PTCB Pharmacy Technician (PTCE) — All Questions

Which brand name corresponds to the generic drug atorvastatin?

• a.Zocor
• b.Pravachol
• c.Crestor
• d.Lipitor✓

Atorvastatin is marketed under the brand name Lipitor. Zocor is simvastatin, Crestor is rosuvastatin, and Pravachol is pravastatin; all four are statins, which is why the names are easily confused.

A patient brings in a prescription written for Synthroid. What is the generic name of this medication?

• a.Propylthiouracil
• b.Methimazole
• c.Liothyronine
• d.Levothyroxine✓

Synthroid is the brand name for levothyroxine, a synthetic T4 thyroid hormone. Liothyronine is synthetic T3 (Cytomel), while methimazole and propylthiouracil are antithyroid agents used for hyperthyroidism, not replacement therapy.

Prinivil and Zestril are brand names for which generic drug?

• a.Losartan
• b.Enalapril
• c.Ramipril
• d.Lisinopril✓

Lisinopril is sold as both Prinivil and Zestril. Enalapril (Vasotec) and ramipril (Altace) are different ACE inhibitors, and losartan (Cozaar) is an angiotensin II receptor blocker rather than an ACE inhibitor.

Which generic medication is sold under the brand name Glucophage?

• a.Glipizide
• b.Metformin✓
• c.Pioglitazone
• d.Glyburide

Glucophage is the brand name for metformin. Glipizide (Glucotrol) and glyburide (DiaBeta) are sulfonylureas, and pioglitazone (Actos) is a thiazolidinedione; all lower blood glucose but by different mechanisms.

A patient picks up a refill for Norvasc 5 mg tablets. Which generic name should appear on the label?

• a.Amlodipine✓
• b.Atenolol
• c.Nifedipine
• d.Diltiazem

Norvasc is amlodipine, a dihydropyridine calcium channel blocker. Atenolol (Tenormin) is a beta blocker, while nifedipine (Procardia) and diltiazem (Cardizem) are other calcium channel blockers sold under different brand names.

Omeprazole is marketed under which brand name?

• a.Protonix
• b.Prevacid
• c.Prilosec✓
• d.Nexium

Omeprazole is sold as Prilosec. Protonix is pantoprazole, Nexium is esomeprazole, and Prevacid is lansoprazole; all four are proton pump inhibitors with similar-sounding generic endings.

What is the generic name of Zoloft?

• a.Fluoxetine
• b.Sertraline✓
• c.Citalopram
• d.Paroxetine

Zoloft is the brand name for sertraline. Fluoxetine is Prozac, paroxetine is Paxil, and citalopram is Celexa; all are selective serotonin reuptake inhibitors used for depression and anxiety disorders.

Gabapentin is dispensed under which of the following brand names?

• a.Topamax
• b.Lyrica
• c.Keppra
• d.Neurontin✓

Gabapentin is marketed as Neurontin. Lyrica is pregabalin, Keppra is levetiracetam, and Topamax is topiramate; all are anticonvulsants, and pregabalin is structurally the closest relative to gabapentin.

Which generic diuretic corresponds to the brand name Lasix?

• a.Hydrochlorothiazide
• b.Bumetanide
• c.Spironolactone
• d.Furosemide✓

Lasix is furosemide. Bumetanide (Bumex) is another loop diuretic, hydrochlorothiazide is a thiazide, and spironolactone (Aldactone) is a potassium-sparing aldosterone antagonist.

A generic drug name ending in the suffix '-sartan' indicates that the medication belongs to which class?

• a.ACE inhibitors like ramipril
• b.Angiotensin II receptor blockers✓
• c.Calcium channel blockers (CCBs)
• d.Beta blockers like atenolol

The '-sartan' stem identifies angiotensin II receptor blockers such as losartan and valsartan. Ramipril is an ACE inhibitor, and that class carries the '-pril' stem; atenolol is a beta blocker, and that class carries the '-olol' stem; dihydropyridine calcium channel blockers carry the '-dipine' stem.

Alprazolam (Xanax) is a benzodiazepine. Under federal law, benzodiazepines such as alprazolam are placed in which DEA schedule?

• a.Schedule V
• b.Schedule III
• c.Schedule II
• d.Schedule IV✓

Benzodiazepines, including alprazolam, are Schedule IV controlled substances. Schedule II includes drugs such as oxycodone and amphetamine, Schedule III includes products such as ketamine and some anabolic steroids, and Schedule V includes low-dose codeine cough preparations.21 CFR 1308 (DEA schedules)

Pantoprazole belongs to which drug class?

• a.Proton pump inhibitor✓
• b.H2 receptor antagonist
• c.Prostaglandin analog
• d.Antacid

Pantoprazole is a proton pump inhibitor; the '-prazole' stem marks this class, which blocks the gastric H+/K+ ATPase. H2 receptor antagonists include famotidine, antacids are products such as calcium carbonate, and misoprostol is the prostaglandin analog used for gastric protection.

Metformin is classified as which type of antidiabetic agent?

• a.Sulfonylurea
• b.Biguanide✓
• c.DPP-4 inhibitor
• d.Thiazolidinedione

Metformin is the only biguanide in common use; it lowers hepatic glucose production and improves insulin sensitivity. Sulfonylureas such as glipizide stimulate insulin release, thiazolidinediones such as pioglitazone act on PPAR-gamma receptors, and DPP-4 inhibitors such as sitagliptin end in '-gliptin'.

Azithromycin belongs to which class of antibiotics?

• a.Cephalosporin
• b.Tetracycline
• c.Macrolide✓
• d.Fluoroquinolone

Azithromycin is a macrolide, along with erythromycin and clarithromycin. Fluoroquinolones end in '-floxacin', tetracyclines end in '-cycline', and cephalosporins usually begin with 'cef-' or 'ceph-'.

Which of the following medications is a loop diuretic?

• a.Chlorthalidone
• b.Furosemide✓
• c.Spironolactone
• d.Hydrochlorothiazide

Furosemide acts on the ascending loop of Henle and is classified as a loop diuretic. Hydrochlorothiazide and chlorthalidone are thiazide-type diuretics acting on the distal tubule, and spironolactone is a potassium-sparing agent.

In the FDA Orange Book, an 'AB' therapeutic equivalence code means that the product:

• a.Has been approved for the same indications but was never compared with the brand
• b.Has demonstrated bioequivalence and may be substituted for the reference listed drug✓
• c.May be dispensed only with written permission from the prescriber
• d.Contains a different active ingredient that produces a similar effect

An AB code means actual or potential bioequivalence problems have been resolved with adequate in vivo or in vitro data, so the product is therapeutically equivalent to the reference listed drug and can be substituted. It does not mean the ingredient differs, and no special prescriber permission is required beyond ordinary state substitution rules.FDA

A product carries a 'BX' code in the Orange Book. What does this indicate?

• a.Available data are insufficient to establish therapeutic equivalence✓
• b.The product has been withdrawn from the market for safety reasons
• c.The product is fully bioequivalent to the reference listed drug
• d.The product is available only as a brand name

Codes beginning with B indicate products the FDA does not consider therapeutically equivalent, and BX specifically means the data are insufficient to determine equivalence, so automatic substitution is not appropriate. AB is the code for demonstrated equivalence, and market withdrawal is handled through separate FDA actions, not the equivalence code.FDA

Which medication is generally considered a narrow-therapeutic-index drug for which switching between manufacturers warrants extra caution and monitoring?

• a.Ibuprofen
• b.Loratadine
• c.Amoxicillin
• d.Warfarin✓

Warfarin has a narrow therapeutic index, so small changes in blood level can cause bleeding or clotting and INR monitoring is needed after any product change. Amoxicillin, ibuprofen, and loratadine have wide margins between effective and toxic doses and are not narrow-therapeutic-index agents.

Montelukast is most commonly prescribed for which condition?

