initiate?
a. Hydrocortisone 1% cream – apply as twice daily needed
b. Referral and recommend tacrolimus 0.1% ointment – apply twice daily as
needed
c. Diphenhydramine 25-50 mg as four times daily as needed
d. Referral and recommend prednisone 10 mg daily for 5 days
Answer – in this scenario, the dermatitis does not sound severe. Topical OTC steroid like
hydrocortisone would be the most appropriate initial step and if that does not clear things up,
the patient would need to be referred to a primary care provider for a prescription for a more
potent steroid or tacrolimus. Diphenhydramine could be used to augment, but it wouldn’t be
the most appropriate to relieve/treat the dermatitis. In severe cases, systemic therapy like
prednisolone may be appropriate, but this situation is pretty limited to small areas of the body.

14. Which of the following is true regarding the use of ticagrelor?

a. It can help lower uric acid levels in patients with gout
b. CYP3A4 drug interactions are a significant clinical concern
c. Ticagrelor has a boxed warning for increasing the risk of liver failure
d. Doses of less than 100 mg of aspirin cause a reduction in effectiveness of
ticagrelor
Answer – CYP3A4 drug interactions are a major clinical concern with the use of ticagrelor.
There is also a boxed warning for ineffectiveness if doses of aspirin are HIGHER than 100 mg.
Ticagrelor has been associated with increasing uric acid levels.
 15. A 61 year old with reduced ejection fraction CHF is in for a routine recheck of his labs.
He is on furosemide 40 mg once daily, lisinopril 5 mg once daily, metoprolol 25 mg twice
daily, spironolactone 50 mg once daily, aspirin 81 mg daily, and famotidine 20 mg once
daily. Labs 3 months ago revealed creatinine = 1.1 mg/dL, sodium 138 mEq/L,
potassium 4.9 mEq/L, BUN 12 mg/dL, BNP = 91 pg/mL. Upon checking today, his labs
reveal creatinine = 2.1 mg/dL, sodium = 139 mEq/L, potassium = 5.0 mEq/L, BUN = 44,
BNP = 68 pg/mL. Which of the following actions would be most appropriate?
a. Reduction in furosemide
b. Increase in furosemide
c. Discontinuing famotidine
d. Initiating sodium polystyrene sulfonate
Answer – with the elevated BUN/Creatinine ratio, this looks like a case of dehydration.
Reducing the furosemide would help best manage this situation. Reduction in spironolactone
and/or lisinopril could be a consideration as well, but is obviously not listed as a choice.
Increasing furosemide could exacerbate the dehydration scenario. Giving Kayexalate (SPS) for a
potassium of 5.0 would not be appropriate. Famotidine is dose adjusted based on renal
function, but this is a pretty low dose already and would not need to be discontinued.

16. One of you patients is concerned about the use of her Epi-Pen. She uses it about 1-2
times per year for allergic reactions/angioedema type symptoms where she has
difficulty breathing. She takes a lot of other medications and she had heard on the news
that some medications can prevent this epinephrine from working. Which medication
would be most likely to cause a concern?
a. Clonidine
b. Metoprolol
c. Acetaminophen/diphenhydramine for sleep
d. Ranitidine
Answer – the beta-blocker can possibly reduce the effects of epinephrine and would have the
potential to blunt the response.

17. A study was looking to investigate if the H2 blocker ranitidine had any effect on the rate
of MI. Study participants were monitored for 5 years. 1,000 patients were on ranitidine
and 1,000 were on placebo. Over that 5 year period, 70 had a heart attack in the
ranitidine group while 90 had a heart attack in the placebo group. What would be the
relative risk reduction of ranitidine?
a. 20
b. 0.78
c. 2%
d. 1.22
Answer – Ranitidine had a protective effective (made up example) and the relative risk is solved
by taking the absolute risk of the treatment group (7%) divided by the absolute risk of the
control group (9%). Remember that if a relative risk value is less than 1, it portrays a risk
reduction and if it is greater than 1, it portrays a greater likelihood of the outcome being
studied.

18. From the question above, what would be the number needed to prevent one heart
attack?
a. 20
b. 50
c. 100
d. 10
Answer – Solving for number needed to treat, you take 1/ARR. ARR = absolute risk reduction.
9%-7% is 2% or 0.02. 1 divided by 0.02 = 50.

19. In trying to minimize observation bias in a clinical trial, which of the following is the best
strategy?
a. Designing the trial to utilize continuous data
b. Comparing drugs against the standard of practice versus placebo
c. Ensuring that the patients are randomized to each group
d. Blinding the researchers
Answer – Blinding the researchers (medical personnel) from knowing which patients received
the treatment and which ones didn’t would be the best way to minimize observational bias. The
researchers the ones determining diagnosis and assessment and you ideally would not want
them to know who is receiving treatment and who isn’t.

20. Which of the following would not be a significant barrier to implementing

pharmacogenomics testing in trying to optimize patients’ medication therapy.
a. Prescriber uncertainty of clinical and economic benefits
b. Financial concerns of patients and/or payers
c. Ethical concerns of providers
d. Delays in therapy when awaiting results
Answer: C. Ethical concerns of providers is not a significant barrier to implement
pharmacogenomics testing. Prescriber uncertainty of benefits, who pays for the testing, and the
delay in waiting for the test results in starting medication if testing is done reactively would all
be potential barriers.

21. A 51 year old female patient with AIDS has been diagnosed with Cryptococcal
pneumonia. They would like to begin outpatient therapy as the patient’s symptoms
don’t appear terribly severe. Which of the following would be most appropriate?
a. Fluconazole
b. Sulfamethoxazole/trimethoprim
c. Ciprofloxacin
d. Ganciclovir
Answer – Cryptococcus is a fungal infection and fluconazole would be a potential option to use
here. Ganciclovir and the other agents would not cover this infection.
 22. A newly diagnosed 22 year old asthma patient has a reported peak expiratory flow
reading of 71% of predicted. She is asking if she should begin a prednisone burst. Which
of the following would be the most appropriate initial step?
a. Recommend giving 2 puffs of albuterol at this time
b. Wait and reassess in 60 minutes
c. Go to the emergency room now
d. Start the prednisone and reassess in one hour
Answer – A reduction in peak expiratory flow of 20% or more off a patient’s previous best
would potentially be indicative of an exacerbation. It would be most appropriate to give the
initial doses of albuterol to help improve respiratory status quickly. Next steps would probably
be determined by clinical response to the inhalations.

23. Which of the following would not be considered one of the 9 core chronic conditions
that Medicare sponsors can choose to target beneficiaries from?
a. HIV
b. CHF
c. COPD
d. Osteoporosis
Answer – There are nine core chronic conditions. If drug plan sponsors are choosing to target
beneficiaries eligible for MTM by chronic conditions, they must choose at least five. HIV is not a
core chronic condition.

24. You are looking to develop a point of care testing program. Which of the following
actions would be an initial step to providing CLIA Waived tests?
a. Contact state department of health
b. Apply to CMS for waiver
c. Start providing lab testing, then you must apply for waiver within 1 year of
starting your ambulatory care practice
d. Train all staff members on how to do the testing
Answer – Your state department of health would be your first place to start the process of
obtaining a CLIA certificate of waiver.

25. A 55 year old female is undergoing chemotherapy for metastatic breast cancer. She has
been having some issues with urination and has been diagnosed with bladder cystitis.
Which of the following chemo agents would be most likely to cause this?
a. 5-fluorouracil
b. Cyclophosphamide
c. Cisplatin
d. Paclitaxel
Answer – Cyclophosphamide is associated with bladder cystitis. Mesna and fluid replacement
may help prevent this complication.

26. Which organization or agency is responsible for the creation of ICD codes for billing (i.e.
99211-99214?
 a. CMS
b. WHO
c. MedWatch
d. NIH
Answer – The World Health Organization is responsible for creating and updating ICD
(international classification of diseases). CMS and other payers utilize these codes as a means
to classify tasks and procedures.

27. With regards to cervical cancer, which of the following is false?

a. HPV is the most common cause
b. Subtypes 6, 11 with HPV are strongly associated with cervical cancer
c. Pap-smear is an important screening tool
d. Postcoital bleeding and spotting can be a potential symptom of cervical cancer
Answer – Human Papilloma virus is the most common cause of cervical cancer. Subtypes 6, 11
are most associated with genital warts. 16, and 18 are the most common cancer causing
subtype of HPV. Gardisil-9 is the vaccine of choice to help prevent HPV and associated
complications.

28. In a patient with depression who is taking a tri-cyclic antidepressant, which of the
following complications would be most likely to result from overdose?
a. Respiratory failure
b. Cardiac abnormalities
c. Renal failure
d. GI perforation
Answer – TCA’s can cause sinus tachycardia especially in supratherapeutic concentrations. A
patient with a preexisting prolonged QTc may be of higher concern. If you remember that
atropine is used to stimulate the heart in bradycardia, this will help you remember that
anticholinergics can cause tachycardia.

29. With respect to warfarin drug interactions, which of the following is true?
a. Metronidazole inhibits CYP2C19 which can substantially raise INR
b. After a course of rifampin is discontinued, INR will likely drop
c. Amiodarone can raise levels of warfarin concentrations by inhibition of CYP3A4
and lead to elevations in INR
d. An increase in green leafy vegetable intake can lead to elevations in INR
Answer – Amiodarone does interact with warfarin and can raise concentrations. Metronidazole
inhibits CYP2C9 and leads to elevations in INR, not CYP2C19. Because it is an enzyme induced,
when rifampin is discontinued, we will likely have elevations in INR. Green leafy vegetables with
high vitamin K will cause INR to drop.

30. Lucy is a 71 year old female who has been on conjugated estrogen for a period of 12
years. She is scared about tapering off of estrogen due to the hot flashes she
experienced when she has tried off it in the past. She would like to know the risk of
continuing with the estrogen replacement. Which one of the following is NOT a risk of
 continuing with estrogen chronically?
a. Breast Cancer
b. Ovarian Cancer
c. Colorectal Cancer
d. Blood Clot
Answer: C. Colorectal cancer is not a risk when using chronic estrogen therapy. Breast,
ovarian, and DVT are all risks associated with long term use.

31. A physician has approached you about helping to develop an ambulatory care pharmacy
practice in her clinic. Which of the following benefits would be least likely to happen?
a. Reduced drug costs
b. Improved access to care
c. Improved clinical outcomes
d. Saved time for the physician
Answer – Reduce drug costs would be the least likely benefit from developing an ambulatory
care pharmacy practice. Some evidence indicate that direct drug costs may go up due to
increased adherence and patient compliance to medication therapy. Access, clinical outcomes,
and physician time savings should all be positive outcomes from developing a practice.

32. Which of the following oral NSAIDs would it be recommended to take for no more than
5 days?
a. Piroxicam
b. Sulindac
c. Ketorolac
d. Nabumetone
Answer – Ketorolac has a warning against using for more than 5 days. This is due to the
significant risk of GI bleeding events.

33. A 55 year old male has a complex medical history including seizure disorder and atrial
fibrillation. The cardiologist is going to initiate amiodarone for his atrial fibrillation. He
has been on phenytoin for years. Which of the following would be most likely to
happen in this situation with respect to potential drug interactions?
a. Reduced dosing of amiodarone will be likely due to phenytoin’s potential to
increase concentrations
b. Increased doses of both medications will be necessary as they can both induce
each other’s metabolism
c. Phenytoin toxicity risk will be increased
d. Amiodarone and phenytoin do not affect each other
Answer – Phenytoin can potentially increase metabolism of amiodarone which may necessitate
a higher dose of amiodarone than without it. Amiodarone does have the potential to raise
phenytoin levels and contribute to toxicity, so C is the most correct answer.
 34. A 34 year old male patient has been diagnosed with depression. He is concerned about
sexual dysfunction as he has heard that some medications can cause this issue. Which
of the following would be the best choice to avoid this potential adverse effect?
a. Duloxetine
b. Nortriptyline
c. Fluvoxamine
d. Mirtazapine
Answer – Mirtazapine and bupropion are the two lower risk agents when it comes to causing
sexual dysfunction. TCA’s, SSRI’s, and SNRI’s all can potentially contribute to this issue.

35. In a clinical trial, mirabegron cardiovascular adverse effects are being monitored.
Specifically, the test subjects will have their blood pressure monitored. Which of the
following types of variables would blood pressure be?
a. Independent
b. Nominal
c. Ordinal
d. Continuous
Answer – Blood pressure would be a continuous variable. In this situation, it would not be an
independent variable because the blood pressure change would be dependent upon the drug
(mirabegron) and dose of the medication. Blood pressure is easily measured and reproducible
and is not subjective data.

36. A patient has a history of Addison’s disease. In light of this diagnosis, which of the
following would be least concerning to monitor in a patient on lisinopril, carbamazepine,
and chlorthalidone?
a. Risk for hyperkalemia
b. Risk for hyponatremia
c. Elevated risk for ACE inhibitor cough
d. Risk for hypotension
Answer – in Addison’s disease, cortisol and aldosterone can be in short supply. This would
potentially increase the risk of elevated potassium, low sodium, and also cause low blood
pressure. We would need to be a little extra careful using these agents as lisinopril and
chlorthalidone could lower blood pressure too much, carbamazepine and chlorthalidone could
contribute to hyponatremia, and the lisinopril could cause or exacerbate hyperkalemia. There
would not be an elevated risk for ACE cough in this patient due to Addison’s.

