BCPS practice test: 47 free cases across every domain

Study cases written by our editors, not BPS items. The real BCPS exam is computer-based multiple choice, answered in order with no going back.

1. Case 01Nephrology & urology

   A 74-year-old woman has taken omeprazole 40 mg daily for 6 years and furosemide 40 mg daily for heart failure. Her potassium is 2.9 mEq/L despite KCl 40 mEq daily for a week, and total calcium is 7.6 mg/dL with albumin 4.0 g/dL. She reports muscle cramps. Which action is most appropriate?

   1. AOption A: Increase potassium chloride to 80 mEq daily
   2. BOption B: Start calcitriol 0.25 mcg daily for the hypocalcemia
   3. COption C: Add spironolactone 25 mg daily to retain potassium
   4. DOption D: Check magnesium, replete it, and reassess the PPI

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Long-term PPI use (especially with a loop diuretic) can cause hypomagnesemia, and low magnesium causes renal potassium wasting and impaired PTH secretion, producing hypokalemia and hypocalcemia that do not correct until magnesium is replaced; the PPI indication should then be reviewed. Doubling KCl fails while magnesium stays low. Calcitriol and spironolactone treat downstream effects without correcting the cause.

   A

   Doubling potassium fails while magnesium stays low, because hypomagnesemia keeps the kidney wasting potassium.

   B

   Calcitriol treats a downstream effect; the low calcium comes from magnesium-dependent PTH failure and corrects once Mg is replaced.

   C

   Spironolactone may raise potassium a little, but it leaves the magnesium deficit and the PPI cause untouched.

   D

   Correct: long-term PPI plus a loop diuretic points to hypomagnesemia, which drives both the refractory hypokalemia and the hypocalcemia.

2. Case 02Pulmonology & GI

   A 28-year-old woman presents to the emergency department with a severe asthma exacerbation. She has received three doses of nebulized albuterol 5 mg with ipratropium 0.5 mg and prednisone 50 mg orally 1 hour ago. Peak flow remains 35% of personal best, SpO2 is 93% on 2 L oxygen, and she can speak only in phrases. Which medication should be given next?

   1. AOption A: Montelukast 10 mg orally now
   2. BOption B: Magnesium sulfate 2 g IV over 20 minutes
   3. COption C: Azithromycin 500 mg IV once daily
   4. DOption D: Aminophylline 5 mg/kg IV load, then infusion

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   GINA recommends a single dose of IV magnesium sulfate 2 g for severe exacerbations that do not respond to initial bronchodilator and corticosteroid treatment, because it reduces hospital admission. Aminophylline adds toxicity (arrhythmias, vomiting) without more bronchodilation than optimal SABA therapy and is not recommended. Antibiotics are not indicated without evidence of bacterial infection, and oral montelukast has no role in acute severe asthma.

   A

   Montelukast has no role in acute severe asthma; it is a maintenance controller, not a rescue drug.

   B

   Correct: GINA supports a single 2 g IV magnesium dose when severe asthma does not respond to initial bronchodilators and steroids.

   C

   Antibiotics are not indicated in an exacerbation without signs of bacterial infection, and azithromycin will not reverse bronchospasm.

   D

   Aminophylline adds arrhythmia and vomiting risk without extra bronchodilation beyond optimal SABA, so it is not recommended.

3. Case 03Special populations

   A 30-year-old woman at 14 weeks of gestation has new moderate-to-severe major depression (PHQ-9 of 19) despite 6 weeks of weekly cognitive behavioral therapy. She has no history of mania or prior antidepressant use. Which medication is most appropriate to start?

   1. AOption A: Paroxetine
   2. BOption B: Zuranolone
   3. COption C: Esketamine nasal spray
   4. DOption D: Sertraline

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Sertraline has the largest body of reproductive safety data among SSRIs, with no consistent signal for major malformations, and is a preferred first-line choice when pregnancy-related depression needs medication. Paroxetine has been associated with cardiac malformations after first-trimester exposure and is generally avoided. Zuranolone is approved for postpartum depression and carries embryo-fetal toxicity warnings, and esketamine is reserved for treatment-resistant depression under a REMS with very limited pregnancy data.

   A

   Paroxetine is the SSRI most linked to cardiac malformations after first-trimester exposure and is usually avoided in pregnancy.

   B

   Zuranolone is labeled for postpartum depression and carries embryo-fetal toxicity warnings, so it does not fit a 14-week pregnancy.

   C

   Esketamine is reserved for treatment-resistant depression under a REMS and has little pregnancy data; she has never tried an antidepressant.

   D

   Correct: sertraline has the largest reproductive safety record among SSRIs and is a preferred first choice when antenatal depression needs a drug.

