# Sample Question On Calculating Metabolic acidosis Anion Gap

The laboratory finding reveals that 57 year-old patient is suffering from metabolic acidosis. What kind of metabolic acidosis is he suffering from?

ABG: 7.21/32/98
100% O2 Sat on Room Air
Electrolytes: Na 145 mEq/L, K 4.5 mEq/L, Cl 105 mEq/L, HCO3 25 mEq/L

a.            Anion-gap metabolic acidosis
b.            Non-Anion-gap metabolic acidosis
c.             Cation gap metabolic acidosis
d.            Non-Cation-gap metabolic acidosis

The laboratory finding reveals that 57 year-old patient is suffering from metabolic acidosis. What kind of metabolic acidosis is he suffering from?

ABG: 7.21/32/98
100% O2 Sat on Room Air
Electrolytes: Na 145 mEq/L, K 4.5 mEq/L, Cl 105 mEq/L, HCO3 25 mEq/L

a.            Anion-gap metabolic acidosis
b.            Non-Anion-gap metabolic acidosis
c.             Cation gap metabolic acidosis
d.            Non-Cation-gap metabolic acidosis

Answer(a):  If the patient is suffering from metabolic acidosis (low pH with low HCO3), the next step is to calculate the anion gap because the anion gap helps determining the etiology of the metabolic acidosis.

The anion gap is the difference between the measured serum cations (positively charged particles) and the measured serum anions (negatively charged particles). The commonly measured cation is sodium and the measured anions include chloride and bicarbonate.

Anion gap = [Na+] - ([Cl-] + [HCO3-])

The normal anion gap value is between 8 and 12. An anion gap of greater than 12 is "increased".

The differential diagnosis for an elevated anion gap metabolic acidosis (simply called "anion gap acidosis") differs from the differential diagnosis for an non-elevated anion gap metabolic acidosis (simply called "non-anion gap acidosis").

So, in the above example:

Anion gap = [Na+] - ([Cl-] + [HCO3-])

Anion gap = 145 - (105 + 25)

Anion gap = 15

The calculated anion gap = 15(above the normal gap of 8-12), therefore there is an anion gap acidosis.

# Naplex Sample Question on Promethazine and Codeine

NABP reports a recent rise in forged prescriptions for Promethazine with Codeine. Promethazine with codeine, a Schedule V CS, has been used for years as a cough medication. Abusers commonly refer to it as:

a. Elixir of Heaven
b. Purple Drank
c. Orange Cocktail
d. Levoni's Drink
e. ProCod Mix

NABP reports a recent rise in forged prescriptions for Promethazine with Codeine. Promethazine with codeine, a Schedule V CS, has been used for years as a cough medication. Abusers commonly refer to it as:

a. Elixir of Heaven
b. Purple Drank
c. Orange Cocktail
d. Levoni's Drink
e. ProCod Mix

Answer: (b) Purple Drank. NABP reports a recent rise in forged prescriptions for promethazine with codeine. Promethazine with codeine, a Schedule V CS, has been used for years as a cough medication. Abusers commonly refer to it as "purple drank." "Purple drank" is a combination of promethazine with codeine mixed with a carbonated soda, such as Sprite or Mountain Dew, and candy, such as crushed Jolly Ranchers, mixed in for additional flavor.

The NABP has seen an increase in forged prescriptions for promethazine with codeine, and pharmacists have unknowingly filled them across United States in recent months. Pharmacists should be on the alert for promethazine with codeine prescriptions and perform due diligence in confirming that the prescription is legitimate.

Look for common red flags such as a prescription being presented right before closing, an out-of-the-area prescriber you do not recognize, a patient you do not recognize, a large quantity or exact quantity for "473 mL," or a cash-paying patient you do not know.

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# Naplex Sample Question on PMP InterConnect

Which of the following information is/are TRUE about PMP InterConnect?

I. InterConnect is comprehensive and thorough tool for prescribers and dispensers to use in identifying potential opioid abuse.

II. InterConnect is a highly secure communications exchange platform that facilitates the transmission of PMP data across state lines to authorized requestors, while ensuring that each state's data-access rules are enforced.