37. Which of the following is a disadvantage of immediate release exenatide compared to

liraglutide?
a. Needs to be administered with food
b. Increased risk for thyroid tumors
c. Cost
d. Increased risk of hepatotoxicity
Answer – Exenatide immediate release is dosed twice daily and needs to be given with food
which is a significant downside. Both liraglutide and exenatide have the warning for thyroid
tumor risk. Cost concerns aren’t much different between these agents and isn’t typically an
advantage for liraglutide. Exenatide doesn’t notably increase hepatotoxic risk compared to
liraglutide.

38. A new medication is being evaluated for the treatment of migraines. The new drug
indicates that the number needed to harm for the side effect of diarrhea was 88. Which
of the following is most accurate in interpreting the number needed to harm?
a. Diarrhea would be a common side effect for this medication
b. Severe diarrhea is problematic and the risk is substantial
c. Diarrhea is not very common
d. None of the above
Answer – number needed to harm is an indicator of the safety of a medication. The higher the
number, the safer a medication is. In this example, a number needed to harm (NNH) of 88
means that for 88 patients treated, one will have diarrhea. This is very low for a minor side
effect like diarrhea. NNH generally doesn’t give any indication of the severity of a side effect,
just how often it occurs.

39. A 58 year old male patient has been diagnosed with essential tremor. It has bothered
him all his life, but not to the extent that he wanted to do anything about it. He is now
ready to take medication to help manage this. Past medical history includes
hypertension, BPH, Type 2 diabetes, anemia, and osteoarthritis. Labs: GFR = 79 mls/min,
K+ = 5.1 mEq/L, Na+ = 141 mEq/L, Hemoglobin = 12.2 g/dL. BP = 139/88, HR = 57 BPM.
Which of the following would be most appropriate to initiate?
a. Benztropine
b. Primidone
c. Nadolol
d. Carbamazepine
Answer – Carbamazepine would not have a role in managing essential tremor. Using the beta-
blocker would be risky given the low pulse already. Benztropine typically is not utilized unless
that tremor is drug induced (i.e. antipsychotics). The anticholinergic nature of the medication
could also exacerbate BPH. Primidone would be the best choice in this situation.

40. A patient is experiencing fatigue likely due to anemia. Current labs include B12 = 730
pg/mL, ferritin 234 ng/mL, folic acid 17 ng/mL, potassium = 4.8 mEq/L, sodium 134
mEq/L, hemoglobin = 9.7, creatinine = 1.9 mg/dL, MCV = 88 fL/cell. Which of the
following would be most appropriate to manage the anemia?
a. Addition of ferrous sulfate
b. Addition of B12
c. Addition of folic acid
d. None of the above
Answer – this is likely anemia of chronic kidney disease given the elevated creatinine and the
normal to high levels of ferritin, folic acid, and B12. MCV is also indicative of a normocytic
anemia. Erythropoietin could be considered if anything was going to be done.
 41. A 5 year old male who weighs 25 kg has had a recent asthma exacerbation. This is his
first one in quite a while. He is on budesonide nebulizer twice daily and uses his
albuterol nebulizer about 1-2 times per month. The primary care provider would like to
prescribe prednisolone for the exacerbation. Which of the following would be most
appropriate?
a. Since he doesn’t have many exacerbations, using montelukast for 10-14 days
would be appropriate
b. Initiate prednisolone 5 mg daily for 5 days
c. Initiate prednisolone 20 mg daily for 5 days
d. Do not utilize prednisolone and schedule albuterol nebulizer 4 times per day for
5 days
Answer – the most appropriate use of prednisolone for an asthma exacerbation is a dose of 0.5-
1 mg/kg/day. The dose of 20 mg for 5 days would fall in this range and be the most
appropriate. Montelukast would not be appropriate for an acute exacerbation. Increasing
albuterol use may occur, but the steroid is recommended for exacerbations.

42. A 34 year old female is experiencing hypertensive episodes and they are considering
starting her on medication therapy. Which of the following would be safest for her to
take?
a. Enalapril
b. Nifedipine
c. Metoprolol
d. Spironolactone
Answer – Enalapril and spironolactone are absolutely contraindicated. Metoprolol likely should
be avoided if possible as well. Nifedipine is utilized in pregnancy and would be the safest
option of the medications listed.

43. Researchers are looking at a group of patients who are taking allopurinol. They want to
do a study where they simply take the blood pressure of a group of patients on the
medication and also take the blood pressure of a group of patients not on the
medication (control group). They will compare those results to help determine if
allopurinol increases blood pressure. What type of research would this best describe?
a. Randomized controlled trial
b. Cohort
c. Cross sectional study
d. Case study
Answer – Studying patients at a moment in time would be best described as a cross sectional
study.

44. An 88 year old male has a past medical history of hypertension, GERD, hyperlipidemia,
MI, CAD, diabetes, and osteoarthritis. He has just been diagnosed with atrial fibrillation.
What is his Chads2Vasc score?
a. 3
b. 4
 c. 5
d. 6
Answer – He has a history of hypertension (1), age > 75 (2), diabetes (1), and vascular disease
(1) for a score of 5. Anticoagulation would be indicated in this patient according to this score.

45. One of your patients is concerned about potential adverse effects from levothyroxine
supplementation. She thinks her dose is too high. Which of the following would likely
not be associated with an excessive dose?
a. Anxiety
b. Tremor
c. Bradycardia
d. Increased appetite
Answer – With excessive levothyroxine intake, metabolism would be ramped up and there is
risk to it contributing to tachycardia, increased appetite, weight loss, tremor, anxiety, and
insomnia. Long term excessive thyroid supplementation could also be associated with
osteoporosis.

46. A physician is asking which iron preparation has the highest elemental iron. Which of
the following would you recommend?
a. Ferrous gluconate
b. Ferrous fumarate
c. Ferrous sulfate
d. All of the above have equivalent elemental iron
Answer – Ferrous fumarate has the highest amount of elemental iron. It tends to be a little
more expensive and as you get higher amounts of elemental iron, you may encounter more GI
side effects as well. Ferrous sulfate is often used first due to cost and tolerability, but fumarate
has the highest elemental. Gluconate has the lowest elemental iron.

47. Which of the following would be an indirect cost in association with operating an MTM
program?
a. Education and training
b. Dedicated salary for a pharmacist’s time
c. Office supplies
d. Lights and electricity in an existing pharmacy
Answer: Lights and electricity in an existing pharmacy – Lights and electricity in a space that
would operating anyway would be an example of an indirect cost. Salary, paying for education
and training, and supplies would all be direct costs toward operating an MTM program.

48. In utilizing the incident-to billing codes, which of the following is true?
a. A nurse practitioner would not be able to provide direct supervision under
Medicare rules
b. Incident-to codes can be billed under Medicare Part D for pharmacists
c. The supervising provider must sign off on all notes and documentation from the
pharmacist
 d. The NPI of the Medicare provider is used to bill incident-to codes
Answer – The NPI of the Medicare provider is used to bill as pharmacists are not considered
providers and they need to bill under another provider. A NP is listed as someone who is able
to provide direct supervision under Medicare. Incident-to codes are billed under Medicare B.
The supervising practitioner does not need to sign off on all notes and documentation.

49. Which of the following physiological changes happen as a patient ages?

a. Increased flexibility of vessels leading to an increased risk in aneurysms
b. Increased activity of the baroreceptor reflex leading to an increase in falls
c. Increase in total body water
d. Potential increased volume of distribution for lipophilic drugs
Answer – As we age, fat % does increase and can lead to a greater volume of distribution for
lipophilic drugs. Total body water tends to reduce and elderly are more susceptible to
dehydration. Vessels become more stiff and rigid. The baroreceptor reflex reduces in activity
and this can lead to an increase risk of dizziness and falls upon position changes.

50. Which of the following oral opioids would be the most potent?
a. Morphine
b. Oxycodone
c. Hydrocodone
d. Codeine
Answer – Oxycodone would be the most potent opioid of the group here. 20 mg of oxycodone
is approximately equivalent to 30 mg of oral morphine and 30 mg of hydrocodone. Codeine is
the least potent. 200 mg of codeine is approximately equivalent to 30 mg of morphine.

51. An elderly patient has a really difficult time remembering to take his medications in the
evening. He has significant COPD and forgets to take his medication especially when he
has to do it twice per day or more. Which of the following would be most appropriate?
a. Umeclidinium
b. Aclidinium
c. Ipratropium
d. Glycopyrronium
Answer – Umeclidinium is the one that will be used primarily once daily and would be most
appropriate in this patient where adherence is an issue. Aclidinium and glycopyrronium are
typically dosed twice daily. Ipratropium can be dose even more often. Tiotropium would also
be an option (not listed) as this is also dosed once daily.

52. An elderly patient with mild dementia is having some urinary incontinence.
Anticholinergic therapy is desired to help manage these symptoms. Which of the
following would be the most appropriate option to help minimize the impact on
cognition?
a. Tolterodine
b. Oxybutynin oral tablets
c. Oxybutynin patch
 d. Trospium
Answer – Trospium is hydrophilic and should not cross the blood brain barrier under normal
circumstances. This would likely have the least impact on cognition if an anticholinergic is
necessary.

53. You have met with a patient for the first time for an MTM visit. The initial visit took 45
minutes. Which of the following MTMS codes should NOT be utilized?
a. 99605
b. 99606
c. 99607
d. All codes could be used in the above situation
Answer: B. 99606 – MTMS code 99606 should not be used in this situation as this code is
designated for the initial 15 minutes of an MTM visit of an ESTABLISHED (i.e. one you have met
with before) patient. You would use 99605 for the initial 15 minutes with a new patient and
99607 for each additional 15 minutes.

54. In a patient with type 1 diabetes who is medically ill, which of the following is false?
a. Increased cortisol release can contribute to hyperglycemia
b. Closer monitoring of blood sugars would be recommended
c. Insulin should be held for at least 4-6 hours upon recognition of symptoms of
feeling ill
d. Consider use of small boluses (5-10% of usual total daily dose) of rapid acting
insulin throughout the day as needed based upon blood sugar
Answer – With infection, blood sugars can be thrown out of whack. They can be low or they
can increase the risk of DKA if they get too high. Cortisol and epinephrine production are
generally increased which can raise blood sugars. If the patient is vomiting or not eating well,
this can increase the risk of hypoglycemia. Closer monitoring of blood sugars and utilization of
more of sliding scale short term can be helpful to avoid dangerously high or low BS. All of the
above except C are true. Holding insulin for that long of a time would be risky and is not
generally recommended.

55. ST is a 55 year old female with atrial fibrillation, hypothyroidism, hypertension, and
osteoarthritis. She was recently diagnosed with a UTI. Given that culture and sensitivity
is not an issue, which one of the following antibiotics would potentially interact with this
patient’s amiodarone for atrial fibrillation?
a. Amoxicillin
b. Cephalexin
c. Nitrofurantoin
d. Levofloxacin
Answer: D. Levofloxacin could interact with amiodarone and increase the risk of QTc
prolongation. It would be best to avoid this combination when other alternatives exist. Side
note: Not using levofloxacin would also be nice to minimize the use of broad spectrum
antibiotics.
 56. According to the GOLD guidelines, what spirometry readings would classify a patient as
having moderate COPD?
a. FEV1 > 80% predicted
b. FEV1 between 50 and 80% predicted
c. FEV1 between 30 and 50% predicted
d. FEV1 < 30% predicted
Answer: B. FEV1 between 50 and 80% predicted – FEV1 > 80% predicted correlates to mild
COPD, between 50 and 80% moderate, between 30 and 50% severe and < 30% very severe per
the GOLD guidelines.

57. Researchers are putting together the analysis and interpretation of what they found in
their clinical research. Which of the following sections would this be a part of in the
clinical literature?
a. Methods
b. Results
c. Discussion
d. Conclusion
Answer – the discussion section of the clinical literature is where the authors interpret and
analyze the data and place their thoughts on how to apply this to clinical practice.

58. With regards to the use of opioids and benzodiazepines, which of the following is true?
a. Naloxone has a role in both opioid and benzodiazepine overdose
b. Opioid withdrawal symptoms are generally considered less lethal than
benzodiazepine withdrawal
c. Anxiety, insomnia, and GI upset are common with opioid withdrawal, but not
benzodiazepine withdrawal
d. When benzodiazepines are used with opioids, there is a reduced risk of opioid
induced respiratory depression
Answer – Opioid withdrawal is considered less lethal than benzodiazepines. They both can
certainly be distressing to patients, but death due to opioid withdrawal is less likely. Anxiety,
insomnia, GI problems are common to both types of withdrawal. Naloxone doesn’t play much
of a role in management of benzodiazepine overdose. Benzo’s in combo with opioids increase
the risk of respiratory depression.

59. A patient would like the recombinant Zoster Vaccine because she currently has an active
Shingles episode. She is 57 years old. Which of the following is true with regards to this
vaccine?
a. It is a one time dose
b. It would not be indicated for her as she is not yet 60 years old
c. They should wait to give her the dose until after the shingles episode has
resolved
d. The Zoster Live Vaccine should be given in place of the recombinant zoster
vaccine
Answer – Recombinant Zoster Vaccine (Shingrix) is indicated in patients who are greater than
50 years old. It is a 2 dose course and more effective than the previous Zoster Live Vaccine
(Zostavax). Even if she has had the Zoster Live Vaccine, she should still receive the recombinant
vaccine. With active shingles, vaccination should wait until it has resolved.

