Question #1
Patient Name: Kirk Johns
Address: 123 Camden Drive
Age: 66
Sex: Male
Height: 5' 8"
Weight: 182 lbs (82.7 kg)
Allergies: Opioids
Diagnoses:
Medication Record
| Rx Number | Date | Physician | Drug and Strength | Quantity | Sig | Refills |
| 10087136 | 8/17 | George | Warfarin 5 mg | 30 | 1 qd | 5 |
| 10087137 | 8/17 | George | Xalatan 0.005% | 2.5 | 1ou HS | 5 |
| 10087138 | 8/17 | George | Toujeo | 10 | UAD | 5 |
| 10087139 | 8/17 | George | Apidra | 20 | UAD | 5 |
| 10087140 | 8/17 | George | Insulin needles 31G | 100 | UAD | 5 |
| 10087141 | 8/17 | George | Glucagon | 3 | UAD | 5 |
| Laboratory Tests (Normal values) | 8/16 |
| Sodium (135 - 147 mEq/L) | 141 mEq/L |
| Potassium (3.5 - 5.2 mEq/L) | 4.3 mEq/L |
| Chloride (95 - 107 mEq/L) | 101 mEq/L |
| Calcium (8.8 - 10.3 mg/dL) | 9.9 mEq/L |
| Albumin (3.2 – 5 g/dL) | 3.8 g/dL |
| Serum Creatinine (0.5 -1.4 mg/dL) | 2.1 mg/dL |
| BUN (7 - 20 mg/dL) | 19 mg/dL |
| Total Cholesterol (< 200 mg/dl) | 228 mg/dL |
| HDL Cholesterol (> 35 mg/dl) | 44 mg/dL |
| LDL Cholesterol (65 – 180 mg/dl) | 155 mg/dL |
| Triglycerides (< 150 mg/dL) | 144 mg/dL |
| AST (< 35 IU/L) | 19 IU/L |
| ALT (< 35 IU/L) | 17 IU/L |
| Glucose, fasting (60 - 110 mg/dl) | 188 mg/dL |
| A1c (< 6 %) | 10.0% |
| Blood pressure (120/80 mmHg) | 112/72 mmHg |
| Heart Rate (60 - 100 BPM) | 82 BPM |
| Temperature (97.8 F - 99 F / 36.5 C - 37.2 C) | 98.7 F |
Additional info:
No pharmacist notes
1) Mr. Johns’ average plasma glucose level for the past 60-90 days approximates which of the following?
Answer:
The correct answer is D. Mr. Johns’ A1c is 10.0%. The A1c represents the blood glucose level over an approximate 60-90-day time frame. Although 4–6% is normal range, <6.5–7% is often the goal for a patient with diabetes mellitus. The following table approximates the A1c correlation to average plasma glucose:
| A1c% | Mean Plasma Glucose |
| 6 | 126 mg/dl |
| 7 | 154 mg/dl |
| 8 | 183 mg/dl |
| 9 | 212 mg/dl |
| 10 | 240 mg/dl |
| 11 | 269 mg/dl |
| 12 | 298 mg/dl |
Kaplan's NAPLEX Review Book 2017: pp. 526.1
Question #2
Patient Name: Kirk Johns
Address: 123 Camden Drive
Age: 66
Sex: Male
Height: 5' 8"
Weight: 182 lbs (82.7 kg)
Allergies: Opioids
Diagnoses:
Medication Record
| Rx Number | Date | Physician | Drug and Strength | Quantity | Sig | Refills |
| 10087136 | 8/17 | George | Warfarin 5 mg | 30 | 1 qd | 5 |
| 10087137 | 8/17 | George | Xalatan 0.005% | 2.5 | 1ou HS | 5 |
| 10087138 | 8/17 | George | Toujeo | 10 | UAD | 5 |
| 10087139 | 8/17 | George | Apidra | 20 | UAD | 5 |
| 10087140 | 8/17 | George | Insulin needles 31G | 100 | UAD | 5 |
| 10087141 | 8/17 | George | Glucagon | 3 | UAD | 5 |
| Laboratory Tests (Normal values) | 8/16 |
| Sodium (135 - 147 mEq/L) | 141 mEq/L |
| Potassium (3.5 - 5.2 mEq/L) | 4.3 mEq/L |
| Chloride (95 - 107 mEq/L) | 101 mEq/L |
| Calcium (8.8 - 10.3 mg/dL) | 9.9 mEq/L |