4. Case 04Infectious diseases

   A 70-year-old woman has C. difficile infection with hypotension requiring norepinephrine, abdominal distension with ileus, WBC 32,000 cells/mm³, and lactate 4.1 mmol/L. She has a nasogastric tube in place. Which regimen is most appropriate?

   1. AOption A: Oral vancomycin 125 mg every 6 hours for 10 days
   2. BOption B: Vancomycin 500 mg NG and PR every 6 h plus IV metronidazole
   3. COption C: IV vancomycin 15 mg/kg every 12 hours plus oral metronidazole
   4. DOption D: Fidaxomicin 200 mg by NG tube twice daily for 10 days, alone

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   Hypotension and ileus define fulminant CDI, for which IDSA/SHEA recommends vancomycin 500 mg four times daily by mouth or NG, adding rectal vancomycin when ileus limits delivery, plus IV metronidazole, which reaches the colon via bile and the inflamed bowel wall. IV vancomycin is not excreted into the colon and does not treat CDI. Fidaxomicin has no data in fulminant disease, and 125 mg of oral vancomycin is the dose for non-fulminant infection.

   A

   Oral vancomycin 125 mg is the non-fulminant dose; with shock and ileus it may never reach the colon.

   B

   Correct: shock and ileus define fulminant CDI, treated with high-dose enteral and rectal vancomycin plus IV metronidazole.

   C

   IV vancomycin is not excreted into the colon, so it cannot treat C. difficile at any dose.

   D

   Fidaxomicin has no supporting data in fulminant disease, and giving it alone ignores the ileus that blocks enteral delivery.

5. Case 05Biostatistics

   A pharmacist searching PubMed with the free-text terms ‘linezolid serotonin’ retrieves many irrelevant articles. Which strategy will most improve the relevance of the results?

   1. AOption A: Remove all filters and search the terms in all fields
   2. BOption B: Combine the MeSH headings for both concepts with AND
   3. COption C: Combine the two terms with OR to capture all synonyms
   4. DOption D: Add a truncation symbol to each free-text keyword

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   Using controlled MeSH headings (‘Linezolid’ and ‘Serotonin Syndrome’) joined by AND retrieves only articles indexed for both concepts, which improves specificity. OR broadens the search to articles on either concept, the common Boolean mistake. Truncation and all-field searching also widen retrieval rather than focus it.

   A

   Dropping filters and searching all fields widens retrieval and adds more noise, the opposite of the goal.

   B

   Correct: controlled MeSH headings joined with AND return only articles indexed for both linezolid and serotonin syndrome.

   C

   OR returns articles on either concept alone, which broadens the result set instead of focusing it.

   D

   Truncation captures more word endings and so pulls in more records; it does not improve relevance.

6. Case 06Critical care

   A 64-year-old man is intubated for pneumonia-related respiratory failure and is expected to need mechanical ventilation for 3–5 days. Pain is controlled with a fentanyl infusion (analgesia-first). The team’s goals are light sedation (RASS 0 to −1) and minimizing delirium. HR is 84 beats/minute and MAP 72 mm Hg. Per the 2025 PADIS focused update, which sedative is most appropriate?

   1. AOption A: Propofol infusion
   2. BOption B: Midazolam continuous infusion
   3. COption C: Dexmedetomidine infusion
   4. DOption D: Lorazepam intermittent IV boluses

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   The 2025 PADIS focused update suggests dexmedetomidine over propofol for adults on mechanical ventilation when light sedation and less delirium are the priorities, and his HR and MAP leave room for its bradycardia and hypotension. Propofol remains acceptable and is the tempting answer, but it does not give the delirium advantage. Benzodiazepine infusions such as midazolam or lorazepam prolong ventilation and increase delirium and are not recommended.

   A

   Propofol is acceptable, but the 2025 PADIS update favors dexmedetomidine when light sedation and less delirium are the stated priorities.

   B

   A midazolam infusion accumulates, prolongs ventilation and increases delirium, so benzodiazepine infusions are not recommended.

   C

   Correct: the 2025 PADIS update suggests dexmedetomidine over propofol for light sedation with delirium reduction, and his HR and MAP allow it.

   D

   Lorazepam boluses are still benzodiazepine-based sedation, linked to deeper sedation and more delirium.

7. Case 07Therapeutics & patient management

   A 62-year-old man with chronic low back pain takes oxycodone ER 20 mg every 12 hours and oxycodone IR 5 mg about twice daily. He also has obstructive sleep apnea. His orthopedist sends a new prescription for diazepam 5 mg three times daily for muscle spasm. Which recommendation is most appropriate?

   1. AOption A: Avoid diazepam, use a nonsedating option, and offer naloxone
   2. BOption B: Dispense diazepam and reduce oxycodone ER by 50% the same day
   3. COption C: Change diazepam to alprazolam 0.25 mg three times daily
   4. DOption D: Dispense diazepam because his total opioid dose is under 90 MME

   Pick an option: the verdict and a note on every option open here.

