FPGEE FPGEE MCQ Exam — Questions and Answers
Question 1: A patient with severe renal impairment (CrCl < 30 mL/min) requires anticoagulation. Which agent requires the MOST significant dose adjustment?
- Warfarin
- Dabigatran (Correct answer)
- Apixaban
- Fondaparinux
Correct answer: Dabigatran
Dabigatran is 80% renally eliminated and is contraindicated in severe renal impairment (CrCl < 30 mL/min).
Question 2: Which pharmacokinetic parameter is most affected by hepatic enzyme induction by rifampin?
- Volume of distribution
- Renal clearance
- Oral bioavailability and hepatic clearance (Correct answer)
- Protein binding
Correct answer: Oral bioavailability and hepatic clearance
Rifampin induces CYP450 enzymes, increasing hepatic metabolism and reducing oral bioavailability of susceptible drugs.
Question 3: A prescriber orders aminoglycoside therapy. Which parameter best correlates with aminoglycoside efficacy?
- Time above MIC
- AUC/MIC ratio
- Peak/MIC ratio (Correct answer)
- Trough concentration
Correct answer: Peak/MIC ratio
Aminoglycosides exhibit concentration-dependent killing; their efficacy correlates best with the peak concentration to MIC ratio.
Question 4: Which receptor mechanism is responsible for the therapeutic effect of benzodiazepines in treating anxiety?
- Blockade of NMDA receptors
- Positive allosteric modulation of GABA-A receptors (Correct answer)
- Inhibition of serotonin reuptake
- Agonism at adenosine receptors
Correct answer: Positive allosteric modulation of GABA-A receptors
Benzodiazepines enhance the effect of GABA at GABA-A receptors by positive allosteric modulation, increasing chloride ion conductance.
Question 5: A patient on methotrexate presents with mucositis. Which agent is used to rescue from methotrexate toxicity?
- N-acetylcysteine
- Leucovorin (folinic acid) (Correct answer)
- Mesna
- Dexrazoxane
Correct answer: Leucovorin (folinic acid)
Leucovorin (folinic acid) bypasses the dihydrofolate reductase enzyme blocked by methotrexate, restoring folate function.
Question 6: According to USP <797>, what is the beyond-use date for a high-risk compounded sterile preparation stored at room temperature?
- 24 hours (Correct answer)
- 48 hours
- 72 hours
- 30 days
Correct answer: 24 hours
Under USP <797>, high-risk compounded sterile preparations stored at room temperature must be used within 24 hours.
Question 7: Which drug class is associated with development of drug-induced lupus erythematosus?
- ACE inhibitors
- Hydralazine and procainamide (Correct answer)
- Thiazide diuretics
- Beta-blockers
Correct answer: Hydralazine and procainamide
Hydralazine, procainamide, and isoniazid are classic causes of drug-induced lupus erythematosus.
Question 8: A 65-year-old patient requires a loading dose of digoxin. Which factor most significantly affects the volume of distribution (Vd) of digoxin?
- Hepatic function
- Serum albumin level
- Lean body weight and tissue binding (Correct answer)
- Renal tubular secretion
Correct answer: Lean body weight and tissue binding
Digoxin has a very large Vd (~7 L/kg) due to extensive binding to skeletal muscle and other tissues; lean body weight is used to dose it.
Question 9: Which enzyme is responsible for the first-pass metabolism of morphine to morphine-6-glucuronide?
- CYP3A4
- CYP2D6
- UGT2B7 (UDP-glucuronosyltransferase) (Correct answer)
- MAO-B
Correct answer: UGT2B7 (UDP-glucuronosyltransferase)
Morphine undergoes extensive glucuronidation by UGT2B7 in the liver and intestinal wall, producing morphine-6-glucuronide (active) and morphine-3-glucuronide.
Question 10: A patient taking phenytoin for seizures is started on valproic acid. What is the expected net effect on phenytoin?
- Decreased total phenytoin with possible increased free phenytoin levels (Correct answer)
- Increased total and free phenytoin
- Decreased total and free phenytoin
- No significant change
Correct answer: Decreased total phenytoin with possible increased free phenytoin levels
Valproic acid displaces phenytoin from protein binding (decreasing total levels) while also inhibiting its metabolism, often raising free (active) phenytoin.
Question 11: Under the OBRA '90 regulations, pharmacists are required to perform which activities when dispensing medications to Medicaid patients?
- Drug utilization review (DUR), patient counseling, and maintaining medication records (Correct answer)
- Only label verification and dispensing
- Therapeutic substitution and prior authorization
- Compounding and repackaging only
Correct answer: Drug utilization review (DUR), patient counseling, and maintaining medication records
OBRA '90 mandates prospective DUR, patient counseling offers, and maintenance of patient medication records for Medicaid outpatient prescriptions.