60. A 67 year old female patient has a past medical history of stroke, Parkinson’s, cirrhosis,
esophageal stricture, heartburn, and Ulcerative colitis. She is having difficulty
swallowing her medications. Which of the following would be least likely to exacerbate
her dysphagia?
a. Ulcerative colitis
b. Esophageal stricture
c. Parkinson’s disorder
d. Stroke
Answer – All of the above would be likely to increase her risk for dysphagia with the exception
of ulcerative colitis.

61. A pharmacist is developing an ambulatory care practice within their community

pharmacy. Which of the following billing codes would not be a potential source of
revenue?
a. G0108
b. 99605
c. 99211
d. State Medicaid MTM programs
Answer – 99211 would need to be billed incident to – this would need to be done in physician
based clinic. Diabetes management codes, 99605, and state Medicaid MTM programs
(depending upon the state) may all be potential sources of revenue for a community pharmacy.

62. In the case of a patient with SIADH due to carbamazepine, which of the following
symptoms would be least likely to occur?
a. Edema
b. Confusion
c. Increased risk of seizures
d. Nausea and vomiting
Answer – Edema would be least likely to occur in hyponatremia due to SIADH. CNS changes like
confusion, seizures (if severely low), and GI upset would be the most common symptoms that a
patient would present with in addition to the lab revealing low sodium levels.

63. Which of the following medications would concentrations go up when a patient quits
smoking?
a. Clonidine
b. Clozapine
c. Risperidone
d. Empagliflozin
Answer – Clozapine concentrations can go up when patients quit smoking cigarettes. Cigarette
smoking induces CYP1A2 which is a primary metabolic pathway for the breakdown of clozapine.
We should monitor for toxicity.

64. When developing an ambulatory practice, a SWOT analysis may be a useful tool. Which
of the following is incorrect regarding the SWOT acronym?
a. Strengths
b. Weaknesses
c. Objective data
d. Threats
Answer – SWOT stands for strengths, weaknesses, opportunities, and threats. You want to
identify positive and negative attributes of your pharmacy setting. You also have to look at
what could use improvement or what your location provides (i.e. lots of geriatrics, diabetes,
asthma, etc.). Threats is essentially competition, i.e. is there a pharmacy nearby doing the exact
same thing?

65. One of your patients is having significant signs and symptoms of depression. She has
discussed possibly starting to take an antidepressant with her primary provider. Her
past medical history is fairly unremarkable with the exception of IBS with predominantly
diarrhea which appears under control. She is 46 years old. Known allergies to: Sulfa
drugs, amoxicillin - Which of the following antidepressants would be least appropriate?
a. Sertraline
b. Escitalopram
c. Citalopram
d. All of the above are equivalent
Answer: Sertraline is the most highly serotonergic and will likely have the highest chance of
causing diarrhea in this patient as they have already had a problem with this in the past.
Escitalopram and citalopram would be more appropriate in this situation to minimize the risk of
exacerbating this patient’s IBS.

66. Which of the following is a potential downside of motivational interviewing compared to

providing instructions to patients as to how they should manage their disease.
a. Time consuming
b. Worse outcomes
c. Reduced adherence
d. Increased healthcare costs
Answer – One big disadvantage of motivational interviewing is that it can take a significant
amount of time to listen to the patient, be empathetic, and develop a plan based upon the
patient’s ideas and preferences.

67. Which of the following would not be part of the plan of care in a patient receiving
cyclosporine for plaque psoriasis?
a. Monitor kidney function
b. Minimize use to as short of duration as possible
 c. Reserve for severe cases
d. Monitor CPK
Answer – With cyclosporine, we really want to try to minimize use if possible and use only for
severe cases and as short of a time as possible. Monitoring kidney function is also important
with cyclosporine. Checking CPK would not be a critical part of the plan of care.

68. It is determined that the incidence of cognitive impairment was overestimated by the
physicians tasked with monitoring patients in a clinical trial for a new medication.
Which of the following would best describe this bias?
a. Selection bias
b. Recall bias
c. Observation bias
d. Education bias
Answer – Observation bias is done by the investigators. This occurs when they see an event
happen when it actually isn’t occurring. This can also be represented by observers exaggerating
the impact of an event.

69. Which of the following is false with regards to the use of varenicline?
a. Patients should not smoke while taking this medication
b. GI upset and vivid dreams are two of the more common side effects
c. Administration after eating with a full glass of water is recommended
d. All of the above are true
Answer – Patients can smoke while using this medication. A quit day is typically selected about
a week after starting varenicline, but alternatively can select a date up to 35 days after starting
the medication. Certainly, it is allowable to smoke while on the medication. The partial
nicotine agonist effect should hopefully curb the reward from smoking.

70. Which of the following Annual Wellness Visits cannot be performed by a pharmacist?
a. G0402
b. G0438
c. G0439
d. All of the above can be done by a pharmacist
Answer – G0402 needs to be done by a physician or other qualified practitioner. This is the
initial “Welcome to Medicare” visit done within 12 months of Medicare enrollment. The first
annual Medicare wellness visit (G0438) and subsequent Medicare wellness visits (G0439) can
be done by a pharmacist.

71. With the use of selegiline in Parkinson’s disease, which of the following should be
monitored for?
a. Drug interaction with diphenhydramine
b. Drug interaction with escitalopram
c. Reduced concentrations of carbidopa/levodopa upon initiation when used in
combination
d. Drug interaction with clopidogrel
Answer – Selegiline has MAOI activity and could increase the risk of serotonin syndrome when
used in combination. This is usually only a concern with patients on higher doses, but it should
be monitored for. The tyramine/food interaction is also possible, but not near as likely as MAOI
antidepressants due to selegiline’s activity on MAO type – B. Meaningful interactions with
diphenhydramine and clopidogrel wouldn’t be that clinically significant. Selegiline would raise
concentrations of dopamine by reducing enzymatic breakdown.

72. Which of the following is false regarding GLP-1 agonists?

a. They are available in twice daily, once daily and once weekly injectable
formulations
b. They can lower A1C by 1-1.5%
c. GI adverse effects are the most common
d. They are associated with weight gain
Answer: D. They are associated with weight gain – GLP-1 agonists are advantageous in that
they can help with weight loss versus weight gain. Downsides; injectable (except oral
semaglutide), expensive. Liraglutide actually has a product that is specifically indicated for
weight loss (3 mg dosing vs. 1.8mg).

73. Which of the following is true with regards to the use of misoprostol in prevention of
NSAID induced ulcers?
a. It is considered just as effective as PPI’s
b. It is an option in patients who are pregnant
c. It causes constipation as its major adverse effect
d. It should be avoided due to risk of SJS
Answer – Misoprostol is considered just as effective as PPI’s; however, its side effect profile is
what prevents us from using it. It has a high incidence of GI adverse effects like GI pain, upset
and diarrhea. Constipation is not common. It doesn’t have a significantly higher incidence of
SJS compared to other medications. It should absolutely be avoided in pregnancy (remember
that the medication is used in abortion).

74. A 45 year old male patient has been diagnosed with a tumor that is excessively secreting
aldosterone. Which of the patient’s medications would potentially exacerbate the
effect of aldosterone on potassium?
a. Spironolactone
b. Metolazone
c. Ivabradine
d. Amlodipine
Answer – Excessive aldosterone production would likely lead to hypokalemia. Hypokalemia is
most likely to be exacerbated by diuretics like loops and thiazides. Metolazone being a thiazide
like diuretic would lower potassium levels. Spironolactone would potentially help block the
aldosterone effects. Ivabradine and amlodipine would likely have no to minimal impact on
potassium.

75. With the use of valproic acid, which of the following is false?
 a. Drug levels to assess efficacy for migraine prophylaxis should be checked
periodically
b. Ammonia levels should be checked in any patient displaying confusion or
potential CNS adverse effects
c. Adding valproic acid to lamotrigine can increase the risk of lamotrigine induced
rash
d. Valproic acid tends to cause more weight gain than weight loss
Answer – Valproic acid levels are typically not drawn for migraine prophylaxis. We are going to
monitor clinical response (reduction of migraine # and severity). In the event of possible
toxicity, we may check a level, but this would not likely be done for efficacy. In seizure
disorder, it would be much more important to assess levels. The other statements about VPA
are true.

76. A 44 year old Army veteran has a history of PTSD and nightmares. He also is having
elevated blood pressures. Which of the following would potentially be beneficial for
both of these indications?
a. Valsartan
b. Prazosin
c. Hydralazine
d. Chlorthalidone
Answer – Prazosin has some potential benefit for its antihypertensive effect as well as in the
management of nightmares.

77. Which of the following is not an accurate education point with lidocaine patches?
a. Patches can be cut to fit the size of the painful location
b. Up to 3 patches can be used at once
c. Recommend a 12 hour lidocaine free period out of every 24 hours
d. All of the above are appropriate education points
Answer – all of the above are true in this question. 12 hours on/12 hours off, 3 patches at a
time are ok (but expensive), and the patches can be cut, unlike fentanyl, clonidine, oxybutynin
patches etc.

78. Which of the following would be the least effective strategy at delaying progression of
peripheral arterial disease?
a. Appropriate assessment and initiation of statin therapy
b. Use of pentoxifylline for prophylaxis measures
c. Smoking cessation
d. Initiating aspirin therapy
Answer – Pentoxifylline isn’t that effective of an agent for peripheral arterial disease and if it
does have any benefit, it will likely be just for symptoms of things like intermittent claudication.
It would not have a role in delaying progression and reducing long term risk. Management of
cardiovascular risk such as hypertension, statin, aspirin, and smoking cessation would be the
best strategy to help reduce risk of future complications from PAD.
 79. A 55 year old male has diagnoses of hypertension, BPH, depression, and GERD. He
reports experiencing significant sexual dysfunction. Which of his medications would be
most likely to cause this?
a. Finasteride
b. Lisinopril
c. Terazosin
d. Bupropion
Answer – Finasteride ultimately reduces dihydrotestosterone levels by inhibition of 5-alpha-
reductase. This reduction in dihydrotestosterone is most likely to contribute to sexual
dysfunction.

80. Of the following HIV agents, which would place a patient at highest risk for fat deposits
in the back and neck contributing to “buffalo hump”?
a. Lopinavir/ritonavir
b. Emtricitabine
c. Raltegravir
d. Maraviroc
Answer – the protease inhibitors would be most associated with this adverse effect and likely to
cause the fat redistribution as mentioned above.

81. Why is sulfamethoxazole avoided in the later stages of pregnancy?

a. Risk of tooth discoloration for the baby
b. Risk of abnormal limb formation
c. Risk of hemolytic anemia
d. Sulfamethoxazole can be used in all stages of pregnancy
Answer – Sulfamethoxazole can cause hemolytic anemia and in particular, in those that have
G6PD deficiency.

82. As a preceptor, you’d like the student to educate a new asthma patient on how to use
an inhaler. Throughout the process, the preceptor provides direct feedback to the
student as they see necessary. This process would be considered:
a. Instruction
b. Modeling
c. Coaching
d. Facilitating
Answer – This would be coaching. Modeling would involve the preceptor giving the education
first and the student copying (modeling). Instruction would be simply giving information on
how to do the task to the student without the activity. Facilitating involves giving the student
independence to do the activity without much oversight and then talk about it later.

83. A 68 year old male has atrial fibrillation. Which of the following would NOT be used for
rate control?
a. Amiodarone
b. Metoprolol
 c. Verapamil
d. Digoxin
Answer: A. Amiodarone – Non-dihydropyridine calcium channel blockers and beta blockers are
typical meds used for rate control. Amiodarone is used for rhythm control not rate.

84. Which of the following would not be associated with the use of trazodone?
a. Lower doses are typically used for insomnia while higher doses are more
associated with the antidepressant benefit
b. A common side effect is dry mouth
c. The patient on blood pressure medication should monitor for orthostasis risk
d. Thyroid levels should be monitored 3-6 months following initiation
Answer – monitoring of thyroid levels would not be necessary. Dry mouth, sedation, and
orthostasis would all be important adverse effects to monitor for. Lower doses are typically
used for insomnia, while higher doses are usually necessary to get the antidepressant effect.

85. In the management of Crohn’s disease, which of the following is true in regards to the
use of oral budesonide?
a. Low bioavailability due to high first pass effect
b. Primarily metabolized via CYP 2D6
c. It has an extremely long half-life compared to other corticosteroids (weeks)
d. It has no risk of HPA suppression
Answer: A. Low bioavailability due to high first pass effect – oral budesonide is metabolized via
3A4 and has a very high first pass effect making bioavailability very low. It has a short half-life
and may carry less of a risk for HPA suppression compared to other corticosteroids, but
certainly does have some risk when used chronically.

86. Phenobarbital will have highest potential to cause deficiency of what vitamin?
a. B12
b. B1
c. Vitamin D
d. Vitamin C
Answer – Phenobarbital can induce metabolism of vitamin D. This can ultimately lead to
deficiency and potential issues with bone formation etc.

87. A 62 year old female has a history of cardiovascular disease, alcoholism, Raynaud’s
disorder, atrial fibrillation, diabetes, stroke, cirrhosis, and history of medication non-
compliance. With the new onset of atrial fibrillation, it is determined to initiate warfarin
for anticoagulation and stroke prevention. She is started on 5 mg once daily of warfarin
and an INR is to be checked daily. Upon checking the INR after the first day, it was 2.1.
Which of the following actions would be most appropriate?
a. Continue current dose and recheck INR in 1 week
b. Stop warfarin and start apixaban
c. Question patient about adherence
d. Reassess other diagnoses and risk/benefit of using anticoagulation
Answer – With this patient’s history of cirrhosis, we should reassess anticoagulation in this
scenario. Remember that with liver impairment, we can have a reduced capacity to make
clotting factors. This is the most likely the cause of the elevated INR compared to the one dose
of warfarin. This elevation is likely not due to an adherence issue. Continuing current dose and
rechecking in one week would be very risky as this INR is likely to go higher as warfarin takes 3-
7 days to get to full effect.