| Albumin (3.2 – 5 g/dL) | 3.8 g/dL |
| Serum Creatinine (0.5 -1.4 mg/dL) | 2.1 mg/dL |
| BUN (7 - 20 mg/dL) | 19 mg/dL |
| Total Cholesterol (< 200 mg/dl) | 228 mg/dL |
| HDL Cholesterol (> 35 mg/dl) | 44 mg/dL |
| LDL Cholesterol (65 – 180 mg/dl) | 155 mg/dL |
| Triglycerides (< 150 mg/dL) | 144 mg/dL |
| AST (< 35 IU/L) | 19 IU/L |
| ALT (< 35 IU/L) | 17 IU/L |
| Glucose, fasting (60 - 110 mg/dl) | 188 mg/dL |
| A1c (< 6 %) | 10.0% |
| Blood pressure (120/80 mmHg) | 112/72 mmHg |
| Heart Rate (60 - 100 BPM) | 82 BPM |
| Temperature (97.8 F - 99 F / 36.5 C - 37.2 C) | 98.7 F |
Additional info:
No pharmacist notes
2) When Mr. Johns administers his Toujeo prior to breakfast (7:30 am), it will exert its peak effect:
Answer:
The correct answer is E. This is a commonly encountered patient counseling question in which a pharmacist is asked to explain the duration / peak effect for an insulin product. In this case, the patient is receiving insulin glargine (Toujeo ®) and the question is asking for its peak effect. A summary table of selected insulin products is provided below.
| Insulin Products | ||||
| Insulin Preparation | Onset of Action | Peak Effect | Duration of Action | Other Notes |
Rapid-acting Insulin
| 5-15 minutes | 1-2 hours | 4-5 hours |
|
| Regular Insulin | 20-60 minutes | 2-4 hours | 8-10 hours |
|
| NPH Insulin | 1-2 hours | 4-8 hours | 10-20 hours |
|
Long-acting Insulin
| 1-2 hours | Relatively flat / no peak | 20-24+ hours |
|
| Premix-Mixed Insulin | Based on action of the individual insulin (see above) | Based on action of the individual insulin (see above) | Based on action of the individual insulin (see above) | Based on action of the individual insulin (see above) |
Kaplan's NAPLEX Review Book 2017: pp. 149.1
Question #3
Patient Name: Kirk Johns
Address: 123 Camden Drive
Age: 66
Sex: Male
Height: 5' 8"
Weight: 182 lbs (82.7 kg)
Allergies: Opioids
Diagnoses:
Medication Record
| Rx Number | Date | Physician | Drug and Strength | Quantity | Sig | Refills |
| 10087136 | 8/17 | George | Warfarin 5 mg | 30 | 1 qd | 5 |
| 10087137 | 8/17 | George | Xalatan 0.005% | 2.5 | 1ou HS | 5 |
| 10087138 | 8/17 | George | Toujeo | 10 | UAD | 5 |
| 10087139 | 8/17 | George | Apidra | 20 | UAD | 5 |
| 10087140 | 8/17 | George | Insulin needles 31G | 100 | UAD | 5 |
| 10087141 | 8/17 | George | Glucagon | 3 | UAD | 5 |
| Laboratory Tests (Normal values) | 8/16 |
| Sodium (135 - 147 mEq/L) | 141 mEq/L |
| Potassium (3.5 - 5.2 mEq/L) | 4.3 mEq/L |
| Chloride (95 - 107 mEq/L) | 101 mEq/L |
| Calcium (8.8 - 10.3 mg/dL) | 9.9 mEq/L |
| Albumin (3.2 – 5 g/dL) | 3.8 g/dL |
| Serum Creatinine (0.5 -1.4 mg/dL) | 2.1 mg/dL |
| BUN (7 - 20 mg/dL) | 19 mg/dL |
| Total Cholesterol (< 200 mg/dl) | 228 mg/dL |
| HDL Cholesterol (> 35 mg/dl) | 44 mg/dL |
| LDL Cholesterol (65 – 180 mg/dl) | 155 mg/dL |
| Triglycerides (< 150 mg/dL) | 144 mg/dL |