   Best answer: A.

   His opioid dose is about 75 MME/day (50 mg oxycodone × 1.5), and adding any benzodiazepine produces synergistic respiratory depression—a combination the CDC 2022 guideline and FDA boxed warning say to avoid, especially with sleep apnea—so a nonsedating approach plus naloxone is safest. There is no ‘safe’ MME level for co-prescribing, and the 2022 guideline dropped the 90 MME cap. Abruptly cutting the opioid by 50% risks withdrawal and uncontrolled pain, and switching to alprazolam keeps the same interaction.

   A

   Correct: an opioid plus a benzodiazepine causes synergistic respiratory depression, worse with sleep apnea, so avoid diazepam and offer naloxone.

   B

   Halving the long-acting opioid abruptly risks withdrawal and uncontrolled pain and still leaves a benzodiazepine in the regimen.

   C

   Alprazolam is another benzodiazepine and carries the same boxed-warning interaction with opioids.

   D

   No MME level makes co-prescribing safe, and the 2022 CDC guideline no longer treats 90 MME as a cap.

8. Case 08Therapeutics & patient management

   A 72-year-old woman is on day 2 after an ischemic stroke. She failed the nurse’s bedside swallow screen, and her oral medications (aspirin, atorvastatin, lisinopril, and metformin) are due. The pharmacist must decide which dosage forms she can safely receive. With which team member should the pharmacist coordinate first?

   1. AOption A: Registered dietitian nutritionist
   2. BOption B: Physical therapist
   3. COption C: Speech-language pathologist
   4. DOption D: Occupational therapist

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   A failed swallow screen requires a formal swallowing evaluation by speech-language pathology, which determines whether she can take anything by mouth and in what consistency—information the pharmacist needs to choose crushed, liquid, rectal, or IV alternatives. The dietitian sets nutritional needs and diet texture once the swallow study is done but does not assess aspiration risk. Occupational and physical therapists address self-care and mobility, not swallowing safety.

   A

   The dietitian sets nutrition goals and diet texture after the swallow evaluation but does not assess aspiration risk.

   B

   Physical therapy addresses mobility and gait, not whether she can safely swallow tablets.

   C

   Correct: a failed bedside screen calls for a formal speech-language pathology swallow evaluation, which tells the pharmacist which dosage forms are safe.

   D

   Occupational therapy works on self-care tasks; swallow safety belongs to speech-language pathology.

9. Case 09Therapeutics & patient management

   A 52-year-old woman with primary hypothyroidism (TSH 11.8 mIU/L, free T4 0.6 ng/dL) is started on levothyroxine 75 mcg daily. Which monitoring plan is most appropriate to decide whether the dose needs adjustment?

   1. AOption A: Check TSH 6–8 weeks after starting therapy
   2. BOption B: Check TSH 1–2 weeks after starting therapy
   3. COption C: Check total T4 1–2 weeks after starting therapy
   4. DOption D: Check free T3 6–8 weeks after starting therapy

   Pick an option: the verdict and a note on every option open here.

   Best answer: A.

   In primary hypothyroidism TSH is the most sensitive marker of replacement adequacy, and because levothyroxine has a half-life of about 7 days, steady state and a stable TSH response take about 6–8 weeks. Checking TSH at 1–2 weeks reflects a non-steady state and can prompt premature dose changes. Free T3 is unreliable for titration because peripheral T4-to-T3 conversion keeps it normal until late, and total T4 is affected by binding-protein changes.

   A

   Correct: TSH is the titration marker, and with a 7-day half-life levothyroxine needs about 6–8 weeks to reach steady state.

   B

   TSH at 1–2 weeks reflects a non-steady state and can trigger premature dose changes.

   C

   Total T4 is skewed by binding-protein changes, and 1–2 weeks is too early to judge any marker.

   D

   Free T3 stays normal until late because peripheral conversion compensates, so it is a poor guide to dose.

10. Case 10Therapeutics & patient management

    A 70-year-old man with atrial fibrillation takes warfarin 5 mg daily (35 mg/week), with INRs stable at 2–3 for a year. Today his INR is 4.6. He has no bleeding, no falls, and no new medications, but ate less than usual during a recent viral illness. Which action is most appropriate?

    1. AOption A: Give 4-factor prothrombin complex concentrate
    2. BOption B: Hold one dose, then resume at a lower weekly dose
    3. COption C: Continue the current dose and recheck in 4 weeks
    4. DOption D: Give vitamin K 2.5 mg orally and hold warfarin for 2 days

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    For an INR between 4.5 and 10 without bleeding, CHEST guidance is to hold one or two doses and resume at a modestly reduced weekly dose, rechecking the INR within about a week; routine vitamin K is not recommended because it does not reduce bleeding and can make re-anticoagulation harder. 4F-PCC is reserved for major bleeding. Continuing the same dose for 4 weeks leaves him exposed to bleeding risk while the INR is above range.