88. A 45 year old female has an A1C of 7.1. She has some cognitive impairment due to mild
mental retardation. She is in charge of her medications and has been able to
appropriately manage them. She currently takes metformin 1,000 mg twice daily and
glipizide 5 mg once daily. In the last 4 weeks, she has had three hypoglycemia episodes.
Which medication might be likely to impact her ability to recognize early symptoms of
hypoglycemia?
a. Pseudoephedrine
b. Propranolol
c. Topiramate
d. Venlafaxine
Answer – The propranolol would be the most likely agent that would blunt the signs and
symptoms of hypoglycemia. Sweating usually is unaffected by the beta-blocker which the
patient could be educated on to monitor for. Certainly, we’d also reassess the use of the
sulfonylurea and maybe switch to an alternative oral agent (i.e. DPP4, SGLT2, etc.)

89. Which of the following is an advantage of pioglitazone over acarbose?

a. Once daily dosing
b. Weight neutral to weight loss
c. Lower risk of hypoglycemia when used alone
d. More effective A1C lowering
Answer – once daily dosing is the advantage of using pioglitazones over alpha-glucosidase
inhibitors like acarbose. Acarbose and pioglitazone aren’t typically used much with all of the
newer available agents. Pioglitazone causes weight gain, while acarbose needs to be dosed
frequently throughout the day and cause a lot of GI side effects. Relative effectiveness of A1C
lowering isn’t clinically significantly different between these agents.

90. How frequently can a Targeted Medication Review be completed and billed for?
a. Monthly
b. Quarterly
c. Bi-annually
d. Yearly
Answer – Targeted Medication Reviews can be done on a quarterly basis. Comprehensive
Medication Reviews can be completed and billed on an annual basis.

91. A 38 year old presents to discuss some trouble with his feet. He has noticed itching,
burning and redness in between his toes. Past medical history is heartburn for which he
takes ranitidine. The symptoms have been happening for a few months. It has become
 painful of late. He also reports working out and showing at the local gym. Which of the
following would be most appropriate to recommend?
a. Recommend referral to podiatrist
b. Initiate topical clotrimazole
c. Oral fluconazole would be recommended
d. Recommend topical nystatin
Answer – This appears to be a case of athlete’s foot and topical clotrimazole would be a very
appropriate over the counter selection. The case does not appear to warrant oral therapy at
this time.

92. A 61 year old female has a history of Factor 5 Leiden. Which of the following
medications would most likely increase complications associated with this diagnosis?
a. Raloxifene
b. Alendronate
c. Teriparatide
d. Denosumab
Answer – Factor 5 is a clotting disorder where a patient is at higher risk of DVT/blood clots.
Raloxifene can potentially increase this risk in comparison to the other osteoporosis agents
listed.

93. A patient is placed on azathioprine for severe Crohn’s disease. Which of the following
would be least important in regards to its use?
a. Azathioprine can increase the risk of lactic acidosis and this should be
monitored for
b. LFT’s should be monitored
c. Allopurinol can significantly raise concentrations and lead to myelosuppression
d. Azathioprine can increase the risk of malignancy
Answer – Lactic acidosis would not be common with the use of azathioprine. It is an
immunosuppressant medications and infection and malignancy risk should be monitored.
Allopurinol can significantly raise concentrations and LFT’s should be monitored in patients on
chronic therapy as well.

94. Which of the following would not be consistent with drug induced Cushing’s syndrome?
a. Weight loss
b. Acne
c. Osteoporosis risk
d. Erectile dysfunction
Answer – Weight gain would be common with drug (steroids) induced Cushing’s syndrome.
Acne, OP, ED, fatigue, CNS changes, abnormal fat distribution (i.e. buffalo hump, elevated BP,
and elevated blood sugars are all associated with elevated levels of corticosteroids.

95. A patient is receiving furosemide and metolazone for her CHF. She also has
uncontrolled diabetes. Which of the following medications would have greatest impact
on increasing the risk of dehydration?
 a. Metformin
b. Glipizide
c. Semaglutide
d. Empagliflozin
Answer – While there is evidence that the SGLT2 inhibitors could reduce the risk of heart failure
hospitalization, they do have a mild diuretic effect and could potentially worsen dehydration
risk. There have been case reports of acute kidney injury due to this. It would probably be best
to avoid this medication if kidney function is already poor as it also lacks blood sugar lowering
benefit when renal function is impaired. If kidney function is adequate, you would need to
closely monitor as the patient is at higher risk of renal complications due to the diuretics.
Metformin obviously shouldn’t be used in the setting of significant kidney impairment, but it is
not strongly associated with cause renal impairment on its own.

96. Which treatment regimen would be most appropriate for initial therapy for treatment
of peptic ulcer due to H. Pylori?
a. Clarithromycin and omeprazole
b. Lansoprazole, bismuth, metronidazole, and tetracycline
c. Levofloxacin, azithromycin, and omeprazole
d. Amoxicillin, oral vancomycin, tetracycline, and omeprazole
Answer – A PPI, bismuth, metronidazole, and tetracycline (or doxycycline) quadruple therapy is
the usual regimen of choice. Levofloxacin generally has higher rates of resistance and isn’t
typically used in first line therapy barring contraindications or allergies to other agents. Oral
vancomycin isn’t typically used in the management of H. pylori (used as drug of choice in C.
Diff).

97. One of your patients has recently been diagnosed with GERD and Barrett’s esophagus.
He doesn’t like to take medication and would prefer not to take his omeprazole any
longer. He has taken it for about 4 weeks at this point. Which of the following actions
would you recommend that he take?
a. 4 weeks should be long enough, he will likely be able to stop following discussion
with his physician
b. Management of Barrett’s should continue for at least 12 weeks, he should
continue until then and follow up with his physician for reassessment
c. He should continue at least one year, then follow up for reassessment
d. Educate him that he will likely have to continue this medication for the rest of
his life
Answer – Best evidence in the management of Barrett’s is to continue the PPI indefinitely to
reduce the risk of esophageal adenocarcinoma. Uncontrolled acid reflux may lead to further
damage and increase the risk for cancer formation.

98. Which of the following regarding eye drop administration is incorrect?

a. You should wait at least 5 minutes between eye drops
b. To ensure adequate efficacy, you can advise patients to place their finger gently
on the tear duct and gently apply pressure
 c. The tip of the eye dropper can gently touch the eye as long as the dropper is
immediately rinsed after administration
d. Recommend that if the eye dropper is chipped or cracked that the patient
should not use the eye dropper
Answer: The tip of the eye dropper can gently touch the eye as long as the dropper is
immediately rinsed after administration – To avoid contamination, it is NOT recommended to
touch the eye dropper to the eye. The other statements are correct regarding eye drop
administration.

99. Which of the following would be least expected with use of roflumilast?
a. Improvement in respiratory symptoms
b. Risk of drug induced rash
c. Potential to cause weight loss
d. Risk of neuropsychiatric events
Answer: Risk of drug induced rash – Roflumilast is a PDE-4 inhibitor used in the treatment of
COPD. Improvement in respiratory symptoms, risk of weight loss and neuropsychiatric events
would be the most probable outcomes associated with this medication (there are
warnings/precautions about possible GI effects/weight loss and neuropsychiatric events).

100. A 64 year old with Type 2 diabetes presents to her annual physical and has her A1C
drawn. Past medical history includes hypertension, CAD, osteoarthritis, constipation,
and urinary incontinence. She also recently had a lengthy back surgery that lasted
about 4 hours just a couple weeks ago. She reports feeling a little tired, but overall pain
has improved. Her blood sugars are under decent control and she reports that they
have been between 80-130 most days and she has not had any hypoglycemia. Current
medications include; metformin, glipizide, aspirin, clopidogrel, rosuvastatin, clonidine,
lisinopril, sennosides, and tolterodine. Labs include WBC = 4.9 cells/L, Hemoglobin 9.1
g/dL, potassium 5.2 mEq/L, sodium = 141 mEq/L, Creatinine 1.0 mg/dL, A1C = 5.3.
Which of the following actions would be most appropriate with her diabetes?
a. Reduce or discontinue glipizide
b. Reduce or discontinue metformin
c. Continue same medications, continue to monitor blood sugar and repeat A1C
in 3 months
d. Discontinue lisinopril which is being used to help with diabetic nephropathy
Answer - The potassium level is not that severely elevated and should be continued at this time.
Follow up potassium in the next 3-6 months might be appropriate, but discontinuing at this
point doesn’t seem appropriate. The A1C is likely falsely low due to the blood loss and
substantial anemia likely from the surgery. No hypoglycemia is noted when she is checking and
she reports no episodes. Reducing or changing metformin or glipizide at this time seems
inappropriate.

101. Which of the following is true with the use of rivaroxaban in the management of atrial
fibrillation?
a. Usual dosing is 15 mg BID for 21 days, then 20 mg daily
 b. In patients with Creatinine clearance of 52 mls/min, dosages should be reduced
c. Phenytoin and rivaroxaban combination should be avoided
d. When converting to warfarin, rivaroxaban can be discontinued and warfarin can
be started at the usual time
Answer – The only true statement here would be that phenytoin and rivaroxaban combination
should be avoided. Phenytoin is a strong inducer of 3A4 and could lead to reduced
concentrations. The usual cut off for renal adjustments is 50 mls/min. 15 BID for 21 days is
dosing for DVT treatment. Typically, it is recommended to switch to enoxaparin and then
bridge to warfarin. The enoxaparin would be discontinued when the INR is at goal.

102. When using NSAIDs, which of the following strategies would be most effective to
minimize the risk of drug induced renal dysfunction?
a. Switching traditional NSAIDs to celecoxib
b. Adding low dose hydrochlorothiazide with the NSAID
c. Encourage adequate exercise
d. None of the above
Answer: None of the above – NSAIDs can cause renal impairment, and while using celecoxib
can possibly help GI bleed risk, the risk to the kidney remains the same. Adding low dose HCTZ
would likely increase risk to the kidney and while exercise is generally a good thing to
recommend, it wouldn’t likely have an impact on kidney risk in relation to drug related causes.

103. JS is having some frequency of urination at night. She would like a medication to help
with this. She has a history of hypertension, DVT/PE, and GERD. Current medications
include omeprazole 20 mg once daily, chlorthalidone 12.5 mg twice daily, ranitidine
150 mg in the evening, rivaroxaban 20 mg once daily, and amlodipine 5 mg once daily.
BP = 112/58, pulse = 62. Which of the following would be the most appropriate
recommendation?
a. Initiation of trospium
b. Discontinuation of 2nd dose of chlorthalidone
c. Initiation of oxybutynin
d. Initiation of mirabegron
Answer – Since the frequency is happening at night and blood pressure is very well controlled,
the best solution to avoid contributing to polypharmacy would be to discontinue the 2nd
chlorthalidone dose. If unsuccessful in reducing frequency, then it would be reasonable to
consider alternative options.

104. A 38 year old breastfeeding female has been diagnosed with bacterial mastitis. Which
of the following would be the most appropriate agent to initiate?
a. Ciprofloxacin
b. Cephalexin
c. Sulfamethoxazole/trimethoprim
d. Azithromycin
Answer – A simple beta-lactam would be the drug of choice for mastitis. Also remember that
we need to think about medications that would be compatible with breastfeeding. Beta-
lactams are typically not an issue as we give these medications to the baby as well.

105. A 64 year old male has a history of hypertension, renal transplant, Parkinson’s,
osteoarthritis, neuropathy, and Barrett’s esophagus. His wife is noting that he has had
a change in cognition and is more confused. She also says he is reporting seeing
spiders on the walls and this is very distressing to him. Which of his medications would
be most likely to contribute to this?
a. Clonidine
b. Tacrolimus
c. Duloxetine
d. Carbidopa/levodopa
Answer – Drugs that can increase dopamine levels are associated with hallucinations and CNS
changes. Carbidopa/levodopa is often associated with hallucinations and CNS changes. He is
likely supratherapeutic with this medication and a reduction might be considered in this
situation.

106. Which of the following would not be considered one of the CMS goals of the
Medication Therapy Management program?
a. Review of medication costs
b. Development of compounded dosage forms that may be necessary for a
patient
c. Identification of drug interactions
d. Reducing the risk of adverse effects
Answer – MTM is intended to be a review of a patient’s medications to develop goals of
therapy, identify drug interactions, adverse effects, assess adherence and make sure there are
no barriers to appropriate medication use such as medication costs.

107. A 52 year old male has controlled hypertension at 126/74 and is taking amlodipine 10
mg daily. He has a pretty unremarkable medical history otherwise. His LDL was
checked 6 months ago and was 206. He was going to try to implement lifestyle
changes. It was repeated today and revealed an LDL of 198. Which of the following
would be the most appropriate treatment for this patient?
a. Simvastatin 40 mg daily
b. Pravastatin 10 mg daily
c. Atorvastatin 10 mg daily
d. Rosuvastatin 20 mg daily
Answer – Given the LDL of >190, this patient should be receiving a high intensity statin.
Rosuvastatin 20 mg is the only medication that would get us to high intensity management.