• a.Gastroesophageal reflux disease
• b.Asthma maintenance and allergic rhinitis✓
• c.Relief of an acute asthma attack
• d.Chronic obstructive pulmonary disease

Montelukast is a leukotriene receptor antagonist taken on a schedule for long-term asthma control and for allergic rhinitis. It has no bronchodilator activity, so it cannot relieve an attack that is already under way; that calls for a short-acting beta agonist such as albuterol. It is not an approved treatment for chronic obstructive pulmonary disease, and reflux is treated with acid suppressants such as omeprazole.

Tamsulosin is indicated primarily for the treatment of:

• a.Benign prostatic hyperplasia✓
• b.Erectile dysfunction
• c.Overactive bladder
• d.Urinary tract infection

Tamsulosin is an alpha-1 blocker that relaxes smooth muscle in the prostate and bladder neck, improving urine flow in benign prostatic hyperplasia. Overactive bladder is treated with antimuscarinics such as oxybutynin, erectile dysfunction with agents such as sildenafil, and urinary infections with antibiotics.

A patient is discharged after coronary stent placement with a prescription for clopidogrel (Plavix). What is the purpose of this medication?

• a.To slow the heart rate and lower blood pressure
• b.To lower LDL cholesterol and blood lipids
• c.To inhibit platelet aggregation and prevent clot formation✓
• d.To control blood glucose in type 2 diabetes

Clopidogrel is an antiplatelet agent that blocks the P2Y12 ADP receptor, reducing the risk of stent thrombosis, myocardial infarction, and stroke. Lowering LDL cholesterol and blood lipids is the role of statins such as atorvastatin, controlling blood glucose in type 2 diabetes belongs to agents such as metformin, and slowing the heart rate while lowering blood pressure is what beta blockers such as metoprolol do.

A patient newly diagnosed with hypothyroidism presents a prescription. Which medication is expected?

• a.Methimazole
• b.Prednisone
• c.Metformin
• d.Levothyroxine✓

Hypothyroidism is treated by replacing the missing hormone with levothyroxine. Methimazole suppresses thyroid hormone production and is used for hyperthyroidism, metformin treats type 2 diabetes, and prednisone is a corticosteroid used for inflammation.

Which of the following products should NOT be crushed before administration?

• a.Immediate-release lisinopril tablet
• b.Chewable montelukast tablet
• c.Enteric-coated aspirin tablet✓
• d.Scored metoprolol tartrate tablet

The enteric coating on aspirin is designed to keep the tablet intact until it passes the stomach, so crushing destroys that protection and increases gastric irritation. Immediate-release and scored tablets may generally be split or crushed, and chewable tablets are meant to be broken down in the mouth.

How should a sublingual nitroglycerin tablet be administered during an episode of chest pain?

• a.Dissolved in a glass of juice and swallowed with food
• b.Chewed thoroughly and swallowed with a sip of water
• c.Placed under the tongue and allowed to dissolve without swallowing✓
• d.Swallowed whole with a full glass of water and food

Sublingual tablets dissolve under the tongue so the drug is absorbed directly into the bloodstream through the oral mucosa, giving rapid onset and bypassing first-pass liver metabolism. Chewing and swallowing the tablet, washing it down with water, or dissolving it in juice all send the dose through the digestive tract, where first-pass metabolism removes most of it before it can relieve chest pain.

A patient is dispensed otic drops for an ear infection. Which counseling point is correct?

• a.The drops should be diluted with water before each use
• b.The drops must be refrigerated and instilled cold
• c.The drops may be used in either the ear or the eye if needed
• d.The drops are for the ear only and must never be instilled in the eye✓

Otic products are not manufactured to be sterile and isotonic for ocular use, so instilling them in the eye can cause pain and injury; ophthalmic drops, by contrast, may be used in the ear. Otic drops are normally stored at room temperature, warmed slightly in the hand if cold, and are never diluted by the patient.

Insulin glargine (Lantus) is administered by which route?

• a.Intramuscular
• b.Intradermal
• c.Intravenous
• d.Subcutaneous✓

Insulin glargine is injected into subcutaneous fat, where its slow, steady absorption produces basal coverage over about 24 hours. Intravenous administration would produce an immediate, unpredictable drop in glucose and is reserved for regular insulin, while intramuscular and intradermal routes are not used for insulin therapy.

A patient taking lisinopril reports a persistent dry, tickling cough that started a few weeks after beginning therapy. What is the most likely explanation?

• a.The cough indicates an allergic reaction requiring epinephrine
• b.Dry cough is a recognized ACE inhibitor effect related to bradykinin accumulation✓
• c.Lisinopril does not cause cough, so the symptom is unrelated
• d.The cough is a sign that the dose is too low

ACE inhibitors block breakdown of bradykinin in the respiratory tract, and the resulting dry, nonproductive cough is a well-known reason patients are switched to an ARB such as losartan. It is not an anaphylactic reaction, and the cough is dose-independent rather than a sign of underdosing.

Which symptom should a patient starting atorvastatin be told to report promptly to the prescriber?

• a.A dry, persistent cough at night
• b.Unexplained muscle pain, tenderness, or weakness✓
• c.Swelling of the ankles and feet each evening
• d.An unusually slow pulse noticed on waking

Statins can cause myopathy and, rarely, rhabdomyolysis, so new unexplained muscle pain, tenderness, or weakness needs prompt evaluation and possible creatine kinase testing. A dry persistent cough is the classic adverse effect of ACE inhibitors such as lisinopril, ankle and foot swelling is characteristic of dihydropyridine calcium channel blockers such as amlodipine, and an unusually slow pulse points toward a beta blocker such as metoprolol — none of the three is a characteristic statin effect.

A patient is starting a course of metronidazole. Which counseling point is most important?

• a.Avoid alcohol during therapy and for several days after the last dose✓
• b.Double the next dose if a dose is missed to stay on schedule
• c.Expect the urine to turn bright blue for a few days
• d.Take each dose on a completely empty stomach with water

Metronidazole combined with alcohol can produce a disulfiram-like reaction with flushing, nausea, vomiting, and palpitations, so alcohol is avoided during therapy and for a few days afterward. The drug may be taken with food to reduce stomach upset, it can darken urine to a reddish-brown rather than turning it blue, and doubling up after a missed dose raises the risk of adverse effects instead of catching the schedule back up.

A patient stabilized on warfarin asks whether it is acceptable to take ibuprofen for back pain. What is the appropriate response?

• a.Ibuprofen raises bleeding risk with warfarin; the patient should check with the prescriber first✓
• b.Ibuprofen may be taken only if the warfarin dose is skipped that day
• c.Ibuprofen decreases warfarin's effect, so the warfarin dose must be doubled
• d.Ibuprofen has no interaction with warfarin and may be taken freely

NSAIDs such as ibuprofen irritate the gastrointestinal lining and inhibit platelet function, which adds to warfarin's anticoagulant effect and increases bleeding risk, so the prescriber should be consulted and acetaminophen is often preferred. The interaction increases rather than decreases bleeding risk, and patients should never adjust or skip warfarin doses on their own.

How should unopened vials of insulin glargine be stored in the pharmacy?

• a.In the refrigerator at 2-8 °C, protected from freezing✓
• b.In a warming cabinet held at 30-35 °C
• c.At room temperature only, discarded after 7 days
• d.In the freezer at -10 °C until needed

Unopened insulin is stored in the refrigerator at 2-8 °C, where it remains stable until the manufacturer's expiration date. Freezing denatures insulin and makes the vial unusable, storage in a warming cabinet shortens potency well before the labeled expiration, and the room-temperature limit that does exist applies to a vial already in use, not to unopened stock in the pharmacy.

'Controlled room temperature' on a manufacturer's storage label corresponds to which temperature range?

• a.8-15 °C
• b.15-20 °C
• c.20-25 °C✓
• d.2-8 °C

Controlled room temperature is defined as 20-25 °C, with brief excursions permitted between 15 and 30 °C. The 2-8 °C range describes refrigeration, while 8-15 °C corresponds to a cool storage area and 15-20 °C falls below the controlled room temperature range.USP

What is the correct storage instruction for sublingual nitroglycerin tablets?