| AST (< 35 IU/L) | 19 IU/L |
| ALT (< 35 IU/L) | 17 IU/L |
| Glucose, fasting (60 - 110 mg/dl) | 188 mg/dL |
| A1c (< 6 %) | 10.0% |
| Blood pressure (120/80 mmHg) | 112/72 mmHg |
| Heart Rate (60 - 100 BPM) | 82 BPM |
| Temperature (97.8 F - 99 F / 36.5 C - 37.2 C) | 98.7 F |
Additional info:
No pharmacist notes
3) When dispensing Mr’ Johns’ latanoprost, which of the following should be explained to the patient by the pharmacist?
Answer:
The correct answer is A, E. Xalatan (latanoprost ophthalmic) is a prostaglandin analog indicated for the treatment of elevated intraocular pressure in glaucoma. As with ALL ophthalmic drops, the patient should not allow the tip of the dropper to touch any surface, including your eyes or hands (choice A is correct). Patients should store an unopened bottle of latanoprost eye drops in a refrigerator (choice E is correct and choice D is incorrect). Then, once they have opened and begun using the latanoprost eye drops, the patient may store them at room temperature (choice C is incorrect). Note: Patients should not use eye drops if it has been longer than 6 weeks since they first opened the bottle (choice B is incorrect).
Kaplan's NAPLEX Review Book 2017: pp. 402.1
Question #4
Patient Name: Kirk Johns
Address: 123 Camden Drive
Age: 66
Sex: Male
Height: 5' 8"
Weight: 182 lbs (82.7 kg)
Allergies: Opioids
Diagnoses:
Medication Record
| Rx Number | Date | Physician | Drug and Strength | Quantity | Sig | Refills |
| 10087136 | 8/17 | George | Warfarin 5 mg | 30 | 1 qd | 5 |
| 10087137 | 8/17 | George | Xalatan 0.005% | 2.5 | 1ou HS | 5 |
| 10087138 | 8/17 | George | Toujeo | 10 | UAD | 5 |
| 10087139 | 8/17 | George | Apidra | 20 | UAD | 5 |
| 10087140 | 8/17 | George | Insulin needles 31G | 100 | UAD | 5 |
| 10087141 | 8/17 | George | Glucagon | 3 | UAD | 5 |
| Laboratory Tests (Normal values) | 8/16 |
| Sodium (135 - 147 mEq/L) | 141 mEq/L |
| Potassium (3.5 - 5.2 mEq/L) | 4.3 mEq/L |
| Chloride (95 - 107 mEq/L) | 101 mEq/L |
| Calcium (8.8 - 10.3 mg/dL) | 9.9 mEq/L |
| Albumin (3.2 – 5 g/dL) | 3.8 g/dL |
| Serum Creatinine (0.5 -1.4 mg/dL) | 2.1 mg/dL |
| BUN (7 - 20 mg/dL) | 19 mg/dL |
| Total Cholesterol (< 200 mg/dl) | 228 mg/dL |
| HDL Cholesterol (> 35 mg/dl) | 44 mg/dL |
| LDL Cholesterol (65 – 180 mg/dl) | 155 mg/dL |
| Triglycerides (< 150 mg/dL) | 144 mg/dL |
| AST (< 35 IU/L) | 19 IU/L |
| ALT (< 35 IU/L) | 17 IU/L |
| Glucose, fasting (60 - 110 mg/dl) | 188 mg/dL |
| A1c (< 6 %) | 10.0% |
| Blood pressure (120/80 mmHg) | 112/72 mmHg |
| Heart Rate (60 - 100 BPM) | 82 BPM |
| Temperature (97.8 F - 99 F / 36.5 C - 37.2 C) | 98.7 F |
Additional info:
No pharmacist notes
4) Prior to prescribing warfarin to Mr. Johns, Dr. George orders a pharmacogenomics test. Which of the following are true with respect to the pharmacogenomics of this agent? (Select ALL that apply).