108. A 6 year old has a first degree burn after putting his foot on a hot burner on the stove.
He was climbing up on the counter to get a glass out of the cupboard. He says it is
 painful and itches sometimes as well. Which of the following agents would be most
appropriate to use to help manage discomfort?
a. Aloe
b. Topical hydrocortisone
c. Prednisone
d. Topical diclofenac
Answer – A first degree burn is the least severe type of burn and aloe would be the most
appropriate recommendation here. Corticosteroids can impair healing and are generally
avoided. Topical diclofenac would not have a role in the management of burns.

109. A 71 year old has significant neuropathy and has been tried on duloxetine, venlafaxine,
gabapentin, and pregabalin. The primary care provider would like to consider a TCA to
help with his severe pain. Which of the following would be most appropriate?
a. Amitriptyline
b. Nortriptyline
c. Doxepin
d. Diphenhydramine
Answer – Diphenhydramine is not a TCA and would not be indicated in the management of
neuropathy. Doxepin is generally associated with better relief of itching and other concerns
compared to neuropathy. Nortriptyline is considered a better tolerated TCA in the elderly if
one has to be used. Amitriptyline is more likely to cause complications in the elderly.

110. A 66 year old female is on chronic trimethoprim for UTI prophylaxis. Which of the
following additions would potentially interact with trimethoprim and lead to
electrolyte abnormalities?
a. Metolazone
b. Carbamazepine
c. Losartan
d. Sertraline
Answer – Trimethoprim has the potential to raise potassium levels and this is more prevalent in
patients who are on other medications that can raise potassium.

111. One of your patients presents with a genetic testing profile. It states that they are a
slow metabolizer at CYP3A4 and CYP1A2. They are a rapid metabolizer at enzymes
CYP2D6 and CYP2C19. Which of the following genetic variations would be anticipated
to affect the clinical response to hydrocodone the most?
a. Increased response due to CYP2C19 genetic variation
b. Increased response due to CYP2D6 genetic variation
c. Reduced response due to CYP3A4 genetic variation
d. Reduced response due to CYP1A2 genetic variation
Answer – hydrocodone is converted to hydromorphone which is significantly more potent than
hydrocodone. CYP2D6 is the enzyme responsible for this conversion and a rapid metabolizer at
this enzyme would be expected to have greater opioid activity.
 112. JS is a 79 year old male with a history of cyanocobalamin deficiency. He reports taking
his oral supplement faithfully, but levels remain low. He is on 1,000 mcg once daily.
Which of the following would be most appropriate to replace stores?
a. Take it with vitamin C
b. Change to injectable
c. Add folic acid
d. Increase dose
Answer – In elderly patients, there may be a challenge in absorbing vitamin B12 due to a
deficiency in intrinsic factor. There isn’t any magical way to overcome this and still give the oral
supplement. Of the options provided, the most appropriate option would be to switch to IM
B12.

113. A 43 year old female has a history of bipolar depression, hypertension, rheumatoid
arthritis, and GERD. Labs reveal thrombocytopenia. Which of her medications would
be most likely to contribute?
a. Lamotrigine
b. Valproic acid
c. Methotrexate
d. Valsartan
Answer – Valproic acid has the strongest association with low platelets and could potentially
cause this problem.

114. A 61 year old female has a history of resistant hypertension and was placed on
hydralazine about 1 year ago. She is experiencing fatigue, hair loss, and having a lot of
swelling and pain in her joints. Which of the following assessments would help us
identify what the issue is?
a. ANA
b. CPK
c. ESR
d. BNP
Answer – An antinuclear antibody titer is recommended for patients on hydralazine as this
medication can cause a drug induced Lupus type situation. This lab would help us determine if
the reported problems were due to the medication.

115. 200 patients with fibromyalgia were followed to monitor their frequency of exercise. A
95% confidence interval ranged between 0.28 and 0.47 for the proportion who
exercised regularly. Which of the following statements would be erroneous?
a. More than half exercised regularly
b. The hypothesis that 40% exercise regularly cannot be rejected
c. More than 25% exercised regularly
d. Less than 100 of the patients in the study exercised regularly
Answer – The confidence interval is represented as a proportion. If the confidence interval was
close to 1, that would mean that nearly everyone exercised. We have a proportion between 28
and 47% of the patients meaning less than 50% (100 patients). 40% lies within the confidence
interval and cannot be rejected. Certainly, more than 25% exercised regularly.

116. A 58 year old obese patient has recently been diagnosed with diabetes. His A1C is 8.6
despite efforts to change his lifestyle and eating habits. Past medical history includes
gout, osteoarthritis, an MI 5 years ago, hypertension, hyperlipidemia, and GERD.
Which of the following interventions would be most appropriate?
a. Canagliflozin
b. Metformin
c. Liraglutide
d. Sitagliptin
Answer – Don’t over think this one. Metformin is the initial drug of choice. Liraglutide does
have the potential to reduce cardiovascular risk, but from an efficacy, guideline, and cost
perspective, metformin would be the initial drug of choice if it has never been tried.

117. A 44 year old female presents with increasing fatigue. She also has restless leg
syndrome and has had unusual cravings for ice cubes. Which of the following lab
assessments would be most important?
a. Magnesium
b. Vitamin D
c. Iron
d. Folic Acid
Answer – Restless legs, unique cravings, and possible anemia can happen from iron deficiency.
The others might be appropriate to monitor, but the most likely contributing factor would be
iron deficiency and this would be at the top of the list.

118. A 57 year old male has been started on insulin degludec as his blood sugars have been
very high. He has consistently been in the 300’s-400’s. You are helping instruct him on
using the device. He was instructed to slowly increase his insulin by 2 units over time
until his morning blood sugar was less than 150 mg/dL and then contact his primary
provider. He cannot recall how often he was supposed to increase the dose? You
contact the provider to provide a recommendation. Which of the following would be
most appropriate?
a. Increase the dose daily until reaching goal
b. Increase dose every 3 days
c. Increase dose on a weekly basis
d. Increase dose on a bi-weekly basis
Answer – For the really long acting insulins like degludec, you really want to be careful about
making sure the patient is at or close to steady state before increasing the dose so as to not
substantially increase the risk of hypoglycemia. That timeframe is usually 3-4 days. We
wouldn’t want to wait much longer than we have to in this patient as his sugars are very high.

119. A 61 year old female with CHF presents with worsening shortness of breath. Ejection
fraction is 35%. She has not tolerated loop diuretics in the past. Current vitals include
 BP 144/88, pulse = 67. Labs include creatinine = 1.1 mg/dL, Na+ = 141 mEq/L, K+ = 5.1
mEq/L, ALT 17 u/L, AST 19 u/L, Hemoglobin = 12.1 g/dL. Current medications include
aspirin 81 mg daily, lisinopril 10 mg daily, Carvedilol 6.25 mg twice daily. Which of the
following would be most appropriate to help with her acute exacerbation?
a. Metolazone
b. Spironolactone
c. Add sacubitril/valsartan
d. Increase Carvedilol
Answer – With the challenge of loop diuretic intolerance, we have to consider other options to
help reduce fluid overload. Use of a diuretic would be most important. Adding the
spironolactone would increase the risk of potassium elevations with the current level being 5.1.
Metolazone, a thiazide like diuretic would be the most appropriate to initiate to help the
exacerbation and not raise potassium levels. Increasing lisinopril and carvedilol is reasonable as
we try to maximize doses in CHF, but this likely won’t take care of the acute exacerbation.
Increasing the lisinopril could also add to hyperkalemia. Adding sacubitril/valsartan would not
help with the acute exacerbation and we would also need to DC the ACE inhibitor if we were
going to do that.

120. Which of the following models would a healthcare facility be paid a fixed amount each
month to care for an enrolled patient in a healthcare plan?
a. Fee-for-service
b. Capitation
c. Group practice
d. Partial reimbursement
Answer – Capitation is the term used to describe a reimbursement system that provides a fixed
dollar figure to take care of a patient. Healthcare models are shifting in this direction and away
from fee-for-service.

121. Which of the following would not be consistent with digoxin toxicity?
a. Hyperthyroidism
b. GI upset
c. Confusion
d. Visual changes
Answer – While rare, visual changes can happen. More common to digoxin toxicity is GI upset,
weight loss, and confusion. Hyperthyroidism would not be consistent with digoxin toxicity.

122. For educating an illiterate patient about using insulin, which of the following would be
least effective?
a. Audio/visual presentation
b. Demonstration
c. PowerPoint presentation
d. Educational handouts
Answer – Educational handouts would likely be the least effective in a patient who cannot read.
All other teaching methods would likely involve some sort of pictures or supplemental
education other than just words.

123. You are seeing a patient for medication therapy management. This is a patient you
have established care with for years and have been following. She was in 3 months ago
and had a change in her antihypertensive therapy. You meet with the patient for 15
minutes and in collaboration with the physician, you decide to increase her amlodipine.
Which of the following billing codes would be most appropriate?
a. 99605
b. 99606
c. 99607
d. 99606 and 99607
Answer – This would be a follow up with an established patient. 99606 would be the
appropriate billing code since it only lasted 15 minutes. If it lasted 30 minutes, the appropriate
coding would have been answer D.

124. Which one of the following medications would be least likely to contribute to drug
induced hypertension?
a. A 78 year old female who is taking mirabegron
b. A 55 year old female on conjugated estrogens
c. A 72 year old male on diphenhydramine
d. An 88 year old male on nabumetone
Answer: C. A 72 year old male on diphenhydramine – NSAIDs, mirabegron (beta-agonist
activity), and estrogen therapy would be the most likely culprits as far as exacerbating
hypertension. Diphenhydramine would be least likely to contribute to hypertension.

125. Which of the following would not increase the need for ambulatory care services?
a. Increasing technology allowing for more outpatient procedures
b. Regulatory pressure to lower costs of care
c. Preferred outpatient versus inpatient care
d. Lower numbers of elderly patients
Answer – All of the above except reduced numbers of elderly patients would increase the need
for ambulatory services. Increasing outpatient procedures, reducing costs of care by minimizing
hospital stays and emergency department visits will increase the need for ambulatory care
services. Higher numbers of elderly patients would increase the need for ambulatory services.

126. With regards to use of contraception, which of the following would be incorrect?
a. Progestin only oral products are less sensitive to missed doses than
estrogen/progesterone combination tablets
b. Elevated estrogen in a product is more likely to cause nausea and headaches
c. Progestin only products are safer to use during breast feeding than combination
progestin/estrogen
d. Topical combination patches may be less effective in patients over 90 kg
Answer – All of the above are true with the exception of the first statement. Progestin only
products are much more sensitive to missed or delayed doses. Even if off of timing for a few
hours, this can potentially increase risk of breakthrough bleeding and/or pregnancy.

127. Which of the following is false with regards to Chronic Care Management billing codes?
a. They are billed incident to a primary provider
b. The code is 99490
c. The work can only be completed by pharmacists
d. It can be billed monthly
Answer – All of the above are true with the exception of C. The work can be completed by
pharmacists or other clinical staff (i.e. nurses). It can be billed monthly and the work must take
at least 20 minutes. This is generally not considered a face to face visit but more non-face to
face clinical work. Telephone call check-ins, medication reconciliation, disease state education
are examples of tasks that may be a part of this work.

128. A 71 year old female was recently diagnosed with generalized anxiety disorder. She
was placed on sertraline and this was titrated up to 150 mg once daily. This has not
helped much. The primary provider added buspirone 7.5 mg two times daily as needed.
The patient has tried it a couple of times and hasn’t noticed much benefit. No adverse
effects reported. Which of the following recommendations would be most
appropriate?
a. Recommend discontinuing the buspirone and initiate triazolam
b. Discontinue sertraline and schedule buspirone
c. Schedule buspirone 7.5 mg twice daily and begin to taper off of sertraline
d. Recommend increasing buspirone to 15 mg twice daily as needed
Answer – We would ideally like to give buspirone a trial for several weeks as it takes a while to
work. Discontinuing sertraline at this high of a dose could potentially lead to discontinuation
syndrome. The patient has tried the buspirone and did not experience any side effects so
tapering down on the sertraline appears most appropriate. Buspirone can exacerbate
serotonin risk. PRN buspirone is typically not effective, so increasing the PRN dose would not
be appropriate. Triazolam, a benzodiazepine is not ideal in a 71 year old if we can avoid it.

129. Use of PPI’s is associated with all of the following, except:

a. Low B12 levels
b. Elevated Magnesium levels
c. Increased risk of bone fractures
d. Rebound symptoms with abrupt discontinuation
Answer – PPI’s are associated with low B12, LOW magnesium, fractures, and definitely rebound
symptoms with chronic use and abrupt discontinuation.

130. A patient with glaucoma has been on numerous different eye drops for management.
He says that he noticed excessive eye lash growth with one of his medications which
was unusual. Which of the following would be most likely to do this?
a. Timolol
 b. Brimonidine
c. Dorzolamide
d. Travoprost
Answer – prostaglandins can cause changes in the eye lashes and would be the most likely
medication to cause this problem. It may be considered a beneficial adverse effect for some
who are looking for longer/thicker lashes.

131. A 32 year old female is pregnant and prior to the pregnancy had been managing
depression well with counseling alone. She has had tremendous relapse since
becoming pregnant and drug therapy is desired. Which of the following would be most
appropriate to use?
a. Paroxetine
b. Sertraline
c. Nortriptyline
d. Mirtazapine
Answer – Sertraline has the best track record for safety in pregnancy when compared to
paroxetine. SSRI’s are going to be the first line agent. Nortriptyline and mirtazapine would not
generally be recommended first line in a patient who is pregnant.