III. It is mandatory for all states to participate in PMP Interconnect.

a. I only
b. III only
c. I and II only
d. II and III only
e. All

Which of the following information is/are TRUE about PMP InterConnect?

I. InterConnect is comprehensive and thorough tool for prescribers and dispensers to use in identifying potential opioid abuse.

II. InterConnect is a highly secure communications exchange platform that facilitates the transmission of PMP data across state lines to authorized requestors, while ensuring that each state's data-access rules are enforced.

III. It is mandatory for all states to participate in PMP Interconnect.

a. I only
b. III only
c. I and II only
d. II and III only
e. All

Answer: (I and II only). PMP InterConnect is a highly secure communications exchange platform that facilitates the transmission of PMP data across state lines to authorized requestors, while ensuring that each state's data-access rules are enforced.
It is comprehensive and thorough tool for prescribers and dispensers to use in identifying potential opioid abuse.

The benefits of state PMPs are enhanced by PMP InterConnect because the system provides the means for physicians and pharmacists to more easily identify patients with prescription drug abuse and misuse problems, especially if those patients are crossing state lines to obtain drugs.

Utilizing the program's connected web of information allows appropriate intervention and aid in the prevention of substance abuse and diversion of controlled substances.

Additional information about PMP InterConnect, including a map of participants, is available in the Programs section of the NABP website.
It is NOT MANDATORY for states to participate in PMP InterConnect.

NABP also continues to work with other states to facilitate their participation.

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# A List of Drugs with Their Normal Therapeutic Concentrations.

A List of Drugs with Their Normal Therapeutic Concentrations.

A List of Drugs with Their Normal Therapeutic Concentrations.

Amikacin: 15 to 25 mcg/mL
Aminophylline: 10 to 20 mcg/mL
Amitriptyline: 120 to 150 ng/mL
Carbamazepine: 5 to 12 mcg/mL
Cyclosporine: 100 to 400 ng/mL (12 hours after dose)
Desipramine: 150 to 300 ng/mL
Digoxin: 0.8 to 2.0 ng/mL
Disopyramide: 2 to 5 mcg/mL
Ethosuximide: 40 to 100 mcg/mL
Flecainide: 0.2 to 1.0 mcg/mL
Gentamicin: 5 to 10 mcg/mL
Imipramine: 150 to 300 ng/mL
Kanamycin: 20 to 25 mcg/mL
Lidocaine: 1.5 to 5.0 mcg/mL
Lithium: 0.8 to 1.2 mEq/L
Methotrexate: varies with use
Nortriptyline: 50 to 150 ng/mL
Phenobarbital: 10 to 30 mcg/mL
Phenytoin: 10 to 20 mcg/mL
Primidone: 5 to 12 mcg/mL
Procainamide: 4 to 10 mcg/mL
Quinidine: 2 to 5 mcg/mL
Salicylate: varies with use
Sirolimus: 4 to 20 ng/mL (12 hours after dose; varies with use)
Tacrolimus: 5 to 15 ng/mL (12 hours after dose)
Theophylline: 10 to 20 mcg/mL
Tobramycin: 5 to 10 mcg/mL
Valproic acid: 50 to 100 mcg/mL

# Naplex Sample Questions Tall Man Letters

Which of the following information is TRUE ABOUT Tall Man Letters? [Select All that apply].

a. Several studies have shown that highlighting sections of words using tall man lettering can make similar drug names easier to distinguish.

b. The Institute for Safe Medication Practices (ISMP), the FDA, The Joint Commission, and other safety-conscious organizations such as the National Association of Boards of Pharmacy (NABP) have promoted the use of tall man letters as one means of reducing confusion between similar drug names.

c. Nearly all of surveyed (87%) conducted by ISMP for Tall Man Letters felt that the use of tall man letters by the medical product industry helped to reduce errors in drug selection.

d. Approximately 50% of all survey respondents reported using tall man letters in conjunction with pharmacy-generated product and shelf labels, computer screens, and medication administration records.

e. Use of the tall man letters on computer-generated pharmacy labels was the most prevalent and was considered to be most effective, whereas use of the letters on preprinted order forms was among the least prevalent and was considered to be least effective.

