Pharmacology in Special Populations Practice Questions

72 multiple-choice questions on Special populations for paramedic and EMT students, from Chapter 13 (Principles of Pharmacology). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

72 practice questions

1. A 20-kg child with fever is to receive oral acetaminophen at 15 mg/kg. The dose is:

   1. A. 300 mg
   2. B. 150 mg
   3. C. 600 mg
   4. D. 30 mg
   Show answer

   Answer: A. 300 mg

   15 mg/kg x 20 kg = 300 mg. 150 mg is half the dose (7.5 mg/kg), 600 mg is double (30 mg/kg), and 30 mg reflects a decimal error. Count every acetaminophen source, including combination products, toward the daily maximum.

2. Children differ pharmacologically from adults because:

   1. A. Immature organs and body composition alter kinetics
   2. B. They are not susceptible to drug interactions
   3. C. Their drug metabolism is essentially identical to adults'
   4. D. They always require proportionally higher doses
   Show answer

   Answer: A. Immature organs and body composition alter kinetics

   Organ immaturity, body water content, and fat distribution alter absorption, distribution, and clearance. Neonates in particular clear many drugs slowly.

3. A frail 88-year-old woman with little muscle mass has a normal serum creatinine. Her ability to clear renally excreted drugs is most likely:

   1. A. Normal, exactly as the creatinine indicates
   2. B. Lower than the creatinine suggests
   3. C. Higher than in a young adult
   4. D. Unrelated to drug dosing
   Show answer

   Answer: B. Lower than the creatinine suggests

   Creatinine comes from muscle, so an older adult with little muscle mass can have a normal creatinine despite a reduced glomerular filtration rate; renal drug clearance is often lower than the creatinine suggests. It is not normal, exactly as the creatinine indicates; it is not higher than in a young adult; and renal clearance is directly related to drug dosing.

4. A 78-year-old with heart failure began taking daily naproxen for arthritis and has gained 3 kg, with new dyspnea and edema. The likely drug-related cause is:

   1. A. A delayed naproxen allergy causing edema
   2. B. Naproxen-induced hypoglycemia
   3. C. NSAID-induced sodium and fluid retention
   4. D. Direct naproxen damage to heart muscle
   Show answer

   Answer: C. NSAID-induced sodium and fluid retention

   NSAIDs block renal prostaglandins, causing sodium and water retention and blunting diuretics, a common cause of heart failure decompensation in older adults. A delayed naproxen allergy causing edema would bring hives or angioedema rather than weight gain and dyspnea, naproxen does not cause hypoglycemia, and the problem is fluid retention rather than direct damage to heart muscle.

5. A drug given to a pregnant patient should be chosen considering:

   1. A. Both maternal need and fetal effects
   2. B. Only the drug's effect on the fetus
   3. C. Only the drug's effect on the mother
   4. D. Only the gestational age of the fetus
   Show answer

   Answer: A. Both maternal need and fetal effects

   Treating the mother's life-threatening condition takes priority.

6. Physiologic changes in pregnancy that affect drugs include:

   1. A. A slower heart rate and faster gastric emptying
   2. B. Decreased renal blood flow and clearance
   3. C. Reduced blood volume and cardiac output
   4. D. Increased blood volume and cardiac output
   Show answer

   Answer: D. Increased blood volume and cardiac output

   Pregnancy increases blood volume and cardiac output, alters (slows) gastric emptying, and increases renal clearance. These affect both dose and response.

7. Opioids require extra caution in a patient with obstructive sleep apnea because they:

   1. A. Worsen airway collapse and blunt arousal
   2. B. Trigger bronchospasm in people with sleep apnea
   3. C. Are cleared faster in sleep apnea
   4. D. Raise the seizure threshold too much
   Show answer

   Answer: A. Worsen airway collapse and blunt arousal

   Opioids relax upper airway muscles and blunt the arousal response to hypoxia and rising CO2, so patients with obstructive sleep apnea are prone to dangerous apnea; use lower doses and capnography. Opioids do not trigger bronchospasm in people with sleep apnea, they are not cleared faster in sleep apnea, and they do not raise the seizure threshold too much; seizure risk is not the concern.