132. JS is a 45 year old female who has been having more migraines of late. Typically, she
has only had a couple a year and used naproxen and acetaminophen combination to
manage them. She is now having them about monthly and her PCP would like to start
a triptan. Past medical history includes kidney stones, peptic ulcer disease, IBS, and
hypertension. BP = 128/68, pulse = 66. Which of the following would be a
contraindication to use?
a. Hypertension
b. Kidney stones
c. Peptic ulcer disease
d. None of the above
Answer – None of the above are contraindications. The blood pressure is well managed. It
would be a contraindication if it was uncontrolled.

133. A 91 year old patient has been experiencing significant anxiety since the loss of her
husband. She has been tried on numerous anxiety medications that have had minimal
effectiveness. Her primary provider has tried to avoid benzodiazepines due to her fall
risk. Which of the following benzodiazepines would be safest in this patient to treat her
anxiety?
a. Clonazepam
b. Oxazepam
c. Chlordiazepoxide
d. Diazepam
Answer: Oxazepam – Due to no active metabolites, remember the term “LOT” (lorazepam,
oxazepam, temazepam). These are generally considered the safest to choose in the elderly.
 134. A 58 year old male has had a history of hypertension, hyperlipidemia, morbid obesity,
BPH, and diarrhea predominant IBS. He currently takes loperamide, aspirin,
atorvastatin, and chlorthalidone. He reports feeling down and primary care initiates
sertraline 50 mg once daily. What is the best recommendation?
a. Continue sertraline as prescribed
b. Switch sertraline to escitalopram
c. Switch sertraline to amitriptyline
d. Switch sertraline to mirtazapine
Answer – Sertraline being the worst antidepressant for causing diarrhea should likely be
avoided if other options exist. An SSRI would still be the best choice of the options listed so
switching to escitalopram makes the most sense. Amitriptyline could help with the diarrhea,
but with his BPH should be avoided. Mirtazapine would be pretty likely to cause weight gain in
the patient who is morbidly obese.

135. Which of the following would not be an integral part of an MTM session?
a. Identification of possible new diagnosis
b. Distinguishing potential adverse effects
c. Recognition and evaluation of past medical history in relation to the patient’s
current drug therapy
d. Detect possible barriers to patient medication adherence
Answer: A. Identification of new diagnosis would fall outside of the pharmacist’s scope of
practice and the patient should be referred to a physician or other appropriate healthcare
professional for identification of a new diagnosis.

136. A 55 year old patient has a history of elevated triglycerides, gout, and recent labs reveal
blood pressure 118/72, pulse 77, cholesterol 289mg/dL, HDL 48 mg/dL, LDL 119 mg/dL,
triglycerides, 1123 mg/dL. He is currently on allopurinol 300 mg daily, colchicine 0.6
mg as needed for flares, aspirin 81 mg daily, and lisinopril 10 mg daily. Which of the
following would be most appropriate to address the current situation?
a. Lifestyle modifications
b. Fenofibrate
c. Niacin
d. Fish Oil
Answer – Triglycerides are very high and we should initiate an agent that can help lower these.
Lifestyle modifications would be important, but at these levels, we should initiate drug therapy
due to the risk of pancreatitis. Fenofibrate would be the most appropriate here. Niacin could
exacerbate the patient’s gout.

137. You are working with a physician group to reduce the number of hospital readmissions.
A patient is seen 10 days following a hospital stay. Your role is to make sure the patient
understands their medications, review for adverse effects and drug interactions, and
assesses medication reconciliation. Which of the following billing codes can be billed
incident to for a transitional care visit?
a. 99495
 b. 99496
c. G0463
d. 99211
Answer – the transition care codes are 99495 and 99496. These codes can be billed incident to
the provider and the pharmacist can play a significant role in focusing on medication changes.
The only one that can be billed however is 99495 as this patient was followed up in 10 days. If
the patient is significantly complex and is seen in 7 days or less, 99496 can be billed.

138. You determine that using an ACE inhibitor would be an appropriate option for
hypertension. The patient is a 71 year old female. You do notice in the medical record
that the patient has a history of angioedema from an unknown cause. Other diagnoses
include osteoarthritis, peptic ulcer disease, and alcoholism. Which of the following
would be a risk factor for angioedema?
a. Age
b. Hypertension diagnosis
c. Alcohol use
d. Concomitant use of acetaminophen
Answer – Age>65, previous angioedema history, concomitant use of NSAIDs, female, smoking,
and seasonal allergies are all potential risk factors for angioedema.

139. A 31 year old male presents with severe toe and finger pain. He has been diagnosed
with gout. Which of the following would not be considered a risk factor for gout?
a. Male
b. Marijuana use
c. Use of systemic cyclosporine
d. Use of OTC niacin
Answer – marijuana use has not been an associated risk factor for gout attacks. Male, alcohol
use, family history, meds like thiazides, niacin, cyclosporine, foods high in purines (i.e. seafood),
are all potential contributing risk factors.

140. LC is a 62 year old male who was recently diagnosed with atrial fibrillation. His past
medical history includes GERD, hypertension, diabetes, TIA, constipation, and
osteoarthritis. Current medications include:
• Losartan 50 mg daily
• Nebivolol 5 mg daily
• Omeprazole 20 mg daily
• Metformin 850 mg twice daily
• Glipizide 5 mg twice daily
• Bisacodyl 5 mg po as needed
• Acetaminophen 500 mg twice daily
• Naproxen 500 mg twice daily as needed
• Aspirin 81 mg daily
Given the patient information provided above, which of the following would NOT be
considered a risk factor for stroke?
 a. Hypertension
b. TIA
c. Age
d. Diabetes
Answer: C. Age (62 years old) would not be considered a risk factor in this patient situation.
Looking at the CHADS2Vasc scoring, it would be CHF, hypertension, Age >75, diabetes, and TIA
or stroke = 2 points. This would definitely be a case where anticoagulation would be
appropriate. A score of 2 or more would make warfarin or other anticoagulation appropriate.
Remember that CHA2DS2Vasc gives one point for >65 and 2 points for >75. A score of 1 or 0
with atrial fibrillation, aspirin could be utilized (warfarin could be used for a score of 1 as well).

141. In which phase of clinical trials would the final dosing of the medication be set and
safety and efficacy be monitored for?
a. Phase 1
b. Phase 2
c. Phase 3
d. Phase 4
Answer – Phase 3 is the last step before approval and final dosing is set during this time. In
phase 2, we really look hard at efficacy within a study and final dosing may not be set yet.
Phase 1 involves identifying properties of the drug within humans. I.e. kinetics, dynamics, basic
safety information etc. Usually the drug is given to younger, healthier patients in Phase 1.

142. When designing a clinical trial to investigate a medication versus placebo, which of the
following factors would have greatest impact on the power of the study?
a. Length of time of the study
b. Number of study participants
c. A wider geographical area that is studied
d. None of the above would impact power
Answer – sample size is the easiest was to improve the power of a study.

143. A patient presents to your care with a severe migraine headache. It started about 12
hours ago and 800 mg of ibuprofen has not helped. Cognition is fine and she is able to
answer questions appropriately. Upon assessment of vitals, her blood pressure is
210/112 and pulse is 116. She is currently on lisinopril 10 mg once daily, the ibuprofen
800 mg as needed, and propranolol 20 mg twice daily. Which of the following
recommendations would be most appropriate?
a. Increase propranolol
b. Initiate sumatriptan for her headache
c. Recommend acetaminophen 1,000 mg
d. Refer patient to emergency department
Answer – With this severely elevated blood pressure and symptoms of headache, there could
be a lot going on, and she needs to be further assessed in an emergency department/hospital
type setting. Under normal vital signs circumstances, you could make an argument for either a,
b, or c.
 144. Which of the following would be most likely to impact serum concentrations of
pregabalin?
a. Worsening liver function
b. Taking the medication with food
c. Worsening kidney function
d. Taking it with gabapentin
Answer – While taking it with gabapentin could potentiate the clinical effects, it would not likely
alter the serum concentrations. It is primarily eliminated through the urine, so worsening
kidney function would increase the likelihood that the patient would get elevated levels. Food
shouldn’t impact concentrations much. Liver function changes would also likely not impact
levels significantly.

145. Which of the following would be least important when trying to do medication
reconciliation?
a. Being approachable
b. Review of most recent CBC
c. Asking if the patient takes any topical medications or patches
d. Asking the patient what they are using for each disease state
Answer – review of labwork is important, but typically not that important when strictly doing
medication reconciliation. Here we are just making sure that the medication list is accurate and
up to date so we know what the patient is taking.

146. A 65 year old has a past medical history of gastroparesis, nausea and vomiting, atrial
fibrillation, hypertension and heart failure. Current medications include metoprolol,
omeprazole, amiodarone, lisinopril, aspirin, and amlodipine. Ondansetron was added
about 4 weeks ago on a scheduled basis. Which of the following assessments would be
most appropriate?
a. LFT
b. CPK
c. EKG
d. TSH
Answer – Ondansetron can potentially contribute to QTc prolongation and with the scheduled
dosing and amiodarone, it would be the most important monitoring parameter in this situation.
Ondansetron typically doesn’t impact LFT, CPK, or TSH.

147. A patient with a history of alcoholism has been taking acamprosate to try to reduce
withdrawal symptoms and improve abstinence, which of the following is true regarding
the use of this medication?
a. It is dosed once daily
b. Patient should stop taking if they relapse
c. Diarrhea is one of the most common adverse effects
d. There is a boxed warning on liver toxicity
Answer – Acamprosate is used in alcohol use disorder and one of the most common adverse
effects is diarrhea. A downside of the medication is that it is dosed multiple times per day.
Patients should continue to take the medication even in relapse. There is not a boxed warning
on hepatotoxicity.

148. One of your female patients has a lot of trouble with kidney stones and was prescribed
a medication to help with elimination of them. Which of the following medications
would potentially be most beneficial?
a. Tamsulosin
b. Sulfamethoxazole/trimethoprim
c. Amlodipine
d. Guanfacine
Answer – Alpha blockers have been utilized in females to help pass kidney stones. It isn’t very
common, but this would be the most likely medication to help with this. If they were uric acid
based stones, you may see Xanthine Oxidase inhibitors used (i.e. allopurinol).

149. Which of the following monitoring parameters are part of the REMS program for
bosentan for pulmonary arterial hypertension?
a. Liver function
b. Renal function
c. CPK
d. Skin – Steven Johnson’s Syndrome
Answer – Bosentan is teratogenic and hepatotoxic and has a REMS program because of this.
Liver function assessment would be the most appropriate answer here.

150. Which of the following risks is not associated with hormone replacement therapy?
a. Colon Cancer
b. Breast cancer
c. DVT/PE
d. Stroke
Answer – Colon cancer is likely not an associated risk with HRT. There may be a small
protective effect reported in some of the literature. The other 3 are big reasons why we try to
minimize use/length of therapy with these medications.

151. A 42 year old female has recently begun antiretroviral therapy. She also has a past
medical history of depression, insomnia, and schizoaffective disorder. Which of the
following medications would most likely exacerbate her psychiatric conditions?
a. Lopinavir/ritonavir
b. Zidovudine
c. Efavirenz
d. Enfuvirtide
Answer – C. Efavirenz is notoriously known to cause psychiatric issues as part of its side effect
profile. In this situation, efavirenz should be very closely monitored if utilized.
 152. A 68 year old male with Parkinson’s has a really difficult time with walking at 5 PM in
the afternoon. His movements slow down and he feels stiffer. This has led to some
falls around this time. His current regimen is carbidopa/levodopa 25/100 at 0800,
1200, and 1800. Which of the following would be most appropriate?
a. Initiate pramipexole 0.5 mg twice daily
b. Add a dose of carbidopa/levodopa 25/100 at 3 PM
c. Reduce dose of carbidopa/levodopa to twice daily at 0800 and 2000
d. Stop current immediate release dosing and start carbidopa/levodopa controlled
release 50/200 once daily
Answer – Sinemet CR should be dosed twice daily. Adding pramipexole would not be
appropriate as this patient has a problem at a specific time when concentrations of Sinemet are
lower. Adding a dose prior to the 5 PM period would be the most appropriate step to take to
help alleviate symptoms of his Parkinson’s. Remember the acronym TRAP (R=rigidity and
A=akinesia).

153. Which of the following concerns would not be a clinical concern with the use of
rivastigmine?
a. Tachycardia
b. Weight loss
c. Respiratory disease
d. Peptic ulcer disease
Answer: A. Tachycardia would not be a likely clinical concern with rivastigmine.
Acetylcholinesterase inhibitors for dementia would potentially cause weight loss, should be
monitored closely in patients with respiratory disease, as well as peptic ulcer disease.
Bradycardia is more likely, but pretty low risk.

154. Which of the following therapies for osteoporosis will aid in working on osteoblasts to
build bone?
a. Denosumab
b. Teriparatide
c. Calcitonin
d. Ibandronate
Answer – Teriparatide is the only agent that will work on osteoblast activity and help build
bone. It is recommended to only use this medication for 2 years due to the risk of
osteosarcoma. It is also very costly.