    A

    Four-factor PCC is for major bleeding; an asymptomatic INR of 4.6 does not need urgent reversal.

    B

    Correct: for INR 4.5–10 without bleeding, holding a dose and resuming at a modestly lower weekly dose is the guideline approach.

    C

    Keeping the same dose for 4 weeks leaves him above range with no early recheck.

    D

    Routine vitamin K at this INR without bleeding does not reduce bleeding and can make re-anticoagulation harder.

11. Case 11Oncology & immunology

    A 55-year-old man has had three gout flares in the past year. Serum uric acid is 9.8 mg/dL, eGFR 52 mL/min/1.73 m², and he has no history of kidney stones or cardiovascular disease. He takes colchicine 0.6 mg daily for flare prophylaxis. Which urate-lowering therapy is most appropriate to start?

    1. AOption A: Allopurinol 100 mg daily
    2. BOption B: Allopurinol 300 mg daily
    3. COption C: Febuxostat 40 mg daily
    4. DOption D: Probenecid 500 mg twice daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    The note on each option loads when you answer.

12. Case 12Therapeutics & patient management

    A 45-year-old woman taking escitalopram 20 mg daily is hospitalized with MRSA pneumonia. On day 3 she develops agitation, diaphoresis, temperature 39.4°C, tremor and inducible clonus in both ankles. New medications started on admission include linezolid 600 mg IV every 12 hours, ondansetron 4 mg IV every 8 hours as needed (one dose given), oxycodone 5 mg every 6 hours as needed, and enoxaparin. Which medication is most likely responsible?

    1. AOption A: Oxycodone
    2. BOption B: Enoxaparin
    3. COption C: Ondansetron
    4. DOption D: Linezolid

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.

13. Case 13Therapeutics & patient management

    A 78-year-old patient is admitted from the emergency department with a heart failure exacerbation. The ED note lists home medications copied from a clinic visit 8 months ago. Which action by the admitting pharmacist best establishes the best possible medication history?

    1. AOption A: Defer the medication history until discharge planning begins
    2. BOption B: Use the most recent clinic note as the verified home list
    3. COption C: Order the home medications as listed in the ED note
    4. DOption D: Interview the patient and verify with pharmacy fill records

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.

14. Case 14Safety & practice

    A pharmacy department has categorized 240 medication error reports from the past year by contributing cause. The safety committee wants to identify the few causes responsible for most of the errors so it can prioritize its improvement work. Which quality tool is most appropriate?

    1. AOption A: Run chart
    2. BOption B: Failure mode and effects analysis
    3. COption C: Fishbone diagram
    4. DOption D: Pareto chart

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.

15. Case 15Neurology & psychiatry

    A 74-year-old man with Parkinson disease takes carbidopa/levodopa 25/100 mg five times daily (every 3 hours while awake) and has wearing-off symptoms 30–45 minutes before each dose, without dyskinesia. He developed compulsive gambling on pramipexole 2 years ago, which resolved after it was stopped. He also takes tramadol 50 mg three times daily for osteoarthritis. Which medication should be added?

    1. AOption A: Trihexyphenidyl 1 mg twice daily
    2. BOption B: Entacapone 200 mg with each levodopa dose
    3. COption C: Rasagiline 1 mg once daily
    4. DOption D: Ropinirole 0.25 mg orally three times daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    The note on each option loads when you answer.

16. Case 16Safety & practice

    A hospital proposes a pharmacist-led anticoagulation stewardship service costing $150,000 per year. Administrators want to know whether the monetary value of the outcomes it produces (avoided bleeding admissions and shorter stays) exceeds its cost, expressed as a net benefit. Which pharmacoeconomic analysis is most appropriate?

    1. AOption A: Cost-benefit analysis
    2. BOption B: Budget impact analysis
    3. COption C: Cost-effectiveness analysis
    4. DOption D: Cost-minimization analysis

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    The note on each option loads when you answer.

17. Case 17Safety & practice

    A hospital pharmacy department plans a medication use evaluation (MUE) of piperacillin-tazobactam to determine whether its use is appropriate. Which data collection approach best meets this objective?

    1. AOption A: Audit cases against indication, dose, and duration criteria
    2. BOption B: Compare monthly acquisition cost with the previous fiscal year
    3. COption C: Measure the percentage of doses given by extended infusion
    4. DOption D: Trend days of therapy per 1,000 patient-days on each unit

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    The note on each option loads when you answer.