Answer:
The correct answer is A, C. The VKORC1 gene encodes for the vitamin K epoxide reductase complex subunit 1 (choice C) that is responsible for converting inactive vitamin K epoxide to active vitamin K. This step is required for production of several essential coagulation factors. Patients with mutations at position 1639 (1639G>A) in the VKORC1 gene demonstrate decreased VKORC1 expression. Since VKORC1 is the target for warfarin, patients with decreased VKORC1 expression require lower maintenance doses of warfarin (choice A is correct and choice B is incorrect). This corresponds to a higher risk of warfarin-related adverse events at normal doses. Warfarin’s primary route of metabolism is through CYP2C9 (choice E is incorrect). Other CYP450 isozymes involved in the metabolism of warfarin include CYP3A4, CYP1A2, CYP2A6 and CYP2C8. The impact of the patient’s pharmacogenomics on warfarin’s effectiveness is best measured with an INR assessment (choice D is incorrect).
Kaplan's NAPLEX Review Book 2017: pp. 37.2, 619.2
Question #5
A patient is currently receiving 750 mL of an IV medication solution every 8 hours. If the infusion set delivers 15 drops/mL, what will be the approximate infusion rate in drops/min? (Round the final answer to the nearest WHOLE number.)
Answer:
The correct answer is D. To calculate this answer simply use the following calculation process: [15 gtt / mL] [ 750 mL / 8 hr] [ 1 hr / 60 min] = 23.4 drops / min = 23 drops / min.
Kaplan's NAPLEX Review Book 2017: pp. 667.1
Question #6
A patient receives a letter in December that his Crestor is no longer covered on his insurance plan. If the patient is currently receiving 5 mg Crestor daily, the pharmacist could recommend which of the following as an “equivalent” substitute to the patient’s physician? (Select ALL that apply.)
Answer:
The correct answer is A, C, D, E. The “statins” cause a reduction in LDL-C cholesterol in about 1-2 weeks with a maximum response in 4-6 weeks. They act by competitively inhibiting the enzyme HMG-CoA reductase, which is involved in the rate-limiting step in cholesterol biosynthesis. The table below outlines the equivalent doses of the statins. Thus, choices C, D, and E are correct.
| Equivalent Doses of Statins | |
| Drug | Equivalent Dose (mg) |
| Rosuvastatin (Crestor ®) | 5 |
| Atorvastatin (Lipitor ®) | 10 |
| Simvastatin (Zocor ®) | 20 |
| Lovastatin (Mevacor ®) | 40 |
| Pravastatin (Pravachol ®) | 40 |
| Fluvastatin (Lescol ®) | 80 |
Kaplan's NAPLEX Review Book 2017: pp. 19.1
Question #7
A 62-year-old patient with severe rheumatoid arthritis unresponsive to traditional therapies is prescribed Enbrel ®. When asked by the patient about the relatively safety of vaccines, which of the following should the pharmacist recommend that the patient NOT receive? (Select ALL that apply.)
Answer:
The correct answer is B, D., E. Enbrel ® (entanercept) is an immunosuppressant used for the treatment of plaque psoriasis and psoriatic arthritis. Live virus vaccines are contraindicated for use with this medication. For the NAPLEX, the student should know which vaccines are live and inactivated vaccines. Inactivated vaccines safe for use in patients reeving Enbrel ® include Pneumovax 23 (Streptococcus pneumoniae – choice C), Gardasil (Human Papillomavirus), Daptacel (Diphtheria, tetanus, acellular pertussis) and Fluarix (Influenzae – choice A). The other answer choices are live, attenuated vaccines; hence, should NOT be used.