155. A 57 year old female is diagnosed with resistant hypertension. Current medications
include: hydroxyzine 25 mg every 4 hours as needed for anxiety, citalopram 30 mg
daily, meloxicam 15 mg twice daily, lisinopril 10 mg daily, amlodipine 10 mg daily,
atenolol 100 mg daily, and lovastatin 40 mg daily. Which of her medications would be
most likely to exacerbate resistant hypertension?
a. Hydroxyzine
b. Citalopram
c. Meloxicam
 d. Lovastatin
Answer – NSAIDs have the potential to contribute to elevated blood pressure and this is a high
dose of meloxicam. The other medications likely would not cause this. The exception being
serotonin syndrome which could raise BP, but the patient would be experiencing other
symptoms.

156. Which of the following would not be considered a CMR expectation?

a. Collecting patient specific information
b. Creating a plan to resolve drug therapy problems
c. Interactive discussion with the patient or other authorized individual
d. Administration of all necessary vaccines at time of visit
Answer – The administration of vaccines would not be a necessary component to bill a CMR. It
is an interactive, person-to-person medication review to aid in the patient’s knowledge about
their medications and help them create a plan to resolve drug therapies.

157. A patient has plaque psoriasis. She only has a patch on one elbow at this time. Which
of the following would be the initial drug of choice to manage this?
a. Coal tar
b. Topical corticosteroids
c. Systemic retinoid
d. Topical calcineurin inhibitor
Answer – Topical corticosteroids are the usual place to start when it comes to management of
small areas of psoriasis. Calcineurin inhibitors and topical vitamin D analogs are also potential
options, but usually second line if topical steroids don’t work. Coal tar is pretty messy and not
first line due to this problem. Light therapy, methotrexate, and systemic retinoids might be
considered for patients who have a greater surface area of their body impacted by psoriasis.

158. A new drug is being investigated for its potential to help patients with alcoholism stop
drinking. The drug is used for one year and compared against placebo. Which of the
following tests would be most appropriate to assess statistically significance of the
number of patients who have quit drinking versus those who haven’t?
a. ANOVA
b. Chi-Squared
c. T-test
d. Mann-Whitney
Answer – When comparing nominal data (placing people into groups, drinkers versus non-
drinkers), it would be most appropriate to use the Chi-Squared testing model.

159. With the use of ropinirole for Parkinson’s, which of the following adverse effects would
be least likely?
a. Increase in dehydration risk
b. Orthostasis
c. Behavioral changes
d. Obsessive type behaviors
Answer – Ropinirole and the dopamine agonists would not be likely to cause or contribute to
dehydration. They are likely more associated with edema than dehydration. Orthostasis,
behavior (psych) changes are possible as when you stimulate dopamine receptors, psychiatric
changes are possible. There have been reports of obsessive type behaviors like eating,
gambling, etc.

160. A 54 year old female is on chronic methotrexate for her rheumatoid arthritis. Which of
the following would be true with regards to methotrexate use?
a. Maximum dosing in RA is 15 mg weekly
b. Folic acid levels should be checked monthly for the first 6 months, then twice per
year after that
c. Renal toxicity is more concerning than liver toxicity
d. In a patient who cannot tolerate oral methotrexate due to GI upset, they
would need to switch to an alternative agent
Answer – there is an injectable formulation of methotrexate and if the patient’s GI upset was
not that significant, it would definitely be reasonable to consider a trial of the methotrexate
injection. Liver toxicity is more likely a concern versus impacts on renal function. Folic acid
levels are not routinely monitored. Supplementation is given regardless of level if patient is on
methotrexate. Doses higher than 15 mg can be utilized.

161. In regards to the use of sulfasalazine in the treatment of rheumatoid arthritis, which of
the following would be incorrect?
a. GI side effects are the most common adverse effects
b. Sulfasalazine can impair absorption of vitamin B12
c. CBC and liver function should be monitored
d. Serious infections have been reported with use
Answer: B. Sulfasalazine can impair absorption of vitamin B12 is incorrect – Sulfasalazine can
possibly impair folate absorption, but not B12. The other three are true in regards to the use of
sulfasalazine.

162. A 57 year old male is attempting to quit smoking. Past medical history includes
hypertension and mild osteoarthritis. He takes hydrochlorothiazide 25 mg once daily
and occasional ibuprofen. According to the ATS guidelines of the following agents
would be first line for this patient?
a. Nicotine replacement
b. Bupropion
c. Varenicline
d. All of the above would be acceptable choices
Answer – Nicotine replacement, bupropion, and varenicline were all considered first line
therapies for smoking cessation by previous guidelines, but the most recent ATS guidelines
prefer varenicline over the other options.

163. Which of the following is false with regard to the Affordable Care Act of 2010?
 a. Extended insurance eligibility to adult children up to the age of 26 under their
parent’s insurance plan
b. Attempted to improve coverage of preexisting conditions
c. Created the Medicare Part D drug coverage benefit
d. Established the CMS Innovation Center which allowed for experimental
measures to help improve cost effectiveness of healthcare
Answer – The Medicare Prescription Drug Improvement and Modernization Act of 2003 created
the Part D drug benefit. The other statements were part of the Affordable Care Act
(Obamacare).

164. Which medication is only approved for rheumatoid arthritis in combination with
methotrexate?
a. Infliximab
b. Rituximab
c. Anakinra
d. Adalimumab
Answer – Infliximab is only approved in combination with methotrexate in the management of
rheumatoid arthritis. You may see other biologics used off-label with methotrexate.

165. According to the NIH, waist circumference, elevated triglycerides, low HDL, elevated
blood pressure, and elevated fasting blood sugar are part of the diagnosis for metabolic
syndrome. How many of these 5 does a patient need to have to be diagnosed?
a. 1
b. 2
c. 3
d. 5
Answer – To be diagnosed with metabolic syndrome, a patient would need to have a least 3 of
these. Waistline >35 inches for women, or 40 inches for men; TG 150 mg/dL or higher, HDL <40
in men or <50 in women, BP 130/85 or higher, fasting blood sugar >100mg/dL. **if you are
taking medication to manage these problems, that also counts (i.e. anti-diabetes medication,
antihypertensive therapy, dyslipidemia)

166. Phenytoin is a narrow therapeutic window drug. What is the reason that this
medication follows Michaelis-Menten kinetics?
a. Age related increase in absorption
b. As a patient ages, an increase in volume of distribution due to it lipophilicity
c. Liver enzyme saturation
d. Renal transporter saturation
Answer – phenytoin concentrations can escalate quickly due to liver enzyme saturation. As the
enzyme that metabolizes the drug gets bound up, this leaves a potential for a rapid increase in
drug level and risk of toxicity. Clinically this means that once you reach the saturation level,
small dose increases can lead to big changes in concentration.

167. Which of the following is false with regards to administration of vaccines?

 a. Part B covered vaccines can be administered from a pharmacy
b. Each pharmacy will obtain a Medicare provider number if they would like to
administer vaccines to Medicare patients
c. The shingles vaccine is covered under both Medicare part B and part D
d. Influenza vaccine is a Part B covered vaccine, but can be administered in a
pharmacy
Answer – the shingles vaccine is covered under Medicare Part D only. It is not covered under
Medicare part B. Influenza is covered under part B, but pharmacies can bill for part B vaccines
if they obtain a Medicare provider number.

168. A 78 year old female cannot afford extended release aspirin/dipyridamole for
prevention of her atherosclerotic stroke. Which of the following would be the best
alternative for her?
a. Clopidogrel 75 mg once daily
b. Aspirin 325 mg twice daily
c. Warfarin with goal INR 2-3
d. Apixaban 5 mg twice daily
Answer – Clopidogrel would be the most appropriate selection here. Aspirin monotherapy is a
consideration but not twice daily. Apixaban and warfarin are not indicated in this type of stroke,
only proven beneficial in atrial fibrillation.

169. A 66 year old male is diagnosed with reduced Ejection Fraction Heart Failure. He is
currently taking an ARB and furosemide for the fluid overload. Which of the following
medications would also be indicated barring contraindication?
a. Bisoprolol
b. Propranolol
c. Atenolol
d. Nadolol
Answer – The only beta-blockers that are truly approved for heart failure are bisoprolol,
carvedilol, and metoprolol.

170. A patient has a history of fibromyalgia, atrial fibrillation, hypothyroidism, osteoporosis,

and spinal stenosis. She is reporting extreme fatigue and TSH is 32.6. Current
medications include duloxetine, levothyroxine, magnesium, amiodarone, calcium,
alendronate, and ibuprofen. She has been on these medications for a very long time
and at consistent doses. Which of the following would be least likely to contribute to
the alteration in TSH?
a. Use of calcium
b. Use of magnesium
c. Use of amiodarone
d. Use of duloxetine
Answer – Duloxetine is not typically going to cause any issues with hypothyroidism and would
not be likely to contribute to this issue. It would be important to reassess the timing and use of
calcium and magnesium as these could potentially reduce absorption of the supplement.
Amiodarone can impact thyroid function and should be assessed as well.

171. A 67 year old with severe heart failure is going to be put on ivabradine. Which of the
following would be a contraindication to its use?
a. Use of ondansetron
b. Pulse <60
c. History of pancreatitis
d. BP >160/110
Answer – Bradycardia would be a contraindication to the use of ivabradine as it could
exacerbate this.

172. Which of the following would not be associated with motivational interviewing?
a. Asking the patient why they think their A1C went from 7 to 9
b. Listening to the patient discuss about recent important life changes that has
impacted their desire to take care of themselves
c. Empathizing with the patient about their recent loss of a family member
d. Instructing the patient to eat less carbohydrates and more protein
Answer – D is not consistent with motivational interviewing. Empathy, patient driven goals,
relationship building, and using a significant number of open-ended questions starting with
“why” are consistent with motivational interviewing.

173. A new drug inhibits CYP3A4. You’d like to investigate the change in concentration of
simvastatin following administration. Which study design would be most helpful in
assessing this?
a. Double blind, placebo controlled parallel design
b. Single blind (study participants), placebo controlled parallel design
c. Crossover design with washout period
d. Observational trial with monitoring of incidence of simvastatin adverse effects
for comparing those on the new drug versus those not on the new drug
Answer – The crossover design makes the most sense to ensure minimum problems with
genetic variations between patient groups. This gives you the results before and after if you are
specifically able to monitor concentrations.

174. A patient has an upcoming eye surgery for cataract removal. Which of his medication
could potentially increase the risk for ocular complications?
a. Tamsulosin
b. Finasteride
c. Metformin
d. Hydralazine
Answer – Tamsulosin and the alpha blockers have the potential to contribute to floppy iris
syndrome. Patients undergoing eye surgery for cataracts or glaucoma are at an increased risk
of this happening.
 175. JT is a 59 year old male who has recently started on antidepressant therapy. He was
started on bupropion about 2 weeks ago and is experiencing significant insomnia. His
primary provider would like to try a traditional SSRI. Which of the following would be
most appropriate to try to avoid exacerbating his insomnia?
a. Sertraline
b. Fluoxetine
c. Citalopram
d. Paroxetine
Answer: Paroxetine – Of the SSRI’s, paroxetine is considered the most sedating and would be
most appropriate to use in this situation where we are trying to avoid exacerbating insomnia
(or cause sedation).

176. ST presents with terrible symptoms of BPH. He has had significant retention as well as
frequency. He was started on finasteride about 2-3 weeks ago and states that it has
done absolutely nothing for him. He has a past medical history coronary artery disease,
GERD, and constipation. Which of the following would be the most appropriate course
of action?
a. Recommend discontinuing finasteride and start dutasteride
b. Recommend adding tamsulosin
c. Recommend adding oxybutynin
d. Recommend discontinuing finasteride and start tamsulosin
Answer: Recommend adding tamsulosin – 5 alpha reductase inhibitors can take several months
to begin working for BPH patients. Discontinuing finasteride would not be appropriate at this
point. An anticholinergic could help with the frequency and certainly could worsen the
retention (and constipation) and would not be recommended if an alpha blocker hasn’t been
tried first.

177. KA is a 59 year old female with a history of angina, hypertension, coronary artery
disease, Barrett’s esophagus, osteoporosis, hypothyroidism, and seizure history. Which
of the following would be least likely to contribute to her osteoporosis risk?
a. TSH value of 0.04
b. Use of phenobarbital for seizures
c. Use of chlorthalidone for hypertension
d. Use of pantoprazole for Barrett’s esophagus
Answer - Use of chlorthalidone for hypertension – Thiazide diuretics would not be likely to
contribute to osteoporosis risk. Thiazides can actually raise calcium levels in the body.
Phenobarbital can potentially lead to vitamin D deficiency, hyperthyroidism (suppressed TSH)
could potentially contribute to osteoporosis, and PPI’s are a potential contributor to
osteoporosis as well.

178. With which of the following medications should caution be used if a patient has a
severe allergy to milk protein?
a. Theophylline
 b. Prednisone
c. Fluticasone inhaler
d. Budesonide inhaler
Answer - Budesonide – The Pulmicort Flexhaler contains lactose (milk sugar with milk protein)
and in patients with a severe allergy, we need to be careful.

179. Which of the following medications would have a black box warning for lactic acidosis?
a. Tenofovir
b. Efavirenz
c. Lopinavir
d. Ritonavir
Answer - Tenofovir for the treatment of HIV suppression has a black box warning for lactic
acidosis and hepatic steatosis.