18. Case 18Oncology & immunology

    A 58-year-old man with newly diagnosed acute myeloid leukemia is starting 7+3 induction chemotherapy and is expected to be profoundly neutropenic for about 3 weeks. He takes no other medications, QTc is 430 ms and liver enzymes are normal. Which antifungal prophylaxis is most appropriate?

    1. AOption A: Fluconazole 400 mg orally daily
    2. BOption B: Liposomal amphotericin B 3 mg/kg IV daily
    3. COption C: Posaconazole delayed-release 300 mg daily
    4. DOption D: Caspofungin 50 mg IV daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    The note on each option loads when you answer.

19. Case 19Cardiology

    A 60-year-old man with chronic stable angina has exertional chest pain twice weekly despite metoprolol succinate 200 mg daily and amlodipine 10 mg daily. HR is 56 beats/minute and BP 118/72 mm Hg. He takes sildenafil 50 mg as needed for erectile dysfunction about once a week. QTc is 420 ms, and he takes no CYP3A4 inhibitors. Which medication should be added for angina?

    1. AOption A: Diltiazem ER 120 mg daily
    2. BOption B: Ivabradine 5 mg twice daily
    3. COption C: Ranolazine 500 mg twice daily
    4. DOption D: Isosorbide mononitrate ER 30 mg daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    The note on each option loads when you answer.

20. Case 20Therapeutics & patient management

    A woman with nonvalvular atrial fibrillation has taken apixaban 5 mg twice daily for 3 years without bleeding. At her annual review she has just turned 80, her weight has fallen to 58 kg, and SCr is 1.3 mg/dL. Which change is most appropriate?

    1. AOption A: Reduce apixaban to 2.5 mg twice daily
    2. BOption B: Switch to warfarin due to her age
    3. COption C: Check an anti-Xa level to choose the dose
    4. DOption D: Continue 5 mg twice daily, since SCr is below 1.5

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    The note on each option loads when you answer.

21. Case 21Safety & practice

    A hospital stewardship team reports quarterly antibiotic days of therapy and resistance trends to its prescribers, as the CDC Core Elements recommend. Under the same Core Elements, which element must also be in place for the program to be complete?

    1. AOption A: A rotating schedule that cycles empiric antibiotic classes
    2. BOption B: A physician or pharmacist leader accountable for outcomes
    3. COption C: A fixed 7-day automatic stop order on every antibiotic
    4. DOption D: An ID physician approval requirement for every antibiotic

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    The note on each option loads when you answer.

22. Case 22Safety & practice

    A pharmacist preparing an investigational drug finds that a Spanish-speaking patient with limited English proficiency signed the English consent form after a discussion held without an interpreter. Which action best advocates for this patient?

    1. AOption A: Give the patient a Spanish translation of the form to sign
    2. BOption B: Ask the patient’s adult son to interpret a brief review
    3. COption C: Dispense the dose and notify the investigator afterward
    4. DOption D: Have a qualified medical interpreter redo the consent

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.

23. Case 23Endocrinology

    A 72-year-old woman with severe osteoporosis (prior vertebral fractures, baseline spine T-score −3.6) has completed 24 months of teriparatide; her spine BMD rose by 9%. CrCl is 55 mL/min, and she has no dental problems. Which next step is most appropriate?

    1. AOption A: Stop therapy and repeat DXA in 2 years
    2. BOption B: Restart teriparatide after a 1-year holiday
    3. COption C: Start an antiresorptive such as alendronate
    4. DOption D: Continue calcium and vitamin D only

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    The note on each option loads when you answer.

24. Case 24Pain & palliative care

    A 44-year-old woman has newly diagnosed fibromyalgia with widespread pain, fatigue, and poor sleep. She also has untreated major depression (PHQ-9 of 15). She does not exercise regularly and asks for ‘something strong’ for pain. CrCl is 95 mL/min. Which plan is most appropriate?

    1. AOption A: Oxycodone 5 mg every 6 hours as needed for pain
    2. BOption B: Prednisone 10 mg daily for 2 weeks, then taper
    3. COption C: Pregabalin, plus rest from exercise during pain flares
    4. DOption D: Duloxetine plus a graded aerobic exercise program

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.

25. Case 25Therapeutics & patient management

    A 76-year-old man with HFrEF enrolled in Medicare Part D stopped sacubitril/valsartan and dapagliflozin last month because he could not afford the copays. He lives alone on Social Security with an income below 150% of the federal poverty level and limited savings. Which intervention is most appropriate?

    1. AOption A: Enroll him in the manufacturers’ commercial copay coupon programs
    2. BOption B: Help him apply for the Part D Low-Income Subsidy (Extra Help)
    3. COption C: Stop dapagliflozin, since he does not have diabetes
    4. DOption D: Advise taking each drug every other day to stretch the supply

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    The note on each option loads when you answer.