Question 12: Which antihypertensive agent is absolutely contraindicated in bilateral renal artery stenosis?
- Amlodipine
- Metoprolol
- Lisinopril (Correct answer)
- Hydrochlorothiazide
Correct answer: Lisinopril
ACE inhibitors like lisinopril block angiotensin II–mediated efferent arteriolar constriction, which is the compensatory mechanism maintaining GFR in bilateral renal artery stenosis.
Question 13: A patient develops QT prolongation after starting a new antibiotic. Which agent is MOST likely responsible?
- Amoxicillin-clavulanate
- Azithromycin (Correct answer)
- Doxycycline
- Trimethoprim-sulfamethoxazole
Correct answer: Azithromycin
Azithromycin (and other macrolides) block hERG potassium channels, prolonging the QT interval and increasing the risk of Torsades de Pointes.
Question 14: Which parameter describes the fraction of a drug excreted unchanged in the urine?
- Bioavailability (F)
- Extraction ratio (ER)
- Fraction excreted renally (fe) (Correct answer)
- Intrinsic clearance (CLint)
Correct answer: Fraction excreted renally (fe)
The fraction excreted renally (fe) represents the proportion of absorbed drug eliminated unchanged by the kidneys and determines how much renal impairment affects drug clearance.
Question 15: A pharmacist receives a prescription for oxycodone 5 mg #30. The DEA schedule of oxycodone requires how many days' supply maximum per prescription in most US states?
- 7 days
- 30 days
- 90 days
- No federal day-supply limit exists for Schedule II (Correct answer)
Correct answer: No federal day-supply limit exists for Schedule II
Federally, the DEA does not impose a day-supply limit on Schedule II prescriptions; however, individual states may set their own limits.
Question 16: Which mechanism explains the therapeutic action of metformin in type 2 diabetes?
- Stimulates pancreatic beta-cell insulin secretion
- Activates AMPK, reducing hepatic glucose output (Correct answer)
- Inhibits DPP-4 enzyme
- Blocks SGLT-2 in renal tubules
Correct answer: Activates AMPK, reducing hepatic glucose output
Metformin primarily activates AMP-activated protein kinase (AMPK), suppressing hepatic gluconeogenesis and glycogenolysis to lower blood glucose.
Question 17: A patient on warfarin begins taking high-dose vitamin E supplements. What is the expected effect on INR?
- Decreased INR due to enzyme induction
- Increased INR due to inhibition of vitamin K-dependent clotting factors (Correct answer)
- No effect on INR
- Decreased INR due to increased vitamin K production
Correct answer: Increased INR due to inhibition of vitamin K-dependent clotting factors
High-dose vitamin E impairs vitamin K–dependent carboxylation of clotting factors II, VII, IX, and X, potentiating warfarin's anticoagulant effect and raising INR.
Question 18: Which isomer of albuterol is responsible for its bronchodilatory therapeutic effect?
- R-albuterol (levalbuterol) (Correct answer)
- S-albuterol
- Both isomers equally
- Neither; the metabolite is active
Correct answer: R-albuterol (levalbuterol)
R-albuterol (levalbuterol) is the eutomer that binds beta-2 receptors and causes bronchodilation; S-albuterol may contribute to bronchoconstriction.
Question 19: A patient with Parkinson's disease taking levodopa/carbidopa develops end-of-dose wearing off. Which add-on agent BEST extends levodopa effect?
- Amantadine
- Entacapone (COMT inhibitor) (Correct answer)
- Trihexyphenidyl
- Selegiline MAO-B inhibitor
Correct answer: Entacapone (COMT inhibitor)
Entacapone inhibits COMT, preventing peripheral breakdown of levodopa and extending its duration of action to reduce wearing-off.
Question 20: What is the primary mechanism of resistance to beta-lactam antibiotics in MRSA?
- Beta-lactamase enzyme production
- Altered penicillin-binding protein (PBP2a) encoded by mecA gene (Correct answer)
- Efflux pump overexpression
- Reduced outer membrane permeability
Correct answer: Altered penicillin-binding protein (PBP2a) encoded by mecA gene
MRSA resistance is mediated by mecA gene–encoded PBP2a, a modified penicillin-binding protein with low affinity for all beta-lactam antibiotics.
Question 21: A 28-year-old woman with epilepsy who wants to become pregnant is on valproic acid. Which alternative AED is preferred to minimize teratogenicity?
- Phenobarbital
- Carbamazepine
- Lamotrigine (Correct answer)
- Topiramate
Correct answer: Lamotrigine
Lamotrigine has the lowest teratogenic risk among common AEDs and is preferred for women of childbearing age when seizure control allows.