180. JS is a 56 year old female who has felt fatigued. She has been diagnosed with anemia
and placed on Iron and B12 supplementation. Her current chronic medications include
omeprazole 20 mg daily, metolazone 5 mg daily, spironolactone 25 mg daily,
trimethoprim 100 mg daily, and clonidine 0.1 mg twice daily. Past medical history
includes GERD, CHF, chronic UTI’s, and hypertension. Which of the following
medications should a folic acid level be checked?
a. Clonidine
b. Trimethoprim
c. Spironolactone
d. Metolazone
Answer - Trimethoprim can potentially interfere with folate absorption and exacerbate a pre-
existing deficiency. The omeprazole could potentially contribute to the B12 deficiency.

181. In regards to point of care testing in the ambulatory setting, which of the following
would be incorrect?
a. Patients are significantly more reluctant to accept a finger stick from a
pharmacist versus the traditional clinical model
b. Workflow can be set up similar to an immunization program
c. Hepatitis C and HIV are considered CLIA-waived tests
d. Pharmacists are one of the most accessible health and could significantly
improve health outcomes
Answer - Patients are significantly more reluctant to accept a finger stick from a pharmacist
versus the traditional clinical model – is incorrect. In surveys patients consider pharmacists to
be acceptable at delivery of lab tests as a clinic setting.

182. Investigators are looking into whether sulfasalazine reduces the risk of breast cancer. In
a recent study, the % of patients who developed breast cancer on sulfasalazine was 3%
and the percentage on placebo who developed breast cancer was 13%. What is the
NNT?
a. 20
 b. 33
c. 12
d. 10
Answer – 10 Calculating the absolute risk reduction (ARR) would be 13%-3%; from there, the
NNT would be 1/ARR = 1/10% or 1/0.1 = 10 (This is made up study example by the way)

183. A mother presents with her son for an MTM session. She states that her son uses his
albuterol “multiple” times per day. Upon further questioning and assessment, her son
is experiencing tachycardia. Along with tachycardia, which of the following electrolyte
abnormalities would be possible in a patient who is overusing albuterol?
a. Hypercalcemia
b. Elevated creatinine
c. Hypokalemia
d. Hyponatremia
Answer - Hypokalemia – While significant hypokalemia would be pretty rare with minimal or
even appropriate use of albuterol, in an overdose or abuse type situation of a beta agonist,
hypokalemia could be a possible issue. Hypercalcemia, elevated creatinine, and hyponatremia
would not be as likely as potassium changes.

184. BP is a 36 year old women with a history of migraines with aura. What is the most
appropriate method of contraception for her?
a. Hormonal patch
b. Oral combination hormonal tablets
c. Progestin only oral tablets
d. Progestin only IUD
Answer - Progestin only oral tablets – Women over age 35 with a history of migraines
(regardless of aura) are recommended to use either oral progestin only oral tablets or copper-
releasing IUD (Paragard). Estrogen containing products are not acceptable per the CDC and
WHO.

185. BB is a 34 year old female that would like to start a prescription medication to treat her
obesity. Her other medical conditions include hypertension, depression and GERD.
Current medications include losartan 50 mg daily, bupropion XL 300 mg daily,
fluoxetine 20 mg daily and ranitidine 150 mg nightly. Which medication would be the
best option for BB?
a. Phentermine/topiramate ER
b. Naltrexone/bupropion
c. Liraglutide
d. Orlistat
Answer - Liraglutide – Saxenda (liraglutide 3 mg daily), a GLP-1 agonist would be the best option
for BB. Qsymia (phentermine and topiramate) has the potential to increase blood pressure. The
recommended dose Contrave is 2 tablets twice daily, each tablet contains 8 mg naltrexone and
90 mg bupropion, making the total daily dose 32 mg naltrexone and 360 mg bupropion. BB
already takes 300 mg bupropion daily, this addition would put her over the maximum
recommended dose. Orlistat is not a first line agent due to the oily stools adverse effects.

186. JS has contacted you questioning what she should do with her insulin. Her blood sugar
this morning was 223. She woke up feeling very ill with the “stomach flu”. She has not
eaten anything today. She normally takes her insulin glargine in the morning and has
three scheduled doses of rapid acting throughout the day. What is the best course of
action?
a. Recommend scheduling an appointment to be assessed
b. Give her morning dose of rapid acting insulin but not the glargine
c. Give the glargine but hold the rapid acting
d. Give the glargine and the rapid acting
Answer - Give the glargine but hold the rapid acting – In this scenario, it would be best to give
her the long acting with her blood sugar at 223, you can feel pretty comfortable with that and
hold the rapid acting all day if she is not going to eat much. Giving the rapid acting would
increase the risk of dropping the blood sugar abruptly and precipitating a hypoglycemia event
in a patient who can’t hold food down. Increased monitoring would also be very important
with checking blood sugars every 1-2 hours if possible.

187. Which of the following assessment tools would be most appropriate for an elderly
patient who is having some confusion?
a. HAM-D
b. MMSE
c. PHQ-9
d. AIMS
Answer - MMSE – The Mini-mental status exam is intended to screen for Alzheimer’s and would
be the most appropriate in this scenario. PHQ-9 and HAM-D are both used for depression, while
AIMS is used to monitor for Tardive Dyskinesia in patients on antipsychotics (or other drugs that
might block dopamine).

A daughter of one of your patients would like to ask you your thoughts on starting a dementia
medication on her mom. She has been diagnosed with Alzheimer’s and was classified as mild to
moderate at this point according to the daughter. He past medical history includes CHF,
hypertension, GERD, GI bleed, and rheumatoid arthritis. Other than decline in memory, the
daughter/mother have no complaints. Recent labs and vitals:
• Height: 170 cm
• Weight: 40 kg
• Creatinine = 0.9
• Potassium = 4.1
• Hemoglobin = 11.2
• Sodium = 139
• BUN = 17
Current medications:
• Aspirin 81 mg daily
 • Metoprolol 50 mg twice daily
• Omeprazole 20 mg daily
• Methotrexate 15 mg weekly
• Folic acid 1 mg daily
• Furosemide 20 mg daily
188. Which recommendation regarding initiating pharmacotherapy would be most
appropriate?
a. Initiate memantine
b. Initiate donepezil
c. Initiate duloxetine
d. Discontinue methotrexate and reassess in 4-6 weeks
Answer - Initiate Memantine – Initiating Memantine would be more appropriate than donepezil
given the weight and height of the patient. By adding donepezil, you will possibly increase that
risk of weight loss, much more so than the Memantine. Discontinuing methotrexate doesn’t
make much sense and could lead to worsening RA symptoms. Duloxetine is not indicated to
help with dementia.

189. A 75 year old female has a past medical history of GERD, asthma, Type 2 diabetes, and
CHF. She presents with increasing blood pressures; last two readings were 166/98 and
172/96. Which of the following would be most appropriate to initiate?
a. Metoprolol
b. Hydrochlorothiazide
c. Lisinopril
d. Amlodipine
Answer - Lisinopril – With this patient’s past medical history and compelling indications of type
2 diabetes and CHF, the most appropriate agent of choice would be Lisinopril. With CHF, the
metoprolol would also be important down the line, but the ACE with 2 compelling indications
would likely take precedent.

190. At what frequency can a Comprehensive Medication Review be completed?

a. Annually
b. Bi-annually
c. Quarterly
d. Whenever “deemed” appropriate
Answer - Annually – CMR’s can be done on an annual basis and is a top to bottom review of all
medications, OTC’s Herbals etc. (i.e. COMPREHENSIVE), and not more frequently than that.

191. AL is a 52 year old male with osteoarthritis (OA). He presents with worsening OA pain in
many of his joints including hips, knees, and hands. He is currently on Glucosamine and
will take an occasional acetaminophen (about once a week) which he says doesn’t
usually work that well. His past medical history includes BPH, seizures and glaucoma.
What recommendation would you make for him today?
a. Trial topical capsaicin as needed
b. Initiate tramadol as needed
 c. Schedule acetaminophen
d. Trial PRN ibuprofen
Answer - NSAIDs are a preferred agent in the management of OA as long as the patient does
not have contraindications. Acetaminophen hasn’t worked for him and evidence of efficacy in
OA is weak. Capsaicin is not effective when used as needed and the pain is also all over making
capsaicin not very realistic. Tramadol would not be recommended given this patient’s seizure
history and also carries risk for addiction and dependence.

192. You are approached by a colleague who has a patient that has just completed genetic
testing. The patient has an “A” allele for VKORC1 indicating that this patient produces
unusually less VKORC1 than other patients. Her current dose of warfarin is 2.5 mg daily
and recent INR was 2.8, with goal of 2-3. Which of the following actions would be most
appropriate given this new information?
a. Discontinue warfarin and begin aspirin
b. Reduce the dose of warfarin
c. Do not change this patient’s medication
d. Suggest reducing the goal INR to 1.5-2.5
Answer - Do not change this patient’s medication – A shortage of VKORC1 simply means that
less warfarin is required. This has already been compensated for, and the INR is fine. The dose
doesn’t need to be changed. However, if this patient was starting on warfarin for the first time,
it would help you recognize that a lower starting dose would be appropriate.

193. For the calendar year of 2022, which of the following would NOT be an accurate
requirement for automatically enrolling the patient into the Part D targeted beneficiary
MTM program?
a. 2 or more chronic diseases
b. 8 or more medications
c. Are likely to incur over $4,696 in medication costs
d. All of the above are requirements for automatic enrollment
Answer – 2 or more chronic diseases would not be a requirement for automatically enrolling
the patient into the Medicare Part D MTM program, but it should be 3 or more chronic
diseases, however some sponsors may elect (optional) to use less chronic disease states as
their criteria.

194. JE is a 65 year old male with a past medical history of osteoarthritis and gout. He is
currently taking allopurinol and acetaminophen as needed. Upon assessment today, his
blood pressure is 186/78 with a recheck of 182/80. Which of the following
recommendations would be most appropriate?
a. Terazosin
b. Metoprolol
c. Hydrochlorothiazide
d. Amlodipine
Answer - Amlodipine – (CCB’s) is generally considered more effective for isolated systolic
hypertension with beta blockers and alpha blockers being less desirable to use first line without
compelling indications. Hydrochlorothiazide would be a potential option, but with history of
gout and another option available, it would be best to avoid this one.

195. FA’s provider has started them on simvastatin but would also like to start her on a
medication to target her triglycerides. Total cholesterol is 289 mg/dL, triglycerides are
398 mg/dL, HDL 41 mg/dL, and LDL is 193 mg/dL. Which choice below would be
appropriate to add to her atorvastatin?
a. Fenofibrate 54 mg daily
b. Gemfibrozil 600 mg twice daily
c. Niacin 500 mg daily
d. Icosapent Ethyl
Answer - Under the guidelines, specific drug therapy to lower triglycerides is not recommended
until triglycerides are greater than 500. The exception is Icosapent ethyl in high risk CV patients.
For patients at very high CV risk who have TG of 150 mg/dL or greater despite statin use,
Icosapent ethyl might be a potential option. Gemfibrozil is contraindicated in combination with
simvastatin due to an increased risk of myopathy. Niacin generally isn’t utilized due to adverse
effects.

196. Under the current guidelines for cholesterol management, what is the most
appropriate answer regarding lab monitoring?
a. ALT at baseline and 4-12 weeks after medication initiation
b. CK at baseline for all patients
c. Lipid panel 4-12 weeks after medication initiation
d. No lab monitoring is recommended
Answer - Lipid panel 4-12 weeks after medication initiation – ALT is recommended at baseline
and then additionally only if patients present with hepatotoxic symptoms. CK is only
recommended for patients at high risk for myopathy. ACC/AHA guidelines recommend
checking a lipid panel 4-12 weeks after starting a statin, for the purpose of monitoring for an
expected % drop in LDL and to check for adherence.

197. What is false about SGLT2 inhibitors?

a. They can lower A1C by approximately 0.5-1%
b. They can increase the risk of urinary tract infections and genital fungal infections
c. They can contribute to weight gain
d. All of the above are true
Answer - They can contribute to weight gain – SGLT2 inhibitors lower A1C by approximately
0.5-1% and have an increased risk of urinary tract infections and genital fungal infections. They
are also associated with weight loss and have a low risk of hypoglycemia when used alone.

198. Which antipsychotic is least likely to cause EPS?

a. Clozapine
b. Paliperidone
c. Haloperidol
d. Risperidone
Answer - Clozapine, pimavanserin, and quetiapine are the least likely to cause EPS – clozapine
seldom used due to agranulocytosis risk however. In a Parkinson’s patient, generally quetiapine
will be tried first given no contraindications.

199. Which contraceptive method is not preferred for women with a body weight of over 90
kg?
a. Norelgestromin and ethinyl estradiol patch
b. Oral combination hormonal tablets
c. Progestin only oral tablets
d. Progestin only IM injection
Answer - Norelgestromin and ethinyl estradiol patch – The Othro Evra patch contains
norelgestromin and ethinyl estradiol patch is not recommended for use in women with body
weight > 90 kg due to concerns for decreased efficacy.

200. With regards to prostate cancer, which of the following is false?

a. PSA is a true indicator of prostate cancer
b. Leuprolide can contribute to erectile dysfunction and hot flashes
c. Prostate cancer is often a slow growing type of cancer
d. Finasteride is not indicated in the management of prostate cancer
Answer – PSA may be indicative of cancer, but this is not always true and cannot be relied upon
as a diagnostic indicator. Leuprolide is a luteinizing hormone-releasing hormone agonist which
ultimately reduces testosterone production that can feed the cancer. Finasteride is not
indicated for cancer. Prostate cancer is typically a very slow growing cancer.