Which of the following information is TRUE ABOUT Tall Man Letters? [Select All that apply].

a. Several studies have shown that highlighting sections of words using tall man lettering can make similar drug names easier to distinguish.

b. The Institute for Safe Medication Practices (ISMP), the FDA, The Joint Commission, and other safety-conscious organizations such as the National Association of Boards of Pharmacy (NABP) have promoted the use of tall man letters as one means of reducing confusion between similar drug names.

c. Nearly all of surveyed (87%) conducted by ISMP for Tall Man Letters felt that the use of tall man letters by the medical product industry helped to reduce errors in drug selection.

d. Approximately 50% of all survey respondents reported using tall man letters in conjunction with pharmacy-generated product and shelf labels, computer screens, and medication administration records.

e. Use of the tall man letters on computer-generated pharmacy labels was the most prevalent and was considered to be most effective, whereas use of the letters on preprinted order forms was among the least prevalent and was considered to be least effective.

Answer: (a,b,c,d and e). Tall man (uppercase) letters are used within a drug name to highlight its primary dissimilarities and help to differentiate look-alike names. Several studies have shown that highlighting sections of words using tall man lettering can make similar drug names easier to distinguish, and fewer errors are made when tall man letters are used to differentiate products with look-alike names.

The Institute for Safe Medication Practices (ISMP), the FDA, The Joint Commission, and other safety-conscious organizations such as the National Association of Boards of Pharmacy (NABP) have promoted the use of tall man letters as one means of reducing confusion between similar drug names.

From a survey conducted by the ISMP in 2008, most respondents appeared to agree. Nearly all of those surveyed (87%) felt that the use of tall man letters by the medical product industry helped to reduce errors in drug selection, and two-thirds (64%) reported that tall man lettering actually prevented them from dispensing or administering the wrong medication.

A fully alphabetized list of drug names with tall man lettering can be found at www.ismp.org/Tools/tallmanletters.pdf.

TallMan Letter

Approximately 50% of all survey respondents reported using tall man letters in conjunction with pharmacy-generated product and shelf labels, computer screens, and medication administration records. Half to three-quarters of respondents who used tall man letters with look-alike drug name pairs felt that this strategy was effective in reducing the risk of errors, depending on where it was used.

Use of the tall man letters on computer-generated pharmacy labels was the most prevalent and was considered to be most effective, whereas use of the letters on preprinted order forms was among the least prevalent and was considered to be least effective. In general, between one-quarter and one-third of respondents were undecided about the effectiveness of tall man letters, but very few reported that the letters were wholly ineffective in reducing the risk of errors. The use of tall man letters was less widely reported for drugs listed on prescriber order entry screens and smart pump libraries.

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# Naplex Sample Question on Invokana Mechanism of Action

Which of the following statements correctly describes the mechanism of action of Invokana (Canagliflozin)?

a. Increase insulin sensitivity towards blood glucose.
b. Stimulates insulin release from functioning beta cells of pancreas.
c. Delayed the absorption of glucose from gut to blood.
d. Increase gluconeogenesis in the liver.
e. Increase excretion of glucose through kidney.

Which of the following statements correctly describes the mechanism of action of Invokana (Canagliflozin)?

a. Increase insulin sensitivity towards blood glucose.
b. Stimulates insulin release from functioning beta cells of pancreas.
c. Delayed the absorption of glucose from gut to blood.
d. Increase gluconeogenesis in the liver.
e. Increase excretion of glucose through kidney.

Answer: (e). Sodium-glucose co-transporter 2 (SGLT2), expressed in the proximal renal tubules, is responsible for the majority of the reabsorption of filtered glucose from the tubular lumen. Canagliflozin is an inhibitor of SGLT2. By inhibiting SGLT2, Canagliflozin reduces reabsorption of filtered glucose and lowers the renal threshold for glucose (RTG), and thereby increases urinary glucose excretion (UGE).

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# Naplex Sample Question On Invokana Drug Interaction

Which of the following drugs interacts with Invokana (Canagliflozin)? [SELECT All THAT APPLY]

a. Digoxin
b. Rifampin
c. Ketoconazole
d. Trazodone

Which of the following drugs interacts with Invokana (Canagliflozin)? [SELECT All THAT APPLY]

a. Digoxin
b. Rifampin
c. Ketoconazole
d. Trazodone

Answer: (a and b). Co-administration of Canagliflozin with rifampin, a nonselective inducer of several UGT enzymes, including UGT1A9, UGT2B4, decreased Canagliflozin area under the curve (AUC) by 51%. This decrease in exposure to Canagliflozin may decrease efficacy.