26. Case 26Oncology & immunology

    A 24-year-old man with Burkitt lymphoma develops laboratory tumor lysis syndrome 24 hours after starting chemotherapy despite allopurinol and IV fluids: uric acid 13.8 mg/dL, K 5.6 mEq/L, phosphorus 7.2 mg/dL, SCr 2.1 mg/dL (baseline 0.9 mg/dL). G6PD testing is normal. Which intervention is most appropriate?

    1. AOption A: Increase allopurinol to 800 mg daily
    2. BOption B: Give rasburicase 0.2 mg/kg IV over 30 minutes
    3. COption C: Switch allopurinol to febuxostat 120 mg daily
    4. DOption D: Add sodium bicarbonate to alkalinize the urine

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    The note on each option loads when you answer.

27. Case 27Neurology & psychiatry

    A 52-year-old woman (70 kg) is in convulsive status epilepticus that continues after two doses of lorazepam 4 mg IV given 5 minutes apart. She has alcohol-related cirrhosis with thrombocytopenia (platelets 64,000 cells/mm³), and her ECG shows second-degree (Mobitz II) AV block. Which second-phase therapy is most appropriate?

    1. AOption A: Lorazepam 4 mg IV (third dose)
    2. BOption B: Levetiracetam 60 mg/kg IV (max 4,500 mg)
    3. COption C: Valproate 40 mg/kg IV (maximum 3,000 mg)
    4. DOption D: Fosphenytoin 20 mg PE/kg IV

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    The note on each option loads when you answer.

28. Case 28Critical care

    A 50-year-old man with septic shock from pyelonephritis has received 30 mL/kg of balanced crystalloid and cefepime within the first hour. Despite norepinephrine at 0.3 mcg/kg/minute for 2 hours, his MAP is 58 mm Hg. Lactate is 4.1 mmol/L, and an echocardiogram shows normal LV function. Which vasopressor should be added?

    1. AOption A: Epinephrine 0.05 mcg/kg/minute
    2. BOption B: Dopamine 5 mcg/kg/minute
    3. COption C: Phenylephrine 100 mcg/minute
    4. DOption D: Vasopressin 0.03 units/minute

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.

29. Case 29Safety & practice

    A hospital applies a just culture algorithm to four medication events. Which event represents reckless behavior?

    1. AOption A: A pharmacist picks the wrong vial from look-alike packaging while following policy
    2. BOption B: A technician skips a required double count because colleagues routinely do
    3. COption C: A nurse misreads a poorly handwritten dose despite checking it twice
    4. DOption D: A pharmacist verifies a dose known to be 10-fold too high to avoid calling

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.

30. Case 30Biostatistics

    Investigators want to evaluate whether fluoroquinolone use is associated with aortic aneurysm or dissection, an outcome occurring in about 1 per 10,000 patient-years. They have access to a large claims database. Which study design is most efficient for this question?

    1. AOption A: Randomized controlled trial
    2. BOption B: Prospective cohort study
    3. COption C: Cross-sectional study
    4. DOption D: Case-control study

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.

31. Case 31Safety & practice

    A hospital P&T committee reviews the proton pump inhibitor class. Published evidence shows omeprazole, esomeprazole, and pantoprazole are therapeutically equivalent at equipotent doses for inpatient indications; pantoprazole has the lowest net cost and is the only one with an IV formulation on contract. Which formulary decision is most appropriate?

    1. AOption A: Make all PPIs nonformulary and use patients’ own home supply
    2. BOption B: Add pantoprazole with an approved therapeutic interchange
    3. COption C: Add all three PPIs to accommodate prescriber preferences
    4. DOption D: Add esomeprazole because it raises intragastric pH the most

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    The note on each option loads when you answer.

32. Case 32Therapeutics & patient management

    A 66-year-old man with HFrEF started sacubitril/valsartan 3 months ago. His dyspnea has improved from NYHA class III to II, weight is stable, and he has no edema. His BNP has risen from 380 to 520 pg/mL, while NT-proBNP fell from 2,900 to 1,700 pg/mL. Which interpretation is most appropriate?

    1. AOption A: Neprilysin inhibition raises BNP; NT-proBNP shows improvement
    2. BOption B: Both peptides are unreliable on an ARNI; stop measuring them
    3. COption C: Rising BNP signals ARNI failure; switch back to an ACE inhibitor
    4. DOption D: Rising BNP signals worsening HF; increase the furosemide

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    The note on each option loads when you answer.

33. Case 33Neurology & psychiatry

    A 34-year-old woman has major depressive disorder with a seasonal pattern, with mild symptoms each November through March for 3 years. She prefers to avoid prescription medications this winter and has no eye disease or history of bipolar disorder. Which recommendation is most appropriate?