• a.Keep them in the original glass container, tightly closed and protected from light and moisture✓
• b.Keep the bottle open on the bathroom shelf so it can be reached quickly
• c.Store the bottle in the refrigerator at 2-8 °C to keep it potent longer
• d.Transfer the tablets to a weekly pill organizer so doses are not missed

Nitroglycerin is volatile and moisture sensitive, so it must remain in its original tightly closed amber glass container to preserve potency. A pill organizer and an open bottle both expose the tablets to air and to the humidity of a bathroom, and refrigeration adds condensation rather than stability. Any of these can leave the patient holding tablets that no longer work during chest pain.

Latanoprost ophthalmic solution is dispensed to a patient with glaucoma. What are the correct storage directions?

• a.Refrigerate the unopened bottle at 2-8 °C; once opened it may be kept at room temperature for up to 6 weeks✓
• b.Keep the bottle in direct sunlight, since light exposure keeps the solution clear
• c.Keep the bottle frozen and let it thaw at room temperature before the first dose is given
• d.Store it at room temperature indefinitely, with no beyond-use limit after opening

Unopened latanoprost requires refrigeration, and after the bottle is opened it may be stored at room temperature for the period stated in the manufacturer's labeling. Light exposure degrades the drug rather than keeping the solution clear, freezing is not an appropriate way to store an ophthalmic solution, and an opened bottle does carry a limited in-use period rather than none at all.

A prescription is entered for hydroxyzine 25 mg. Which medication is most likely to be selected in error because of a classic look-alike/sound-alike name pair?

• a.Hydralazine✓
• b.Hydrocodone
• c.Hydrocortisone
• d.Hydrochlorothiazide

Hydroxyzine and hydralazine are a well-documented look-alike/sound-alike pair; one is an antihistamine and the other an antihypertensive vasodilator, so a mix-up can cause serious harm. Hydrocortisone is a corticosteroid, hydrochlorothiazide a thiazide diuretic, and hydrocodone an opioid, none of which form this classic confusion pair.

Which of the following is classified as a high-alert medication?

• a.Loratadine 10 mg tablets
• b.Concentrated potassium chloride injection✓
• c.Acetaminophen 325 mg tablets
• d.Docusate sodium 100 mg capsules

Concentrated potassium chloride for injection is a high-alert medication because an undiluted dose can cause fatal cardiac arrhythmia; other high-alert classes include insulin, anticoagulants, opioids, and neuromuscular blockers. Loratadine, acetaminophen at standard strength, and docusate carry a much lower risk of catastrophic harm when an error occurs.

Product labels print certain drug names as buPROPion and busPIRone. What is the purpose of this formatting?

• a.Tall man lettering highlights the differing letters to reduce name selection errors✓
• b.Capital letters mark the product as requiring refrigeration
• c.The uppercase portion shows the manufacturer's abbreviation
• d.Capital letters indicate the drug is a controlled substance

Tall man lettering capitalizes the dissimilar portion of look-alike drug names so staff notice the difference during selection and dispensing. It carries no meaning about controlled substance status, storage requirements, or the manufacturer.

A prescription is written for clonidine to treat hypertension. Which sound-alike medication could be dispensed in error?

• a.Colchicine
• b.Clopidogrel
• c.Clonazepam✓
• d.Clindamycin

Clonidine and clonazepam are a recognized sound-alike pair; clonazepam is a benzodiazepine, so dispensing it instead of an antihypertensive could cause sedation and leave blood pressure untreated. Clopidogrel is an antiplatelet drug, clindamycin an antibiotic, and colchicine a gout agent, and none of these names is close enough to be the classic confusion partner.

A prescription reads: amoxicillin 400 mg/5 mL suspension, give 200 mg by mouth twice daily. How many mL should be given per dose?

• a.5 mL
• b.10 mL
• c.2.5 mL✓
• d.1.25 mL

Since 400 mg is contained in 5 mL, 200 mg is half that amount, or 2.5 mL per dose. The 5 mL volume would deliver 400 mg, 10 mL would deliver 800 mg, and 1.25 mL would supply only 100 mg.

An insulin product is labeled 100 units/mL. A patient is instructed to inject 18 units. What volume corresponds to this dose?

• a.0.9 mL
• b.1.8 mL
• c.0.018 mL
• d.0.18 mL✓

At a concentration of 100 units/mL, each unit equals 0.01 mL, so 18 units equals 0.18 mL. A volume of 1.8 mL would contain 180 units, 0.9 mL would contain 90 units, and 0.018 mL would contain only 1.8 units.

Which drug is placed in Schedule II (C-II), the schedule with an accepted medical use but the highest abuse potential of any prescribable controlled substance?

• a.Ketamine
• b.Hydromorphone✓
• c.Pregabalin
• d.Alprazolam

Hydromorphone is a C-II opioid; other common C-II agents include oxycodone, fentanyl, methylphenidate, and amphetamine. Alprazolam is C-IV, pregabalin is C-V, and ketamine is C-III, so all three carry a lower federally assigned abuse potential. Schedule II drugs have accepted medical use but the greatest abuse and dependence risk among drugs that may still be prescribed.21 CFR 1308 (DEA schedules)

Under the Controlled Substances Act, which statement correctly describes Schedule I substances such as heroin and LSD?

• a.They have a high abuse potential and no currently accepted medical use in the United States, so they cannot be prescribed.✓
• b.They may be dispensed on a written prescription, but that prescription may never be refilled.
• c.They have a low potential for abuse and may be sold over the counter without a prescription.
• d.They may be dispensed with up to 5 refills within 6 months of the date it was written.

The defining feature of Schedule I is a high potential for abuse combined with no currently accepted medical use in the United States, which is why these substances are not dispensed on an outpatient prescription at all. A written prescription that may not be refilled describes Schedule II, and up to 5 refills within 6 months of the date written describes Schedules III and IV. Over-the-counter sale is impossible for any controlled substance in Schedule I, whose lawful handling is limited to registered research and other DEA-authorized activity.21 CFR 1308 (DEA schedules)

What is DEA Form 222 (or its electronic CSOS equivalent) used for?

• a.Registering a new pharmacy with the DEA for the first time
• b.Reporting a significant theft or loss of controlled substances
• c.Documenting the destruction of expired controlled substances on site
• d.Ordering or transferring Schedule II controlled substances between DEA registrants✓

DEA Form 222, or an electronic order placed through the Controlled Substance Ordering System (CSOS), is required for every purchase or transfer of a Schedule II substance between registrants. Schedules III through V may be ordered on an ordinary invoice, which must still be retained. A significant theft or loss is reported on Form 106, destruction is documented on Form 41, and an initial pharmacy registration is made on Form 224.21 CFR 1305 (DEA Form 222 / CSOS)

A pharmacy destroys a quantity of expired Schedule II tablets on site. Which DEA form documents this disposal?

• a.DEA Form 106
• b.DEA Form 224
• c.DEA Form 41✓
• d.DEA Form 222

DEA Form 41 is the registrant's record of controlled substances that have been destroyed, and it must be retained with the pharmacy's controlled substance records. Form 106 is reserved for theft or significant loss, Form 222 is for ordering Schedule II drugs, and Form 224 is the pharmacy's DEA registration application. Destruction records are kept for at least 2 years under federal law; some states are stricter.21 CFR 1307 (DEA Form 41 destruction)

During a routine count the pharmacy discovers that a sealed bottle of oxycodone is missing and suspects diversion. Which action does federal law require?

• a.Notify the DEA and submit DEA Form 106 for the theft or significant loss✓
• b.Submit a new DEA Form 222 to replace the lost stock
• c.Complete DEA Form 41 to document the missing product
• d.Record the shortage on the next biennial inventory only

A theft or significant loss of controlled substances must be reported to the DEA, and Form 106 is the report used to document the circumstances and quantities involved. Form 41 records product that was intentionally destroyed, not product that disappeared, and Form 222 only orders Schedule II stock. Simply noting the discrepancy at the next inventory does not satisfy the reporting duty; state boards often require notification as well.DEA

How often must a DEA registrant take a complete inventory of all controlled substances on hand?