If an inducer of these UGTs (e.g., rifampin, phenytoin, phenobarbital, ritonavir) must be co-administered with Invokana (Canagliflozin) (Canagliflozin), consider increasing the dose to 300 mg once daily if patients are currently tolerating Invokana (Canagliflozin) 100 mg once daily, have an eGFR greater than 60 mL/min/1.73 m2, and require additional glycemic control.

Consider other antihyperglycemic therapy in patients with an eGFR of 45 to less than 60 mL/min/1.73 m2 receiving concurrent therapy with a UGT inducer and require additional glycemic control.

There was an increase in the AUC and mean peak drug concentration (Cmax) of digoxin (20% and 36%, respectively) when co-administered with Invokana (Canagliflozin) 300 mg. Patients taking Invokana (Canagliflozin) with concomitant digoxin should be monitored appropriately.

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# Naplex Sample Question On Invokana

Which of the following information is TRUE about Invokana (Canagliflozin)? [SELECT ALL THAT APPLY]

a. The 300-mg dose of Invokana is proven to show greater A1C reductions than Januvia.
b. It is a once-daily pill that works around the clock.
c. It is not for weight loss, but may help a patient to lose weight-on average 3%.
d. In most clinical trials, the majority of people taking Invokana reached an A1C goal of less than 7%.
e. The most common side effect associated with the use of Invokana is hypoglycemia.

Which of the following information is TRUE about Invokana (Canagliflozin)? [SELECT ALL THAT APPLY]

a. The 300-mg dose of Invokana is proven to show greater A1C reductions than Januvia.
b. It is a once-daily pill that works around the clock.
c. It is not for weight loss, but may help a patient to lose weight-on average 3%.
d. In most clinical trials, the majority of people taking Invokana reached an A1C goal of less than 7%.
e. The most common side effect associated with the use of Invokana is hypoglycemia.

Answer: (a,b,c, and d). Invokana (Canagliflozin) is a sodium-glucose co-transporter 2 (SGLT2) inhibitor indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

The recommended starting dose is 100 mg once daily, taken before the first meal of the day. Dose can be increased to 300 mg once daily in patients tolerating Invokana (Canagliflozin) 100 mg once daily who have an eGFR of 60 mL/min/1.73 m2 or greater and require additional glycemic control.

Invokana (Canagliflozin) is limited to 100 mg once daily in patients who have an eGFR of 45 to less than 60 mL/min/1.73 m2. Assess renal function before initiating Invokana (Canagliflozin). Do not initiate Invokana (Canagliflozin) if eGFR is below 45 mL/min/1.73 m2. Discontinue Invokana (Canagliflozin) if eGFR falls persistently below 45 mL/min/1.73 m2.

It can increase the risk of hypoglycemia when combined with insulin or an insulin secretagogue. A lower dose of insulin or insulin secretagogue may be required to minimize the risk of hypoglycemia when used in combination with Invokana (Canagliflozin).

It causes intravascular volume contraction. Symptomatic hypotension can occur after initiating Invokana (Canagliflozin), particularly in patients with impaired renal function (eGFR <60 mL/min/1.73 m2), elderly patients, patients on either diuretics or medications that interfere with the renin‐angiotensin‐aldosterone system, or patients with low systolic blood pressure.

The most common side effects of Invokana (Canagliflozin) include genital yeast infections, urinary tract infection, and changes in urination.

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# Naplex Sample Question On H. pylori Post Testing

After completing the therapy, H. pylori follow-up status testing shall be done within what time frame to ensure H. Pylori has been completely eradicated?

a. 7 days
b. 72 hours
c. 4 weeks
d. 6 months
e. a month

After completing the therapy, H. pylori follow-up status testing shall be done within what time frame to ensure H. Pylori has been completely eradicated?

a. 7 days
b. 72 hours
c. 4 weeks
d. 6 months
e. a month

Answer: (c) Before the seriousness of H. pylori infections was fully appreciated and when it was still believed that H. pylori eradication therapy could routinely cure more than 90% of patients, confirmation of cure testing was not routinely recommended.