8. In obese patients, dosing considerations include:

   1. A. Avoiding weight-based dosing in these patients
   2. B. Using pediatric doses to limit overdose risk
   3. C. Some drugs use ideal or adjusted weight
   4. D. Always dosing on total (actual) body weight
   Show answer

   Answer: C. Some drugs use ideal or adjusted weight

   Some drugs are dosed on ideal or adjusted body weight rather than total body weight. Lipid-soluble drugs distribute differently than water-soluble ones.

9. Patients in shock may respond unpredictably to medications because:

   1. A. All drugs act faster because of compensatory tachycardia
   2. B. Drug receptors disappear entirely during shock states
   3. C. Hepatic metabolism accelerates markedly during shock
   4. D. Poor perfusion alters absorption and distribution
   Show answer

   Answer: D. Poor perfusion alters absorption and distribution

   Poor perfusion alters absorption and distribution, and acidosis may reduce drug effect. IV or IO routes are preferred in these patients.

10. Hypothermic patients may:

    1. A. Always show exaggerated drug responses
    2. B. Metabolize drugs faster than normal
    3. C. Metabolize drugs slowly and unpredictably
    4. D. Respond to drugs as normothermic patients do
    Show answer

    Answer: C. Metabolize drugs slowly and unpredictably

    Many resuscitation protocols limit repeat doses in severe hypothermia.

11. A patient had anaphylaxis to one drug in a class and now needs treatment. The safest assumption about other drugs in that class is that they:

    1. A. Are safe at a lower dose
    2. B. May cause a similar reaction
    3. C. Are safe by a different route
    4. D. Are safe after diphenhydramine
    Show answer

    Answer: B. May cause a similar reaction

    Drugs in a class share structures, so they may cause a similar reaction (cross-reactivity); avoid the class and consult medical direction about alternatives. A drug is not made safe at a lower dose, safe by a different route, or safe after diphenhydramine pretreatment, because none of these reliably prevents anaphylaxis.

12. A patient who speaks little English hands you her pill bottles. The best way to confirm what she takes and her allergies is to:

    1. A. Use a professional or phone interpreter
    2. B. Have her 8-year-old son translate
    3. C. Rely on the bottle labels alone
    4. D. Speak louder and more slowly in English
    Show answer

    Answer: A. Use a professional or phone interpreter

    A qualified professional or telephone interpreter gives accurate medication and allergy information and protects confidentiality. A child such as her 8-year-old son should not interpret medical details, bottle labels alone miss allergies and actual dosing, and speaking louder and more slowly in English does not overcome a language barrier.

13. Neonates have a less acidic stomach than adults. This tends to increase oral absorption of:

    1. A. Acid-labile drugs such as penicillin G
    2. B. Weakly acidic drugs such as phenobarbital
    3. C. Drugs given intravenously
    4. D. Drugs applied to the skin
    Show answer

    Answer: A. Acid-labile drugs such as penicillin G

    With a higher gastric pH, acid-labile drugs such as penicillin G are destroyed less and absorbed more, while weakly acidic drugs such as phenobarbital are more ionized and absorbed less. Gastric pH has no effect on drugs given intravenously or on drugs applied to the skin.

14. Ibuprofen for fever is labeled for infants starting at about what age?

    1. A. 6 months
    2. B. 2 years
    3. C. 2 weeks
    4. D. 12 years
    Show answer

    Answer: A. 6 months

    Ibuprofen is labeled for infants 6 months and older because of limited safety data and kidney risk in younger infants; acetaminophen is used before that. Waiting until 2 years or 12 years is unnecessary, and 2 weeks is far too young.

15. Infants have a higher proportion of total body water, which affects:

    1. A. Hepatic metabolism of lipid-soluble drugs
    2. B. Absorption of oral drugs from the gut
    3. C. Protein binding of weakly acidic drugs
    4. D. Distribution of water-soluble drugs
    Show answer

    Answer: D. Distribution of water-soluble drugs

    Water-soluble drugs have a larger volume of distribution and are more diluted in infants.

16. The blood-brain barrier in neonates is:

    1. A. Not relevant to drug distribution
    2. B. Fully mature and more protective than adults'
    3. C. Immature, allowing greater CNS drug entry
    4. D. Absent until about one year of age
    Show answer

    Answer: C. Immature, allowing greater CNS drug entry

    Neonates are more sensitive to CNS-active drugs.