    1. AOption A: St. John’s wort 300 mg three times daily
    2. BOption B: Bright light, 10,000 lux for 30 minutes on waking
    3. COption C: Bright light, 10,000 lux for 30 minutes at bedtime
    4. DOption D: Melatonin 10 mg at bedtime throughout the winter

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    The note on each option loads when you answer.

34. Case 34Therapeutics & patient management

    A 66-year-old man with HFrEF (LVEF 30%, NYHA class II) takes lisinopril 20 mg daily, carvedilol 25 mg twice daily, spironolactone 25 mg daily, and dapagliflozin 10 mg daily. BP is 124/76 mm Hg, K 4.4 mEq/L, and SCr 1.1 mg/dL. The team plans to switch lisinopril to sacubitril/valsartan. Which plan is most appropriate?

    1. AOption A: Start sacubitril/valsartan now and taper lisinopril over 1 week
    2. BOption B: Stop lisinopril and start sacubitril/valsartan 36 hours later
    3. COption C: Stop spironolactone, then start sacubitril/valsartan with lisinopril
    4. DOption D: Stop lisinopril and start sacubitril/valsartan the next morning

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    The note on each option loads when you answer.

35. Case 35Therapeutics & patient management

    A 60-year-old woman (actual body weight 135 kg, BMI 48 kg/m²) has MRSA bacteremia. She received a vancomycin loading dose of 2,750 mg, and SCr is 0.8 mg/dL and stable. Which maintenance dosing and monitoring strategy is most appropriate?

    1. AOption A: 15 mg/kg actual weight every 12 hours, no levels
    2. BOption B: Trough-guided dosing targeting 15–20 mg/L
    3. COption C: Bayesian dosing targeting an AUC of 400–600
    4. DOption D: Dose by ideal body weight and follow SCr only

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    The note on each option loads when you answer.

36. Case 36Oncology & immunology

    A 15-year-old kidney transplant recipient takes tacrolimus (trough 6 ng/mL), mycophenolate and prednisone. He now has streptococcal pharyngitis. He had anaphylaxis to amoxicillin at age 6. Which antibiotic is most appropriate?

    1. AOption A: Cephalexin for 10 days
    2. BOption B: Erythromycin for 10 days
    3. COption C: Azithromycin for 5 days
    4. DOption D: Clarithromycin for 10 days

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    The note on each option loads when you answer.

37. Case 37Cardiology

    A 68-year-old woman with a COPD exacerbation receiving albuterol/ipratropium nebulizers develops atrial fibrillation with a ventricular rate of 146 beats/minute. BP is 126/78 mm Hg, LVEF is 60%, and she has wheezing on examination. She has no accessory pathway. Which medication is most appropriate for rate control?

    1. AOption A: Propranolol 1 mg IV every 2 minutes
    2. BOption B: Diltiazem 0.25 mg/kg IV over 2 minutes
    3. COption C: Adenosine 6 mg IV rapid push, then 12 mg
    4. DOption D: Sotalol 80 mg orally twice daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    The note on each option loads when you answer.

38. Case 38Therapeutics & patient management

    A 45-year-old patient (80 kg) with Pseudomonas aeruginosa bacteremia is started on cefepime plus tobramycin 560 mg IV every 24 hours (7 mg/kg extended-interval dosing). SCr is 0.9 mg/dL and stable. Which tobramycin monitoring plan is most appropriate to minimize nephrotoxicity?

    1. AOption A: Random level 6–14 hours post-dose plotted on a nomogram
    2. BOption B: Trough level before the fourth dose, targeting 15–20 mg/L
    3. COption C: Peak level 30 minutes after the dose, targeting 6–10 mg/L
    4. DOption D: Weekly SCr only, without tobramycin concentrations

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    The note on each option loads when you answer.

39. Case 39Safety & practice

    A community pharmacist receives a prescription for a reference biologic (adalimumab) and wants to dispense a lower-cost biosimilar without contacting the prescriber. Under federal law and most state laws, this substitution is permitted only when the biosimilar:

    1. AOption A: shares the reference product’s four-letter suffix
    2. BOption B: is rated AB in the FDA Orange Book
    3. COption C: has been designated interchangeable by FDA
    4. DOption D: is approved for every indication of the reference product

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    The note on each option loads when you answer.

40. Case 40Biostatistics

    A randomized trial compares the mean change in systolic blood pressure after 12 weeks among three antihypertensive regimens (120 patients per group). The data are continuous and normally distributed. Which statistical test is most appropriate for the primary comparison?

    1. AOption A: Kruskal-Wallis test
    2. BOption B: Multiple unpaired t-tests
    3. COption C: Chi-square test
    4. DOption D: One-way ANOVA

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.