Kaplan's NAPLEX Review Book 2017: pp. 506.1, 507.1, 508.1, 509.1
Question #8
A 26-year-old HIV positive male enrolls in a phase 1 clinical trial evaluating the safety of a new CCR5 co-receptor antagonist. If the medication is administered at a dose of 650 mg every 8 hours and the steady-state concentration is 32 mg/L, what is the drug's volume of distribution (in liters)? (Round the final answer to the nearest TENTH.)
Answer:
The correct answer is C. The volume of distribution (Vd) is the ratio of the amount of drug in the body to its plasma concentration. The Vd can be calculated with the following equation: drug dose = [Css] [Vd]. This can be rearranged to [Vd] = drug dose / [Css]. Thus 650 mg / 32 mg/L = 20.3 L.
Kaplan's NAPLEX Review Book 2017: pp. 602.2
Question #9
A pharmacist prepares 500 mL of a 0.75% solution of an experimental antiangiogenic therapy used for the treatment of metastatic colorectal cancer. If the dose ordered is 12 mg/min, how many hours will this solution last? (Round the final answer to the nearest TENTH.)
Answer:
The correct answer is C. The student is asked to calculate the length of time that the IV solution will last when provided with the final volume, percentage strength and administration rate. This problem can be solved with 2 steps:
Kaplan's NAPLEX Review Book 2017: pp. 655.1
Question #10
A child diagnosed with otitis media is prescribed amoxicillin; however, it is ineffective for the treatment of this condition. It is believed that the patient’s otitis media is caused by a beta-lactamase producing bacteria. Using the diagram of amoxicillin below, identify where bacterial beta-lactamase will inactive this medication.
Answer:
The correct answer is C (site 3): The portion of the beta-lactam ring to the left of nitrogen. Amoxicillin is a broad-spectrum semisynthetic antibiotic chemically related to ampicillin. It acts by acylating the penicillin-sensitive transpeptidase C-terminal domain by opening the lactam ring ultimately leading to an inhibition of the third and last stage of bacterial cell wall synthesis and cell lysis. Due to the presence of beta-lactamase producing bacteria, amoxicillin is commonly prescribed with clavulanic acid. Beta-lactamases are enzymes produced by selected Gram-positive and Gram-negative bacteria, including Staphylococcus aureus, Haemophilus influenzae, Moraxella catarrhalis, Neisseria gonorrhoeae as well as Klebsiella and Enterobacter spp. These bacterial enzymes are responsible for resistance to a broad class of-beta-lactam antibiotics, including amoxicillin. Beta-lactamases act by hydrolyzing the beta-lactam ring thus inactivating the antibiotic.
Kaplan's NAPLEX Review Book 2017: pp. 83.1
Question #11
A pharmaceutics professor is discussing the excipient magnesium stearate. This agent is most likely used as a
Answer:
The correct answer is D. The table below outlines excipients that affect drug product bioavailability.
Excipients That Affect Product Bioavailability
| Excipient Category | Examples | Effect on Drug Particles | Effect on Bioavailability | ||||
| Buffer | Potassium and phosphate buffers | Compounds that resist changes in pH upon the addition of limited amounts of acids or bases. | Normalize | ||||
| Disintegrants | Starch, microcrystalline cellulose | Breaks tablet into smaller particles, ↑ dissolution | Possible ↑ | ||||
| Film coating | Enteric coating | Permits transit through the stomach to the small intestine before the medication is released | Normalize | ||||
| Lubricants | Magnesium stearate | Has tendency to waterproof particles in large concentration, making them less soluble | Possible ↓ | ||||
| Surfactants | Tweens, Spans |
| |||||
Kaplan's NAPLEX Review Book 2017: pp. 598.1
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