17. Aspirin is avoided for fever in children and teens with viral illnesses such as influenza or chickenpox because of the risk of:

    1. A. Kernicterus
    2. B. Reye syndrome
    3. C. Gray baby syndrome
    4. D. Serotonin syndrome
    Show answer

    Answer: B. Reye syndrome

    Aspirin given during viral illness in children is linked to Reye syndrome, an acute encephalopathy with liver failure. Kernicterus is bilirubin brain injury in newborns, gray baby syndrome is chloramphenicol toxicity in neonates, and serotonin syndrome comes from serotonergic drugs.

18. Older adults have increased body fat and decreased lean mass, meaning lipid-soluble drugs:

    1. A. Are poorly absorbed orally
    2. B. Have a longer duration of action
    3. C. Are cleared more quickly than usual
    4. D. Require higher doses for the same effect
    Show answer

    Answer: B. Have a longer duration of action

    Lipid-soluble drugs such as benzodiazepines have a larger volume of distribution and longer duration. Diazepam effects are prolonged in the elderly.

19. The FDA warns against codeine and tramadol for breastfeeding mothers mainly because:

    1. A. They shut down the mother's milk production
    2. B. They cause neonatal jaundice
    3. C. The infant may receive an opioid overdose
    4. D. They cause infant hypoglycemia
    Show answer

    Answer: C. The infant may receive an opioid overdose

    Mothers who are ultrarapid CYP2D6 metabolizers turn codeine and tramadol into high levels of active opioid that pass into milk; breastfed infants have had serious breathing problems and deaths (FDA, 2017). These drugs do not shut down the mother's milk production, and neonatal jaundice and infant hypoglycemia are not the concern.

20. 'Start low and go slow' refers to dosing in:

    1. A. Pregnant patients
    2. B. Pediatric patients
    3. C. Geriatric patients
    4. D. Opioid-tolerant patients
    Show answer

    Answer: C. Geriatric patients

    Elderly patients are more sensitive and have less reserve. Opioid-tolerant patients often need higher opioid doses rather than a cautious low start.

21. Antipsychotics carry an FDA boxed warning for older adults with dementia-related psychosis because of:

    1. A. A higher risk of death
    2. B. Severe hypoglycemia
    3. C. Rapid sedative tolerance
    4. D. Kidney stone formation
    Show answer

    Answer: A. A higher risk of death

    The warning is for a higher risk of death: typical and atypical antipsychotics both increase mortality in older adults with dementia, mostly from cardiovascular events and infections, so they are used sparingly. Severe hypoglycemia, rapid sedative tolerance, and kidney stone formation are not the reason for the warning.

22. During cardiac arrest in a pregnant patient, ACLS medication doses should be:

    1. A. Halved to protect the fetus
    2. B. Doubled for her larger blood volume
    3. C. Withheld until after delivery
    4. D. The same as for other adults
    Show answer

    Answer: D. The same as for other adults

    Doses are the same as for other adults; there is no change to resuscitation drug doses in pregnancy: maternal survival comes first, and fetal survival depends on it. Doses are not halved to protect the fetus, not doubled for her larger blood volume, and not withheld until after delivery; add manual uterine displacement and prepare for resuscitative delivery.

23. Most drugs cross the placenta by:

    1. A. Facilitated diffusion via carrier proteins
    2. B. Active transport by placental pumps
    3. C. Passive diffusion of lipid-soluble drugs
    4. D. Pinocytosis by placental cells
    Show answer

    Answer: C. Passive diffusion of lipid-soluble drugs

    Most drugs cross the placenta by passive diffusion, which favors small, lipid-soluble, non-ionized molecules, so assume the fetus is exposed to drugs given to the mother. Carrier-mediated facilitated diffusion (used by glucose), active transport, and pinocytosis move only a few specific substances.

24. The former FDA pregnancy category X indicated:

    1. A. Safe for use in pregnancy
    2. B. Contraindicated in pregnancy
    3. C. Fetal risk unknown or unstudied
    4. D. Safe in late pregnancy only
    Show answer

    Answer: B. Contraindicated in pregnancy

    Category X meant fetal risk clearly outweighed any benefit. Category X drugs include isotretinoin and misoprostol.

25. Which EMS drug is considered relatively safe in pregnancy for seizures (eclampsia)?

    1. A. Low-dose aspirin
    2. B. Magnesium sulfate
    3. C. Valproic acid
    4. D. Phenytoin
    Show answer

    Answer: B. Magnesium sulfate

    Magnesium is first-line for eclamptic seizures.