41. Case 41Safety & practice

    A hospital wants a quality measure that most directly reflects whether clinicians follow evidence-based care for patients admitted with acute myocardial infarction. Which measure is most appropriate?

    1. AOption A: Discharge high-intensity statin rate in eligible patients
    2. BOption B: 30-day all-cause mortality rate for AMI admissions
    3. COption C: Average hospital length of stay for AMI admissions
    4. DOption D: Patient satisfaction scores with cardiac discharge teaching

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    The note on each option loads when you answer.

42. Case 42Therapeutics & patient management

    A 45-year-old man receives methadone 120 mg daily for opioid use disorder. Citalopram 40 mg daily was started 3 weeks ago for depression. Today’s ECG shows a QTc of 512 ms (baseline 468 ms); K is 3.2 mEq/L and Mg 1.5 mg/dL. He has no syncope or palpitations. Which action is most appropriate?

    1. AOption A: Stop methadone today and refer for detoxification
    2. BOption B: Continue all medications, since QTc is under 550 ms
    3. COption C: Switch citalopram to escitalopram 20 mg daily
    4. DOption D: Stop citalopram, replete K and Mg, repeat the ECG

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.

43. Case 43Therapeutics & patient management

    A 60-year-old man with type 2 diabetes uses insulin glargine 24 units SC at bedtime and is starting oral semaglutide 3 mg daily. He usually takes his morning medications with breakfast and coffee. Which administration instruction for oral semaglutide is correct?

    1. AOption A: Crushed into applesauce if the tablet is hard to swallow
    2. BOption B: At bedtime with a full glass of water and the insulin dose
    3. COption C: On waking with ≤4 oz of water, 30 minutes before food
    4. DOption D: With breakfast and coffee to reduce nausea

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    The note on each option loads when you answer.

44. Case 44Therapeutics & patient management

    A 76-year-old man with nonvalvular atrial fibrillation (CHA2DS2-VASc 4, CrCl 64 mL/min, weight 82 kg) refuses warfarin because his brother needed weekly INR checks and had a bleed. He says he wants to lower his stroke risk but values avoiding lab visits. Which is the most appropriate next step?

    1. AOption A: Discuss apixaban’s benefits and risks and offer it
    2. BOption B: Document his refusal and give no antithrombotic
    3. COption C: Refer for left atrial appendage occlusion now
    4. DOption D: Recommend aspirin 81 mg daily as a safer alternative

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    The note on each option loads when you answer.

45. Case 45Therapeutics & patient management

    A 66-year-old hospice patient with metastatic pancreatic cancer takes morphine IR 15 mg orally every 4 hours around the clock and has needed four additional 15-mg breakthrough doses every day this week. Pain is still 7/10, and she has no sedation or renal impairment. The team will convert her to long-acting morphine. Which regimen is most appropriate?

    1. AOption A: Morphine ER 45 mg every 12 hours plus IR 15 mg every 2 hours as needed
    2. BOption B: Morphine ER 75 mg every 12 hours plus IR 15 mg every 2 hours as needed
    3. COption C: Morphine ER 150 mg every 12 hours plus IR 30 mg every 2 hours as needed
    4. DOption D: Morphine ER 75 mg every 12 hours plus IR 75 mg every 2 hours as needed

    Pick an option: the verdict and a note on every option open here.

    Best answer: B.

    The note on each option loads when you answer.

46. Case 46Therapeutics & patient management

    A 59-year-old man with severe ARDS (PaO2/FiO2 85 on PEEP 14) has persistent ventilator dyssynchrony despite deep sedation with propofol and fentanyl, and a continuous neuromuscular blocker is planned for 48 hours. He has septic shock with AKI (SCr 3.4 mg/dL, oliguric) and ischemic hepatitis (ALT 1,240 units/L). Which neuromuscular blocker is most appropriate?

    1. AOption A: Pancuronium intermittent boluses
    2. BOption B: Rocuronium infusion
    3. COption C: Vecuronium infusion
    4. DOption D: Cisatracurium infusion

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.

47. Case 47Neurology & psychiatry

    A 50-year-old woman has episodic migraine with 8 migraine days per month despite 3 months of propranolol 160 mg daily. Topiramate previously caused cognitive slowing. She has resistant hypertension (BP 146/92 mm Hg on four agents) and chronic constipation. Which preventive therapy is most appropriate to add?

    1. AOption A: Erenumab 70 mg SC once monthly
    2. BOption B: OnabotulinumtoxinA 155 units IM every 12 weeks
    3. COption C: Sumatriptan 50 mg orally once daily
    4. DOption D: Galcanezumab 240 mg SC, then 120 mg monthly

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    The note on each option loads when you answer.