Although confirmation for cure testing is currently considered the standard of care, preferably with noninvasive tests such as the stool antigen or a urea breath test, it is often not done.

Post eradication testing is not only useful to confirm H. pylori eradication but also serves to alert the clinician when resistance begins to undermine their locally effective current regimens. In this issue of Clinical Gastroenterology and Hepatology, Gatta et al report a pilot study suggesting that it may be possible to accurately assess cure using changes in serum pepsinogen II levels.

A positive urea breath test (UBT), histology, culture, or rapid urease test (RUT) any time after therapy is considered as evidence of treatment failure. However, it has been recommended that posttreatment testing be delayed for at least 4 weeks after the end of therapy.

This recommendation is based on the fact that it takes time for any remaining bacteria to recover and repopulate the stomach in sufficient numbers to be detected reliably. By 4 weeks, the accuracy of a negative test is in the range of 98% to 100%.

There is little or no gain by repeating negative tests to ensure success (e.g, 2 negative urea breath tests) as a second urea breath test has not shown an increase in accuracy and adds an incremental cost with little clinical benefit.

One caveat among available noninvasive tests is that when using the stool antigen to assess outcome, it may be best to increase the interval from 4 to 6 or 8 weeks to ensure that a positive result is not false positive.

The available data show that the stool antigen tests that use monoclonal anti-H. pylori antibodies are more reliable than polyclonal stool antigen tests and monoclonal antibody-based stool antigen tests are recommended.

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# Naplex Sample Question On Mantoux Test

Which of the following is/are false positive tuberculin skin test reactions? [Select All that apply]

a. Infection with non-tuberculosis mycobacteria
b. Cutaneous anergy
c. Previous BCG vaccination
d. Very old TB infection
e. Recent live-virus vaccination

Which of the following is/are false positive tuberculin skin test reactions? [Select All that apply]

a. Infection with non-tuberculosis mycobacteria
b. Cutaneous anergy
c. Previous BCG vaccination
d. Very old TB infection
e. Recent live-virus vaccination

Answer: (a,c). The Mantoux tuberculin skin test (TST) is the standard method of determining whether a person is infected with Mycobacterium tuberculosis. Reliable administration and reading of the TST requires standardization of procedures, training, supervision, and practice.

The TST is performed by injecting 0.1 ml of tuberculin purified protein derivative (PPD) into the inner surface of the forearm. The injection should be made with a tuberculin syringe, with the needle bevel facing upward. The TST is an intradermal injection. When placed correctly, the injection should produce a pale elevation of the skin (a wheal) 6 to 10 mm in diameter.

The skin test reaction should be read between 48 and 72 hours after administration. A patient who does not return within 72 hours will need to be rescheduled for another skin test.

The reaction should be measured in millimeters of the induration (palpable, raised, hardened area or swelling). The reader should not measure erythema (redness). The diameter of the indurated area should be measured across the forearm (perpendicular to the long axis).

Skin test interpretation depends on two factors:

1. Measurement in millimeters of the induration
2. Person's risk of being infected with TB and of progression to disease if infected

What Are False-Positive Reactions?

Some persons may react to the TST even though they are not infected with M. tuberculosis. The causes of these false-positive reactions may include, but are not limited to, the following:

1. Infection with non-tuberculosis mycobacteria
2. Previous BCG vaccination
3. Incorrect method of TST administration
4. Incorrect interpretation of reaction
5. Incorrect bottle of antigen used

What Are False-Negative Reactions?

Some persons may not react to the TST even though they are infected with M. tuberculosis. The reasons for these false-negative reactions may include, but are not limited to, the following:

1. Cutaneous anergy (anergy is the inability to react to skin tests because of a weakened immune system)
2. Recent TB infection (within 8-10 weeks of exposure)
3. Very old TB infection (many years)
4. Very young age (less than 6 months old)
5. Recent live-virus vaccination (e.g., measles and smallpox)
6. Overwhelming TB disease
7. Some viral illnesses (e.g., measles and chicken pox)
8. Incorrect method of TST administration
9. Incorrect interpretation of reaction

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