26. Drugs given to a breastfeeding mother:

    1. A. Never reach the infant through breast milk
    2. B. Always harm the nursing infant in some way
    3. C. Are inactivated by enzymes in breast milk
    4. D. May reach the infant via breast milk
    Show answer

    Answer: D. May reach the infant via breast milk

    Many drugs appear in breast milk in small amounts.

27. Obese patients present dosing challenges because:

    1. A. Only oral drugs are absorbed reliably in them
    2. B. Most drugs are simply ineffective in them
    3. C. Standard adult doses never need any adjustment
    4. D. Lipid-soluble drugs distribute into fat
    Show answer

    Answer: D. Lipid-soluble drugs distribute into fat

    Fat distribution alters dose requirements, so ideal vs. actual body weight matters. Some drugs are dosed on ideal body weight, others on actual.

28. A patient with cirrhosis and mild confusion needs sedation. Benzodiazepines are risky mainly because they can:

    1. A. Trigger variceal bleeding
    2. B. Cause sudden liver failure
    3. C. Raise ammonia production in the gut
    4. D. Worsen hepatic encephalopathy
    Show answer

    Answer: D. Worsen hepatic encephalopathy

    In cirrhosis the brain is unusually sensitive to GABAergic drugs and clearance is slow, so benzodiazepines can push a patient into deep hepatic encephalopathy and coma. They do not trigger variceal bleeding, they do not cause sudden liver failure, and they do not raise ammonia production in the gut.

29. Patients on dialysis:

    1. A. Have levels altered by dialysis timing
    2. B. Cannot receive IV drugs in either of their arms
    3. C. Clear all drugs at a normal rate between sessions
    4. D. Need no routine daily medications at all
    Show answer

    Answer: A. Have levels altered by dialysis timing

    Drugs may be removed by dialysis or accumulate between sessions, so timing relative to dialysis affects levels.

30. Pediatric patients are at higher risk of toxicity from:

    1. A. Drugs given by the IO route
    2. B. Nebulized albuterol given at the standard doses
    3. C. Intranasal naloxone for an overdose
    4. D. Small dosing errors, such as decimal errors
    Show answer

    Answer: D. Small dosing errors, such as decimal errors

    Because children weigh so little, small errors are proportionally large. A tenfold error is common and dangerous in children. The IO route, standard nebulized albuterol, and intranasal naloxone are routine in children; the danger lies in miscalculated doses.

31. Which tool reduces pediatric dosing errors in the field?

    1. A. Giving half the standard adult dose
    2. B. Asking the parent for the dose
    3. C. Estimating weight from the child's age
    4. D. A length-based tape (e.g., Broselow)
    Show answer

    Answer: D. A length-based tape (e.g., Broselow)

    Length-based tapes give weight estimates and precalculated doses.

32. Children's higher metabolic rate can mean:

    1. A. Longer half-lives for all drugs
    2. B. Poor absorption of oral drugs
    3. C. Slower clearance of most drugs
    4. D. Faster clearance of some drugs
    Show answer

    Answer: D. Faster clearance of some drugs

    Faster clearance may require more frequent dosing. Some drugs are cleared faster in school-age children than adults.

33. Older adults are more sensitive to CNS depressants because of:

    1. A. An increase in CNS receptor numbers
    2. B. A larger volume of total body water
    3. C. Reduced CNS reserve and slower clearance
    4. D. Faster metabolism of sedative drugs
    Show answer

    Answer: C. Reduced CNS reserve and slower clearance

    Reduced CNS reserve, altered receptor sensitivity, and slower clearance contribute. Benzodiazepines and opioids cause more confusion and falls in the elderly.

34. Anticholinergic drugs in the elderly commonly cause:

    1. A. Hyperactivity and excess salivation
    2. B. Confusion and urinary retention
    3. C. Diarrhea and urinary frequency
    4. D. Bradycardia and pinpoint pupils
    Show answer

    Answer: B. Confusion and urinary retention

    Confusion, urinary retention, and constipation are common. The Beers criteria flag anticholinergics as high-risk in older adults.

35. Opioid dosing in opioid-tolerant patients requires:

    1. A. Higher analgesic doses with careful monitoring
    2. B. Standard doses regardless of documented tolerance
    3. C. Avoiding all opioid analgesics completely in them
    4. D. Using only oral opioids and never giving IV doses
    Show answer

    Answer: A. Higher analgesic doses with careful monitoring

    Tolerance raises the required dose but not the danger ceiling.