• a.Every 5 years
• b.Every 2 years✓
• c.Every 12 months
• d.Every 6 months

Federal law requires a biennial inventory, meaning a complete count of controlled substances on hand at least every 2 years, in addition to the initial inventory taken when the registrant begins handling controlled substances. Annual, semiannual, and five-year cycles are not the federal standard, although some states require inventories more often. Schedule II records must be kept separate from all other records and all controlled substance records must be readily retrievable and kept at least 2 years; this is a federal minimum and some states are stricter.21 CFR 1304 (controlled substance records)

A patient presents a written prescription for a Schedule IV benzodiazepine. What is the federal refill limit?

• a.No refills are permitted
• b.Up to 3 refills within 12 months of the date written
• c.Up to 5 refills within 6 months of the date written✓
• d.Unlimited refills for 12 months from the date written

Schedule III and Schedule IV prescriptions may be refilled a maximum of 5 times and only within 6 months of the date the prescription was written, whichever limit is reached first. The no-refill option describes Schedule II, which may not be refilled at all, and neither unlimited refills for a year nor a 3-refill cap matches the federal rule for C-III and C-IV. This is a federal minimum; some states are stricter.21 CFR 1306 (controlled substance prescriptions)

A manufacturer recalls a sterile injectable after finding particulate matter that could cause fatal embolism. How does the FDA classify this recall?

• a.Class IV
• b.Class II
• c.Class I✓
• d.Class III

A Class I recall applies when there is a reasonable probability that use of the product will cause serious adverse health consequences or death, which fits a contaminant capable of causing a fatal event. Class II covers products that may cause temporary or medically reversible harm, and Class III covers products unlikely to cause any adverse health consequence, such as a minor labeling defect. There is no Class IV in the FDA recall classification system.21 CFR 7 (FDA recall classification)

Which statement best describes a Risk Evaluation and Mitigation Strategy (REMS)?

• a.A manufacturer's voluntary copay assistance program that lowers the amount a commercially insured patient pays for a specialty drug
• b.A USP compounding standard that sets the beyond-use dates and the sterile air quality requirements that apply to compounded preparations
• c.An FDA-required safety program that may mandate prescriber certification, patient enrollment, pharmacy certification, or laboratory monitoring before a drug is dispensed✓
• d.A DEA quota program that limits how much of a controlled substance a pharmacy may order and keep in stock in a given month

A REMS is imposed by the FDA when a drug's serious safety risks require controls beyond standard labeling, and its elements can include certifying prescribers and pharmacies, enrolling patients in a registry, and documenting laboratory results before dispensing. Familiar examples are iPLEDGE for isotretinoin, absolute neutrophil count monitoring for clozapine, and the restricted program for thalidomide. Beyond-use dating and air quality standards for compounding come from USP, quotas for controlled substances are set by the DEA at the manufacturing level rather than per pharmacy, and manufacturer copay assistance carries no regulatory safety role at all.FDA REMS (FDAAA 2007)

Which standard governs compounded sterile preparations, including ISO-classified air, garbing, and assignment of beyond-use dates?

• a.21 CFR 1304
• b.USP <800>
• c.USP <795>
• d.USP <797>✓

USP <797> sets the practice standards for compounded sterile preparations, covering ISO-classified engineering controls, personnel hand hygiene and garbing, environmental monitoring, and beyond-use dating. USP <795> applies to nonsterile compounding such as creams and oral suspensions, while USP <800> addresses handling of hazardous drugs regardless of whether the preparation is sterile. 21 CFR 1304 concerns controlled substance recordkeeping and has nothing to do with compounding technique.USP <797>

A technician will compound a chemotherapy agent in a negative-pressure containment room while wearing a chemotherapy-rated gown and two pairs of chemotherapy-rated gloves. Which standard drives these requirements?

• a.USP <795>
• b.USP <797>
• c.USP <800>✓
• d.Drug Supply Chain Security Act (DSCSA)

USP <800> governs the receipt, storage, compounding, and disposal of hazardous drugs in order to protect personnel, patients, and the environment, and it specifies containment engineering controls such as negative pressure rooms plus chemotherapy-rated PPE. Drugs subject to <800> are identified from the NIOSH hazardous drug list. USP <795> and <797> address nonsterile and sterile compounding quality rather than worker exposure, and the DSCSA deals with tracing product through the supply chain.USP <800>

Which action by a pharmacy technician violates the HIPAA Privacy Rule?

• a.Faxing a refill history to the prescribing physician who is managing the patient's therapy
• b.Providing patient records to the pharmacist for an internal medication error review
• c.Telling the patient's neighbor which medications the patient picked up that morning✓
• d.Submitting a claim with the patient's medication details to the patient's insurer

Protected health information may be used or disclosed without separate patient authorization for treatment, payment, and health care operations, and disclosures must be limited to the minimum necessary for the purpose. Billing the insurer is payment, faxing the prescriber is treatment, and an internal error review is health care operations, so all three are permitted. Disclosing a patient's medications to a neighbor serves none of these purposes and is a privacy violation.HIPAA Privacy Rule (45 CFR 164)

Under the Combat Methamphetamine Epidemic Act, what is the federal daily purchase limit of pseudoephedrine base for a single buyer?

• a.3.6 g✓
• b.2.4 g
• c.9 g
• d.7.5 g

The CMEA caps a single purchaser at 3.6 g of pseudoephedrine base per day and 9 g in a 30-day period, so 9 g is the monthly limit rather than the daily one and 2.4 g and 7.5 g are not federal thresholds. Products must be kept behind the counter or in a locked case, and the buyer must show photo identification and sign a written or electronic logbook that is retained for 2 years. These are federal minimums; some states are stricter and require a prescription.Combat Methamphetamine Epidemic Act (CMEA)

A prescriber writes an order for an oral liquid antipsychotic as "1.0 mg by mouth at bedtime." Why is this way of writing the dose considered unsafe?

• a.Doses below 10 mg must always be expressed in mcg
• b.A decimal point is never permitted in an order for a liquid medication
• c.If the decimal point is missed or lost, 1.0 mg is read as 10 mg, a ten-fold overdose✓
• d.The trailing zero shows the dose was rounded and is therefore only an estimate

A trailing zero adds no clinical information but creates real danger: if the decimal point is faint or lost in transmission, 1.0 mg is read as 10 mg. The safe convention is the opposite pair of rules: never use a trailing zero (write 1 mg), but always use a leading zero for doses under one (write 0.5 mg, not .5 mg). Small doses are not converted to mcg simply for being small, decimal points are allowed in liquid orders, and a trailing zero says nothing about rounding.

A handwritten order reads "Humulin R 8U subcutaneously before meals." Which correction should be made before the order is processed?

• a.Have "U" spelled out as "units," because U can be misread as a zero or a four✓
• b.Abbreviate "subcutaneously" to "SQ" to save more room on the label
• c.Replace "before meals" with the shorter frequency abbreviation "QD"
• d.Rewrite the dose as "8.0 units" so the decimal place is clear

The symbol U is one of the most dangerous abbreviations in practice: 8U can be read as 80 or 84, turning an 8 unit insulin dose into a potentially fatal one, so the word units must be written out in full. SQ is itself on the do-not-use list because it is misread as SL, writing 8.0 units introduces a trailing zero that is read as 80 if the decimal point is missed, and QD is on every do-not-use list because it is confused with QOD and QID.

While filling a prescription, a technician scans the barcode on the stock bottle and the dispensing system rejects the scan. What is the correct next action?