36. A patient with a history of substance use disorder who needs pain management should:

    1. A. Be denied opioid analgesia entirely for safety
    2. B. Receive appropriate analgesia with monitoring
    3. C. Receive only NSAIDs regardless of pain severity
    4. D. Receive a placebo in place of active analgesia
    Show answer

    Answer: B. Receive appropriate analgesia with monitoring

    Addiction history is not a reason to withhold pain relief. Untreated pain is a harm; management requires judgment, not denial.

37. For an obese child, a length-based tape (such as Broselow) estimates a weight that is usually:

    1. A. Below the child's actual weight
    2. B. Above the child's actual weight
    3. C. Equal to the actual weight
    4. D. Too inaccurate to use for dosing
    Show answer

    Answer: A. Below the child's actual weight

    The tape estimates weight from length, approximating an ideal weight, so in obese children it falls below the child's actual weight. That suits many drugs dosed on ideal or lean weight, though not all. It is not above or equal to the actual weight, and the tape is not too inaccurate to use for dosing; it remains a standard dosing aid.

38. The FDA advises against over-the-counter cough and cold medicines in children younger than 2 years mainly because of:

    1. A. Reports of serious harm, including deaths
    2. B. Mild drowsiness that worries parents
    3. C. Lack of proven benefit, with no harm reported
    4. D. Reye syndrome from the decongestants
    Show answer

    Answer: A. Reports of serious harm, including deaths

    Decongestants and antihistamines in cough and cold products have caused serious harm, including deaths, in young children, often from dosing errors or combined products, and benefit is unproven. Mild drowsiness is not the concern, harm has been reported, and Reye syndrome is linked to aspirin rather than decongestants.

39. Patients with G6PD deficiency should avoid:

    1. A. Ondansetron for nausea
    2. B. Midazolam for seizures
    3. C. Supplemental oxygen at high flow rates
    4. D. Oxidant drugs such as methylene blue
    Show answer

    Answer: D. Oxidant drugs such as methylene blue

    Oxidizing drugs such as methylene blue and some antimalarials trigger hemolysis in G6PD deficiency. Ondansetron and midazolam are not oxidant drugs and are not known triggers of hemolysis in G6PD deficiency.

40. Malignant hyperthermia is a genetic reaction to:

    1. A. Beta-lactam antibiotics like penicillin
    2. B. Opioids such as fentanyl and morphine
    3. C. Succinylcholine and volatile anesthetics
    4. D. Benzodiazepines and propofol infusions
    Show answer

    Answer: C. Succinylcholine and volatile anesthetics

    Treated with dantrolene.

41. Dosing by ideal body weight is often used for:

    1. A. All drugs given to obese patients
    2. B. No drugs, since actual weight is used
    3. C. Only oral, fixed-dose medications
    4. D. Some paralytics, such as rocuronium
    Show answer

    Answer: D. Some paralytics, such as rocuronium

    Ideal body weight is often used for hydrophilic drugs and some paralytics such as rocuronium in obese patients. Succinylcholine, however, is dosed on actual body weight.

42. A frail elderly patient receiving morphine should be given:

    1. A. No opioids at all, because of the risk of falls
    2. B. A reduced initial dose titrated to effect
    3. C. The full standard adult starting dose of morphine
    4. D. Double the standard dose to ensure pain relief
    Show answer

    Answer: B. A reduced initial dose titrated to effect

    Titration minimizes respiratory depression and hypotension.

43. A child who is an ultrarapid CYP2D6 metabolizer receives codeine. The danger is:

    1. A. Hepatic failure from codeine itself
    2. B. Severe hypertension and tachycardia
    3. C. Rapid conversion to excess morphine
    4. D. Complete lack of analgesic effect
    Show answer

    Answer: C. Rapid conversion to excess morphine

    Rapid conversion to morphine can cause respiratory depression. The FDA contraindicates codeine in children under 12 partly because ultrarapid metabolizers have died from morphine toxicity.

44. A patient who is a poor CYP2D6 metabolizer takes codeine. The likely result is:

    1. A. Serotonin syndrome and clonus
    2. B. Exaggerated pain relief
    3. C. Morphine overdose and apnea
    4. D. Little or no pain relief
    Show answer

    Answer: D. Little or no pain relief

    Codeine is a prodrug that must be converted to morphine by CYP2D6.