• a.Skip the scan and rely on the pharmacist to catch any problem at the final verification instead
• b.Rescan the bottle repeatedly until the system finally accepts it and lets the fill continue
• c.Type the NDC from the stock bottle in by hand and continue filling the prescription as usual
• d.Stop, set the bottle aside, and confirm that the product truly matches the prescription label before going any further✓

A rejected scan is the system telling the technician that the product in hand is not the product on the label, so the fill must stop until the discrepancy is resolved. Typing the NDC by hand, rescanning until the system gives way, and skipping the scan all defeat the purpose of barcode verification, which is an independent electronic check that does not depend on the eyes of the person filling. Relying on the pharmacist's final verification alone removes one layer of protection instead of adding one.FDA

A pediatric order is written for 15 mg/kg per dose for a child who weighs 18 kg. The label produced by the system reads "2,700 mg per dose." What should the technician conclude?

• a.The dose must be recalculated using the child's weight in pounds
• b.The label is correct but the dose should be rounded up to 2,750 mg for easier measuring
• c.The label is correct, because 18 kg multiplied by 15 mg/kg equals 2,700 mg
• d.The label shows a ten-fold overdose; the correct dose is 270 mg per dose✓

18 kg x 15 mg/kg = 270 mg per dose, so 2,700 mg is exactly ten times the intended amount and the label must be stopped and given to the pharmacist. Accepting 2,700 mg repeats the decimal error, and rounding it to 2,750 mg only makes an overdose easier to measure. Weight-based pediatric doses are calculated in kg, so converting to pounds would inflate the dose further.

Technicians are taught to read each prescription three times during the fill process. At which three points should those readings occur?

• a.When the stock bottle is taken off the shelf, when the drug is counted or measured, and when the bottle is returned to the shelf✓
• b.Three times in quick succession at the counting tray, immediately before the tablets are counted out
• c.Once by the technician at drug selection and twice by the pharmacist during the final verification
• d.At drop-off, at the cash register when payment is taken, and again at the pickup window

The three readings are spaced across the physical steps of the fill — selection, counting, and return to stock — so that a wrong-drug or wrong-strength selection is caught at a different moment each time. Three readings in quick succession at the counting tray use the same glance and the same assumption, so they catch almost nothing. Drop-off, payment, and pickup are service steps rather than fill checks, and the technique is a technician self-check that adds to the pharmacist's verification rather than replacing part of it.

Insulin, heparin, warfarin, opioids and concentrated potassium chloride are all classified as high-alert medications. What does that classification mean?

• a.Dispensing errors happen far more frequently with these drugs than with any other medications
• b.An error involving them is far more likely to cause severe or fatal harm, even though errors are not necessarily more frequent✓
• c.They may be dispensed only in unit-dose packaging prepared by the manufacturer, never repackaged
• d.They are the most expensive products the pharmacy carries and are kept locked in the pharmacy safe

High-alert status is about the consequence of an error, not its frequency: these drugs have a narrow margin between a therapeutic dose and a harmful one, so a single mistake can kill. That is why they warrant an independent double check, physical separation from look-alike stock, and standardized concentrations. High-alert drugs are dispensed in ordinary packaging every day, several of them are inexpensive generics, and error frequency is not what puts a drug on the list.

A heparin infusion is prepared by adding 25,000 units of heparin to a 250 mL bag of diluent. Which final concentration should appear on the label?

• a.25 units/mL
• b.100 units/mL✓
• c.10 units/mL
• d.1,000 units/mL

25,000 units divided by 250 mL equals 100 units/mL, and because heparin is a high-alert drug this figure should be confirmed by an independent double check before the bag is released. 10 units/mL and 25 units/mL understate the concentration, while 1,000 units/mL is a ten-fold overstatement that would lead a nurse to infuse far too little or far too much heparin for the ordered rate.

An order calls for potassium chloride 20 mEq to be added to 100 mL of diluent. The stock vial is labeled 2 mEq/mL. What volume should be withdrawn?

• a.2 mL
• b.40 mL
• c.10 mL✓
• d.20 mL

20 mEq divided by 2 mEq/mL equals 10 mL, which is then added to the 100 mL bag. Withdrawing 2 mL or 20 mL would deliver 4 mEq or 40 mEq, and 40 mL would give 80 mEq — four times the order. Concentrated potassium chloride is a high-alert product that must always be diluted before administration and never dispensed as an undiluted vial to a patient care area.

A prescription reads "insulin glargine 14 units subcutaneously at bedtime," but the label that printed reads "inject 14 mL subcutaneously at bedtime." What should the technician do?

• a.Dispense it exactly as printed, since 14 mL of U-100 insulin works out to the same dose as 14 units
• b.Dispense it with a U-100 insulin syringe so that the patient can convert the dose before injecting it
• c.Correct the label to read 14 mL and add an auxiliary label telling the patient to measure carefully
• d.Stop the fill and alert the pharmacist, because the unit of measure was changed from units to mL and would produce a massive overdose✓

Insulin is dosed in units, and 14 mL of U-100 insulin would contain 1,400 units — roughly a hundred times the intended dose — so the fill must stop and the pharmacist must correct the entry. The claim that 14 mL works out to 14 units is false, keeping the mL wording on the label preserves the error, and no auxiliary label or syringe choice can make a wrong unit of measure safe.

One shelf label in a pharmacy reads "hydrOXYzine" and another, stored some distance away, reads "hydrALAZINE." What is the purpose of writing the names this way?

• a.It marks the product as a controlled substance that must be kept in the safe rather than on the open shelf
• b.It highlights the letters that differ between two similar names so the products are less likely to be confused✓
• c.It identifies the part of the drug name that must be typed in capital letters on the patient's label
• d.It shows that the brand-name product must be dispensed because no generic version has been approved

TALL man lettering capitalizes the dissimilar portion of two confusable names so the eye is pulled to the difference rather than to the shared beginning. Controlled substance status is shown by the schedule and the storage requirements that follow from it, not by capitalization, and TALL man lettering says nothing about brand versus generic. The patient label uses ordinary lettering; the capitalization is a shelf and screen aid for staff.

A pharmacy stocks both clonazePAM and cloNIDine. Which storage practice best reduces the risk of pulling the wrong product?

• a.Separate them physically on different shelves and place a shelf alert at each location✓
• b.Highlight the letters the two names have in common so staff notice the similarity
• c.Stock only one of the two and order the other in when a prescription arrives
• d.Shelve them side by side in alphabetical order so both labels can be seen at once

Physical separation plus a shelf alert breaks the automatic reach-and-grab that causes look-alike errors, because the technician must move to a different location and read a warning before selecting. Strict alphabetical shelving is what places these two names next to each other in the first place; marking the letters the names share pulls the eye toward what they have in common, which is the opposite of what TALL man lettering does; and refusing to stock one of them would leave patients without a legitimately prescribed drug.

Which pair of medications is most likely to be involved in a look-alike/sound-alike selection error?

• a.lisinopril and warfarin
• b.predniSONE and predniSOLONE✓
• c.amoxicillin and metformin
• d.ibuprofen and cetirizine

predniSONE and predniSOLONE differ by only a few letters near the end of a long shared stem, sit next to each other alphabetically, and are stocked in similar strengths, which is the classic recipe for a wrong-drug selection. The other pairs share neither spelling, sound nor shelf position, so a technician reaching for one is unlikely to grab the other.

A patient's profile lists busPIRone 10 mg three times daily, but the bottle a technician pulled from the shelf is buPROPion 100 mg. Why was this error likely, and what would have prevented it?

• a.The two names look and sound alike; scanning the barcode and reading the full name with its TALL man lettering before counting would have prevented it✓
• b.The two drugs belong to the same therapeutic class, so checking the class printed on the shelf label would have prevented it
• c.The two drugs are supplied in identical tablet strengths, so comparing the strength on the bottle with the label would have prevented it
• d.The two drugs share the same labeler code in their NDC numbers, so comparing the manufacturers would have prevented it

busPIRone and buPROPion share their first three letters and a similar rhythm, which is why they appear on look-alike/sound-alike lists; a barcode scan plus a deliberate reading of the capitalized portion catches the substitution before any tablets are counted. They are not in the same therapeutic class, they do not necessarily come from the same labeler, and their strengths in this scenario are 10 mg and 100 mg rather than identical.