45. A toddler who ingested a grandparent's clonidine is lethargic, with pinpoint pupils, bradycardia, and slow respirations. This presentation resembles:

    1. A. An anticholinergic toxidrome
    2. B. Serotonin syndrome
    3. C. A sympathomimetic toxidrome
    4. D. An opioid toxidrome
    Show answer

    Answer: D. An opioid toxidrome

    Central alpha-2 agonism causes CNS depression, miosis, bradycardia, and hypotension.

46. Which medication can cause severe toxicity in a toddler from a single adult tablet?

    1. A. A loratadine allergy tablet
    2. B. A docusate stool softener
    3. C. A sulfonylurea such as glyburide
    4. D. An amoxicillin capsule
    Show answer

    Answer: C. A sulfonylurea such as glyburide

    Sulfonylureas, calcium channel blockers, tricyclics, and opioids are classic 'one pill can kill' drugs.

47. A 10-kg child is hypoglycemic. Using D10 at 5 mL/kg, how much should you give?

    1. A. 5 mL
    2. B. 10 mL
    3. C. 50 mL
    4. D. 100 mL
    Show answer

    Answer: C. 50 mL

    5 mL/kg x 10 kg = 50 mL of D10, which delivers 5 g (0.5 g/kg) of dextrose. 5 mL and 10 mL are tenfold and fivefold underdoses, and 100 mL doubles the dose.

48. Because neonates have immature renal function, renally excreted drugs:

    1. A. Are excreted faster than in adults
    2. B. Cannot be given at all
    3. C. Have reduced protein binding only
    4. D. Have prolonged half-lives
    Show answer

    Answer: D. Have prolonged half-lives

    Glomerular filtration and tubular secretion mature over the first months of life.

49. A large 13-year-old weighs 90 kg. The weight-based dose calculates to more than the adult dose. You should:

    1. A. Give no more than the adult maximum dose
    2. B. Withhold the medication
    3. C. Double the adult dose
    4. D. Give the full weight-based dose
    Show answer

    Answer: A. Give no more than the adult maximum dose

    Pediatric weight-based doses are capped at the adult dose.

50. A 15-kg child with suspected opioid overdose needs naloxone at 0.1 mg/kg. The dose is:

    1. A. 0.5 mg
    2. B. 15 mg
    3. C. 1.5 mg
    4. D. 0.15 mg
    Show answer

    Answer: C. 1.5 mg

    0.1 mg/kg x 15 kg = 1.5 mg, below the usual 2-mg maximum.

51. A 25-kg child in anaphylaxis needs IM epinephrine at 0.01 mg/kg (1 mg/mL). The dose is:

    1. A. 0.025 mg
    2. B. 0.5 mg
    3. C. 2.5 mg
    4. D. 0.25 mg
    Show answer

    Answer: D. 0.25 mg

    0.01 mg/kg x 25 kg = 0.25 mg, within the pediatric maximum of 0.3 mg per dose.

52. D10 is preferred over D50 for hypoglycemic neonates and infants because:

    1. A. Concentrated dextrose can damage small veins
    2. B. Infants lack insulin to process D50
    3. C. D10 is more concentrated than D50
    4. D. D50 contains too little glucose for infants
    Show answer

    Answer: A. Concentrated dextrose can damage small veins

    Highly concentrated dextrose can damage small veins and cause large glucose swings. Less concentrated dextrose is safer for small veins and immature glucose regulation.

53. A 20-kg child in cardiac arrest needs IV epinephrine at 0.01 mg/kg, using the 0.1 mg/mL concentration. What volume do you give?

    1. A. 0.2 mL
    2. B. 2 mL
    3. C. 20 mL
    4. D. 0.02 mL
    Show answer

    Answer: B. 2 mL

    0.01 mg/kg x 20 kg = 0.2 mg; at 0.1 mg/mL that is 2 mL. 0.2 mL confuses the milligram dose with the volume, 20 mL is a tenfold overdose, and 0.02 mL is a hundredfold underdose. Pediatric arrest dosing is unchanged in the 2025 AHA guidelines (maximum single dose 1 mg).

54. Reduced hepatic blood flow in older adults means drugs with high first-pass metabolism may have:

    1. A. Faster onset but no change in level
    2. B. No change in effect
    3. C. Higher bioavailability and stronger effects
    4. D. Lower bioavailability
    Show answer

    Answer: C. Higher bioavailability and stronger effects

    Less first-pass extraction lets more active drug reach the systemic circulation.