A stock bottle carries the NDC 00093-0058-01. In the 11-digit 5-4-2 format, what does the middle segment identify?

• a.The manufacturer or labeler that registered the product with the FDA
• b.The package size and the type of container the drug is supplied in
• c.The controlled substance schedule the DEA has assigned to the drug
• d.The specific drug product, meaning its active ingredient, strength and dosage form✓

The three segments run labeler, product and package: the first five digits identify the company, the middle four identify the drug together with its strength and dosage form, and the last two identify the package size. So a change in strength from 10 mg to 20 mg changes the middle segment. Controlled substance schedule is not encoded anywhere in the NDC.FDA

Two bottles from the same manufacturer carry NDC numbers that are identical except for the final two digits. What does this most likely mean?

• a.The two bottles contain different strengths of the same active ingredient
• b.The bottles hold the same drug, strength and dosage form but in different package sizes✓
• c.One bottle is the brand product and the other is its authorized generic
• d.One of the two bottles came from a lot that has passed its expiration date

Only the package segment differs, so the products are identical in ingredient, strength and dosage form and vary only in package size — for example a 100 count bottle versus a 500 count bottle. A brand-to-generic change would alter the labeler segment, a change in strength would alter the product segment, and expiration dating is printed separately and is never part of the NDC.

Which practice best confirms that the stock bottle in hand is the exact product called for by the prescription label?

• a.Compare the lot number on the bottle with the prescription number
• b.Compare the manufacturer's logo on the bottle with the image shown in the dispensing software
• c.Compare only the drug name printed on the label with the name on the bottle
• d.Compare the full 11-digit NDC on the stock bottle with the NDC on the prescription label, segment by segment✓

Matching all 11 digits verifies manufacturer, drug, strength, dosage form and package size in a single check, which is why the NDC is the anchor for both manual and barcode verification. Reading the name alone misses strength and dosage form errors, the lot number and prescription number are unrelated fields, and a logo confirms only the company.

At the pickup window a patient asks the technician whether her new antibiotic will interfere with her birth control pill. What should the technician do?

• a.Read the interaction section of the package insert aloud to the patient
• b.Refer the question to the pharmacist, who is responsible for patient counseling✓
• c.Suggest that the patient look it up on the manufacturer's website
• d.Answer using the interaction screen in the dispensing software

Interpreting a drug interaction for a specific patient is clinical judgment and counseling, which is the pharmacist's role; the technician's correct response is a prompt, courteous hand-off. Reading the insert aloud or repeating what the software screen says is still giving clinical advice, and sending the patient to a website leaves the question unanswered by the professional standing right there.

While entering a prescription for cephalexin, a technician sees a system alert that the patient has a documented penicillin allergy. What is the appropriate action?

• a.Remove the allergy from the profile if the patient says the reaction was mild
• b.Leave the alert unresolved and notify the pharmacist so it can be clinically evaluated✓
• c.Cancel the prescription and tell the patient to contact the prescriber
• d.Override the alert, since cephalexin is not a penicillin

Deciding whether a documented allergy contraindicates a related antibiotic is a clinical judgment reserved for the pharmacist, so the technician's job is to preserve the alert and escalate it. Overriding it, editing the allergy history based on a casual patient comment, or canceling the prescription outright all substitute the technician's judgment for the pharmacist's and can delay needed therapy.

Which step must be performed by the pharmacist before a completed prescription is released to the patient?

• a.Counting the tablets or measuring the liquid to be dispensed
• b.Applying the auxiliary warning labels to the finished container
• c.Scanning the barcode on the stock bottle before counting
• d.The final clinical and product verification of the finished prescription✓

Final verification is where a licensed pharmacist confirms that the right drug, strength, quantity and directions match the prescription and that the therapy is appropriate for that patient, and it cannot be delegated to a technician. Counting, labeling and barcode scanning are all technical tasks a technician performs, and none of them substitutes for the pharmacist's clinical review.

A prescriber's office telephones the pharmacy to give a new prescription. In most states, what should the technician do?

• a.Ask the caller to repeat the order twice, write it down, and file it as a written prescription
• b.Take the order as long as the drug is not a controlled substance and the caller is a licensed nurse
• c.Take the order, enter it into the computer, and have the pharmacist verify the entry afterward
• d.Transfer the call to the pharmacist, because accepting a new verbal prescription is outside the technician's scope in most states✓

Receiving a new oral prescription requires professional judgment about the drug, dose and directions as they are spoken, so most state boards restrict it to the pharmacist and the correct action is to hand off the call. Entering it first and verifying later means the error has already been recorded, a nurse relaying an order does not change the technician's scope, and repeating an order does not convert a verbal prescription into a written one.

In what sequence should personnel garb before entering the buffer area to prepare sterile compounded products?

• a.Mask, gown, shoe covers, hair cover, hand hygiene, sterile gloves
• b.Shoe covers, hair and beard cover, mask, hand hygiene, gown, sterile gloves✓
• c.Hand hygiene, sterile gloves, gown, mask, hair cover, shoe covers
• d.Gown, shoe covers, hair cover, mask, hand hygiene, sterile gloves

Garbing moves from the dirtiest items to the cleanest — feet, then head, then face — with hand hygiene performed after the head and face coverings are in place and immediately before the gown and sterile gloves. All jewelry, watches and artificial or extended nails must be removed before this sequence begins. The other sequences put gloves or gown on before hand hygiene or before the head coverings, which contaminates what has already been donned.USP <797>

While compounding in a horizontal laminar airflow workbench, a technician sets a stack of supplies between the HEPA filter and an open vial. Why is this unsafe?

• a.It blocks the technician's view of the syringe graduations, so the volume drawn up cannot be read accurately
• b.It raises the temperature inside the hood above the range the compounding area must be kept in
• c.It interrupts first air, so the critical site no longer receives unobstructed HEPA-filtered air and may become contaminated✓
• d.It sets off the pressure differential alarm that monitors airflow through the hood, forcing a restart

First air is the clean air leaving the HEPA filter before it touches anything, and any object placed upstream of a critical site creates turbulence and a shadow of unfiltered air over that site. Work should be performed at least 6 inches inside the hood with nothing between the filter and the vial or needle. Temperature limits, alarms and sightlines are not the reason the practice is prohibited.USP <797>

Immediately before puncturing a vial inside the hood, what should the technician do to the rubber septum?

• a.Wipe it with sterile 70% isopropyl alcohol and allow it to air-dry before puncturing✓
• b.Rinse it with sterile water for injection and then puncture it right away
• c.Hold it briefly over an open flame to sterilize the rubber surface
• d.Wipe it with a dry sterile gauze pad to remove any dust from the surface

Sterile 70% isopropyl alcohol needs contact time to kill surface organisms, so the septum must be wiped in one direction and then allowed to dry rather than being punctured while still wet. A dry gauze pad only moves contamination around, sterile water has no antimicrobial action, and open flame is never used in a laminar airflow hood.

A technician is assigned to prepare an intravenous dose of a hazardous antineoplastic drug. Which combination of personal protective equipment and engineering control is required?

• a.Two pairs of chemotherapy-rated gloves and a disposable low-permeability gown, working in a negative-pressure containment device✓
• b.Chemotherapy gloves with no gown, working in a positive-pressure clean bench
• c.One pair of examination gloves and a cloth lab coat, working in a horizontal laminar airflow bench
• d.Sterile gloves and a surgical mask only, working at an open bench with a portable fume extractor

Hazardous drug compounding requires double chemotherapy-rated gloves and a closed-front, low-permeability disposable gown inside a containment primary engineering control that keeps airflow moving inward and vents appropriately, protecting the preparer as well as the preparation. A horizontal or positive-pressure clean bench blows air outward toward the operator, and examination gloves, cloth coats or a mask alone provide no barrier against hazardous drug residue.USP <800>

A technician pulls the wrong strength of a medication but notices the mistake and corrects it before the pharmacist's final check, so the patient is never affected. Under a just-culture approach, what should happen next?

• a.The near miss should be documented and reported internally so the underlying system weakness can be analyzed and corrected✓
• b.It should be reported only if the same technician makes the same mistake a second time later on
• c.The technician should receive formal written discipline so that the mistake is not repeated
• d.Nothing needs to be recorded, because the error was caught in time and no patient was harmed

Near misses are free lessons: reporting one lets the pharmacy run a root cause analysis and fix the shelf layout, label design or workflow that made the error possible before a patient is harmed. A just culture separates honest system-driven error from reckless behavior, so punishing the report or waiting for a repeat simply teaches staff to stay silent and leaves the hazard in place.

A patient develops a severe rash days after starting a newly dispensed sulfonamide antibiotic, and the pharmacist decides to report it to the FDA. Which program should be used?

• a.The manufacturer's product recall notification system, which alerts pharmacies to defective lots
• b.VAERS, the federal system that collects reports of adverse events following vaccination
• c.A DEA Form 106, the federal form used to report the loss or theft of controlled substances
• d.MedWatch, the FDA program for adverse events and product quality problems involving drugs and other medical products✓

MedWatch is the FDA's voluntary reporting pathway for suspected adverse drug reactions, medication errors and product defects, and reports from pharmacies help detect safety signals that clinical trials missed. VAERS is reserved for events after vaccines, DEA Form 106 covers controlled substance loss or theft, and a recall notification moves product off the shelf but is not a way to report a patient reaction.FDA

Metformin 500 mg, sig: 1 tablet by mouth twice daily. Quantity dispensed: 60 tablets. What is the day supply?

• a.60 days
• b.30 days✓
• c.15 days
• d.45 days

The patient takes 1 tablet x 2 times daily = 2 tablets per day. 60 tablets / 2 tablets per day = 30 days. The tempting error is answering 60 days by treating the dispensed quantity as if it were one tablet per day.

Amoxicillin 250 mg/5 mL oral suspension, sig: 1 teaspoonful by mouth three times daily. One 150 mL bottle is dispensed. What is the day supply?

• a.5 days
• b.10 days✓
• c.30 days
• d.7.5 days

One teaspoonful = 5 mL, and 5 mL x 3 doses = 15 mL per day. 150 mL / 15 mL per day = 10 days. Answering 30 days comes from dividing 150 mL by a single 5 mL dose and forgetting that the patient takes three doses each day.

Insulin glargine 100 units/mL is dispensed as one 10 mL vial. The sig reads: inject 30 units subcutaneously at bedtime. Rounded down to whole days, what is the day supply?

• a.33 days✓
• b.3 days
• c.100 days
• d.30 days

A 10 mL vial at 100 units/mL contains 10 x 100 = 1000 units. 1000 units / 30 units per day = 33.3, which is reported as 33 days. Answering 3 days comes from using 100 units as the total vial content instead of 1000 units.

A prescription is written with the sig: ii tabs PO q6h PRN pain. Which set of patient directions is correct?

• a.Place 2 tablets under the tongue every 6 hours as needed for pain
• b.Take 2 tablets by mouth four times daily on a fixed schedule
• c.Take 2 tablets by mouth every 6 hours as needed for pain✓
• d.Take 2 tablets by mouth every 6 days as needed for pain

ii = two, PO = by mouth, q6h = every 6 hours, PRN = as needed. Nothing in the sig makes the dose scheduled rather than as-needed, and PO is by mouth, not sublingual (SL). The most tempting distractor drops PRN and converts q6h into a fixed four-times-daily schedule.

A prednisone taper is ordered using 10 mg tablets: 40 mg daily for 3 days, then 30 mg daily for 3 days, then 20 mg daily for 3 days, then 10 mg daily for 3 days. What quantity should be dispensed?

• a.30 tablets✓
• b.100 tablets
• c.10 tablets
• d.40 tablets

With 10 mg tablets the daily tablet counts are 4, 3, 2 and 1. Each step runs 3 days: (4 x 3) + (3 x 3) + (2 x 3) + (1 x 3) = 12 + 9 + 6 + 3 = 30 tablets. Answering 10 tablets comes from adding 4 + 3 + 2 + 1 and forgetting to multiply each step by its 3 days.

A 22 kg child is ordered cefdinir 10 mg/kg per dose every 8 hours. The suspension supplied is 100 mg/5 mL. What volume should be given per dose?

• a.2.2 mL
• b.33 mL
• c.11 mL✓
• d.22 mL

The dose is 22 kg x 10 mg/kg = 220 mg. At 100 mg/5 mL the concentration is 20 mg/mL, so 220 mg / 20 mg/mL = 11 mL per dose. Answering 2.2 mL comes from dividing 220 mg by 100 mg and forgetting that each 100 mg occupies 5 mL.

An order calls for 375 mg of an antibiotic. The stock solution is labeled 250 mg/5 mL. How many mL should be measured?

• a.15 mL
• b.3.3 mL
• c.5 mL
• d.7.5 mL✓

Set up the proportion 250 mg / 5 mL = 375 mg / x, so x = (375 x 5) / 250 = 1875 / 250 = 7.5 mL. Answering 3.3 mL comes from inverting the proportion and calculating (250 x 5) / 375.

How many grams of dextrose are contained in a 500 mL bag of D5W?

• a.25 g✓
• b.10 g
• c.2.5 g
• d.5 g

D5W is 5% weight/volume, which means 5 g of dextrose per 100 mL. For 500 mL: 5 g/100 mL x 500 mL = 25 g. Answering 5 g comes from reading the 5% as 5 g per bag regardless of volume.

You must prepare 60 g of a 5% hydrocortisone ointment using a 10% ointment and a 2% ointment. How much of each is required?

• a.30 g of the 10% and 30 g of the 2%
• b.15 g of the 10% and 45 g of the 2%
• c.37.5 g of the 10% and 22.5 g of the 2%
• d.22.5 g of the 10% and 37.5 g of the 2%✓

By alligation, the 10% gets 5 - 2 = 3 parts and the 2% gets 10 - 5 = 5 parts, for 8 total parts. 60 g / 8 = 7.5 g per part, so 3 x 7.5 = 22.5 g of the 10% and 5 x 7.5 = 37.5 g of the 2%. The classic error is assigning the parts to the wrong strength, which reverses the two answers.

How many mL of a 50% stock solution are needed to prepare 500 mL of a 10% solution?

• a.100 mL✓
• b.400 mL
• c.50 mL
• d.250 mL

Using C1V1 = C2V2: 50% x V1 = 10% x 500 mL, so V1 = 5000 / 50 = 100 mL of stock, then qs to 500 mL with diluent. Answering 400 mL is the volume of diluent added, not the volume of stock solution required.

An order reads: infuse 1000 mL of 0.9% sodium chloride over 8 hours. What is the flow rate in mL/hr?

• a.250 mL/hr
• b.62.5 mL/hr
• c.125 mL/hr✓
• d.100 mL/hr

Flow rate = total volume / total time = 1000 mL / 8 hr = 125 mL/hr. Answering 62.5 mL/hr comes from dividing by 16 instead of 8, a common slip when the order is misread as a two-bag total.

1000 mL is to infuse over 10 hours using an administration set calibrated at 15 gtt/mL. What is the drip rate in gtt/min?

• a.10 gtt/min
• b.25 gtt/min✓
• c.15 gtt/min
• d.17 gtt/min

1000 mL / 10 hr = 100 mL/hr, and 100 mL/hr / 60 min = 1.67 mL/min. Multiplying by the drop factor: 1.67 mL/min x 15 gtt/mL = 25 gtt/min. Answering 17 gtt/min comes from using a 10 gtt/mL set instead of the 15 gtt/mL set that was specified.