55. A newborn whose mother received an opioid shortly before delivery is apneic and limp. The first priority is:

    1. A. Naloxone first, then ventilation if still apneic
    2. B. IV epinephrine through a UVC
    3. C. Effective positive-pressure ventilation
    4. D. Oral glucose gel on the gums
    Show answer

    Answer: C. Effective positive-pressure ventilation

    Neonatal resuscitation puts effective positive-pressure ventilation first for an apneic newborn; naloxone is not part of initial resuscitation. Naloxone first, then ventilation if still apneic, delays the key intervention; IV epinephrine through a UVC is used only if the heart rate stays below 60 despite ventilation and compressions; and oral glucose gel does not treat apnea.

56. Older adults have less total body water, so water-soluble drugs such as lithium or digoxin tend to:

    1. A. Reach lower plasma concentrations than usual
    2. B. Reach higher concentrations per dose
    3. C. Be eliminated faster than in younger adults
    4. D. Be stored mainly in peripheral body fat
    Show answer

    Answer: B. Reach higher concentrations per dose

    A smaller volume of distribution for water-soluble drugs raises plasma levels.

57. In pregnancy, increased glomerular filtration rate means renally cleared drugs:

    1. A. May be eliminated faster
    2. B. Are eliminated more slowly
    3. C. Accumulate in the fetus only
    4. D. Cannot be used
    Show answer

    Answer: A. May be eliminated faster

    Renal blood flow and GFR rise considerably during pregnancy.

58. ACE inhibitors are contraindicated in pregnancy because they:

    1. A. Reliably induce preterm labor
    2. B. Cause maternal hypertension
    3. C. Cannot cross the placenta
    4. D. Can cause fetal kidney damage
    Show answer

    Answer: D. Can cause fetal kidney damage

    ACE inhibitors can cause fetal kidney damage and other fetal harm. Fetal exposure, especially in the second and third trimesters, can cause renal failure and oligohydramnios.

59. For a pregnant patient needing anticoagulation, heparin is generally preferred over warfarin because heparin:

    1. A. Is taken orally
    2. B. Has no bleeding risk
    3. C. Is a vitamin K antagonist
    4. D. Does not cross the placenta
    Show answer

    Answer: D. Does not cross the placenta

    Heparin is a large, charged molecule; warfarin crosses the placenta and is teratogenic.

60. Opioid analgesia given to the mother shortly before delivery may cause:

    1. A. Neonatal hypertension
    2. B. Prolonged maternal labor in all cases
    3. C. Respiratory depression in the newborn
    4. D. Neonatal hyperglycemia
    Show answer

    Answer: C. Respiratory depression in the newborn

    Opioids cross the placenta; be prepared to support the newborn's ventilation.

61. The FDA Pregnancy and Lactation Labeling Rule (PLLR) replaced the old letter categories with:

    1. A. A single 'safe' or 'unsafe' rating
    2. B. Color-coded risk labels on vials
    3. C. A numeric 1-to-10 risk scale
    4. D. Narrative risk summaries with data
    Show answer

    Answer: D. Narrative risk summaries with data

    Since 2015, labels describe pregnancy, lactation, and reproductive risk in narrative form rather than with A, B, C, D, or X.

62. The risk of drug-induced structural birth defects is greatest during:

    1. A. Labor and delivery
    2. B. The first trimester
    3. C. The postpartum period
    4. D. The third trimester
    Show answer

    Answer: B. The first trimester

    The first trimester is the period of organogenesis. Organ formation occurs roughly weeks 3 to 8 after conception, the most vulnerable period for teratogens.

63. Drugs most likely to pass into breast milk are those that are:

    1. A. Highly ionized drugs at body pH
    2. B. Small, lipid-soluble, unbound molecules
    3. C. Drugs given only by inhalation
    4. D. Large, highly protein-bound molecules
    Show answer

    Answer: B. Small, lipid-soluble, unbound molecules

    Small, nonionized, unbound, lipophilic drugs cross into milk most readily.

64. NSAIDs are generally avoided after about 20 weeks of pregnancy because they can:

    1. A. Trigger eclamptic seizures
    2. B. Raise maternal blood glucose
    3. C. Harm fetal kidneys and narrow the ductus
    4. D. Stimulate strong preterm uterine contractions
    Show answer

    Answer: C. Harm fetal kidneys and narrow the ductus

    After about 20 weeks NSAIDs can reduce fetal kidney function and amniotic fluid, and later in pregnancy they can narrow or close the ductus arteriosus (FDA, 2020). They do not trigger eclamptic seizures or raise maternal blood glucose, and they inhibit rather than stimulate strong preterm uterine contractions (indomethacin has been used as a tocolytic).

65. Fentanyl is often preferred over morphine in patients with renal failure because:

    1. A. Fentanyl is excreted unchanged by the kidneys
    2. B. Morphine is not metabolized by the liver
    3. C. Fentanyl causes no respiratory depression
    4. D. Morphine's active metabolites accumulate
    Show answer

    Answer: D. Morphine's active metabolites accumulate

    Morphine-6-glucuronide and morphine-3-glucuronide build up, causing prolonged sedation and neurotoxicity.

66. A patient with pseudocholinesterase deficiency receives succinylcholine. You should expect:

    1. A. No paralysis at all
    2. B. Immediate seizures
    3. C. Severe hypertension
    4. D. Prolonged paralysis
    Show answer

    Answer: D. Prolonged paralysis

    Succinylcholine is normally broken down by plasma pseudocholinesterase; deficiency prolongs its effect.

67. An infant needs 0.08 mg of a drug supplied as 1 mg/mL. The safest way to prepare the dose is to:

    1. A. Estimate one drop from the vial
    2. B. Dilute it to a measurable volume
    3. C. Round up to 0.1 mL for simplicity
    4. D. Give 1 mL and monitor closely
    Show answer

    Answer: B. Dilute it to a measurable volume

    0.08 mL is hard to measure accurately; dilute it to a measurable volume (for example 0.1 mg/mL, so the dose is 0.8 mL) that is easy to draw up and verify. One drop from the vial varies widely in volume, rounding up to 0.1 mL is a 25% overdose, and to give 1 mL and monitor closely is more than a twelvefold overdose.

68. Sulfonamides are avoided in newborns with jaundice because they:

    1. A. Displace bilirubin, risking kernicterus
    2. B. Fail to cross the blood-brain barrier
    3. C. Increase bilirubin excretion too fast
    4. D. Cause severe hypoglycemia in neonates
    Show answer

    Answer: A. Displace bilirubin, risking kernicterus

    Sulfonamides displace bilirubin from albumin. Displaced free bilirubin can cross the immature blood-brain barrier, causing kernicterus.

69. In a patient with Parkinson disease, which antiemetic should generally be avoided?

    1. A. Metoclopramide
    2. B. Low-dose dimenhydrinate
    3. C. Isopropyl alcohol inhalation
    4. D. Ondansetron
    Show answer

    Answer: A. Metoclopramide

    Dopamine antagonists such as metoclopramide and haloperidol worsen parkinsonian symptoms.

70. Magnesium sulfate should be used cautiously in a patient with myasthenia gravis because it can:

    1. A. Worsen weakness and cause respiratory failure
    2. B. Cause severe hyperglycemia and ketosis
    3. C. Cause an acute hypertensive crisis
    4. D. Increase acetylcholine release at the junction
    Show answer

    Answer: A. Worsen weakness and cause respiratory failure

    Magnesium reduces acetylcholine release at the neuromuscular junction.

71. Older adults often show a reduced heart rate response to beta-agonists and atropine because of:

    1. A. Higher total body water content
    2. B. Faster drug absorption and clearance
    3. C. Declining beta-receptor responsiveness
    4. D. Increased cardiac receptor density
    Show answer

    Answer: C. Declining beta-receptor responsiveness

    Age-related decline in beta-receptor responsiveness and autonomic tone blunts the heart rate response. Cardiac beta-adrenergic responsiveness falls with age.

72. A breastfeeding mother needs a short-acting medication. Her infant's exposure is usually lowest if she:

    1. A. Nurses when the drug level peaks
    2. B. Nurses just before taking the dose
    3. C. Takes the drug with a glass of milk
    4. D. Drinks extra water after the dose
    Show answer

    Answer: B. Nurses just before taking the dose

    Milk drug levels track maternal blood levels, so nursing just before the dose lets the level fall before the next feeding. Nursing when the drug level peaks maximizes exposure, and taking the drug with a glass of milk or drinking extra water after the dose does not change how much enters breast milk.