A 500 mL IV bag is running at 50 mL/hr. How long will the bag last?

• a.25 hours
• b.10 hours✓
• c.5 hours
• d.12.5 hours

Infusion time = volume / rate = 500 mL / 50 mL/hr = 10 hours. Answering 25 hours comes from dividing by 20 mL/hr, and answering 5 hours comes from dividing only half the bag by the rate.

A pharmacy acquires a product for $40.00 and applies a 25% markup on cost. What is the selling price?

• a.$45.00
• b.$50.00✓
• c.$53.33
• d.$42.50

Markup on cost = $40.00 x 0.25 = $10.00, so the selling price is $40.00 + $10.00 = $50.00. Answering $53.33 comes from treating 25% as a margin on the selling price ($40.00 / 0.75) instead of a markup on cost.

A drug has an AWP of $120.00 per 100 tablets. A plan reimburses AWP minus 15% plus a $3.50 dispensing fee. What is the total reimbursement for a 30 tablet prescription?

• a.$30.60
• b.$39.50
• c.$34.10✓
• d.$36.00

AWP for 30 tablets = $120.00 x (30/100) = $36.00. Subtract 15%: $36.00 x 0.85 = $30.60. Add the dispensing fee: $30.60 + $3.50 = $34.10. Answering $39.50 comes from adding the dispensing fee to $36.00 and skipping the 15% discount.

A pharmacy holds a capitated contract paying $6.00 per member per month for 500 enrolled members. What does the pharmacy receive for the month if 900 prescriptions are filled?

• a.$2,400.00
• b.$500.00
• c.$1,500.00
• d.$3,000.00✓

Capitation pays per enrolled member, not per prescription: $6.00 x 500 members = $3,000.00 for the month. The number of prescriptions filled does not change the payment, so calculations built on the 900 prescriptions lead to the wrong answers.

A prescription for 1 tablet daily is filled with 90 tablets on day 1. The plan will not pay for a refill until 75% of the day supply has elapsed. On which day is the refill first payable?

• a.Day 75
• b.Day 45
• c.Day 68✓
• d.Day 90

90 tablets at 1 tablet daily is a 90 day supply, and 75% of 90 days = 67.5 days. Since a partial day does not count, the refill is first payable on day 68. Answering day 75 comes from reading the 75% as 75 days rather than as a percentage of the 90 day supply.

A new written prescription for a Schedule II controlled substance is complete except that the prescriber's DEA number is not on the form. What should the technician do?

• a.Reconstruct the DEA number using the check-digit formula and document the calculation
• b.Give the prescription to the pharmacist so the missing element can be resolved with the prescriber before dispensing✓
• c.Enter and fill the prescription, then obtain the DEA number when the patient picks up
• d.Copy the DEA number from an older prescription in the patient's profile onto the hard copy

A prescription for a controlled substance must carry the required elements, including the prescriber's DEA number, before it can be dispensed. A technician may not supply, guess, or reconstruct a missing element; the correct action is to route the prescription to the pharmacist, who resolves it with the prescriber. Using the check-digit formula only tests whether a number is plausible and cannot create a valid one.21 CFR 1306 (controlled substance prescriptions)

A product carries the 11-digit NDC 00093-3109-56. What does the middle four-digit segment identify?

• a.The package size and package type
• b.The lot number assigned during manufacturing
• c.The specific drug, its strength, and its dosage form✓
• d.The labeler, meaning the manufacturer or distributor

An 11-digit NDC is written in a 5-4-2 format: the first segment is the labeler code, the middle four digits are the product code (drug, strength, and dosage form), and the last two digits are the package code. The lot number is a separate manufacturing identifier and is never part of the NDC.FDA

Which statement is federally required on the label of a dispensed prescription for a Schedule III controlled substance?

• a.Keep this medication in a locked cabinet, away from other household medicines and out of the reach of children
• b.Caution: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed✓
• c.Return any unused doses to the pharmacy so that they can be witnessed and destroyed
• d.Warning: may cause drowsiness; use caution when driving or operating heavy machinery

Federal law requires the transfer warning on the label of any dispensed Schedule II, III or IV prescription. The drowsiness statement is a clinically useful auxiliary label but is not the federally mandated warning, and the storage and return statements are counseling points rather than label requirements.21 CFR 1306 (controlled substance prescriptions)

Under federal packaging law, which dispensed product may routinely be supplied in a non-child-resistant container without any request from the patient or prescriber?

• a.Lisinopril 10 mg tablets
• b.Amoxicillin 250 mg/5 mL oral suspension
• c.Ibuprofen 600 mg tablets
• d.Sublingual nitroglycerin 0.4 mg tablets✓

Sublingual nitroglycerin is a listed exemption from child-resistant packaging because a patient having chest pain must be able to open the container immediately. The other three products require child-resistant packaging unless the patient or prescriber specifically requests otherwise, and a patient waiver may be kept on file for that request.Poison Prevention Packaging Act

Ventolin HFA and Proventil HFA are brand names for which generic drug?

• a.Albuterol✓
• b.Ipratropium
• c.Levalbuterol tartrate
• d.Beclomethasone dipropionate

Ventolin HFA and Proventil HFA are albuterol sulfate metered-dose inhalers, short-acting beta-2 agonists used as rescue inhalers. Levalbuterol is the closest trap: it is the related R-isomer sold as Xopenex, not another name for these products. Ipratropium is Atrovent, an anticholinergic, and beclomethasone is an inhaled corticosteroid used for maintenance, not rescue.

Apixaban (Eliquis) belongs to which drug class?

• a.Antiplatelet agent that blocks the P2Y12 receptor
• b.Vitamin K antagonist
• c.Thrombolytic enzyme that dissolves an existing clot
• d.Direct oral factor Xa inhibitor✓

Apixaban is a direct oral anticoagulant that inhibits factor Xa and does not require routine INR monitoring. The vitamin K antagonist description is the tempting one because warfarin is also an oral anticoagulant used for atrial fibrillation, but warfarin works by blocking vitamin K-dependent clotting factor synthesis and is dosed to an INR. Clopidogrel is the P2Y12 antiplatelet and alteplase is a thrombolytic.

Generic names ending in the stem '-olol', such as metoprolol and atenolol, identify which drug class?

• a.Calcium channel blockers
• b.Beta-adrenergic blocking agents✓
• c.Alpha-1 blockers
• d.Angiotensin-converting enzyme inhibitors

The '-olol' stem marks the beta-adrenergic blocking agents: metoprolol, atenolol, propranolol, carvedilol. ACE inhibitors are the tempting choice because they treat the same conditions and are often on the same profile, but they carry the '-pril' stem, as in lisinopril and enalapril. Dihydropyridine calcium channel blockers end in '-dipine' and alpha-1 blockers such as doxazosin end in '-zosin'.

Ciprofloxacin, levofloxacin and moxifloxacin share the '-floxacin' stem. Which antibiotic class is this?

• a.Third-generation cephalosporins
• b.Macrolide antibiotics
• c.Fluoroquinolones✓
• d.Aminoglycoside antibiotics

The '-floxacin' stem identifies the fluoroquinolone antibiotics. Macrolides are the usual wrong pick because they are also broad-spectrum oral antibiotics, but they end in '-thromycin', as in azithromycin and clarithromycin. Cephalosporins begin with 'cef-' (ceftriaxone, cefdinir), and the aminoglycosides are injectable agents such as gentamicin and tobramycin.

A patient is picking up doxycycline capsules. Which counseling point belongs on this prescription?

• a.Separate each dose from dairy, antacids, and iron or calcium supplements by about two hours✓
• b.Take each dose with a full glass of milk or a serving of yogurt to reduce stomach upset
• c.Take the dose at bedtime right before lying down, when the stomach is empty
• d.No sunscreen or protective clothing is needed while taking this antibiotic

Calcium, magnesium, aluminum and iron bind tetracyclines in the gut and sharply reduce how much drug is absorbed, so doses are spaced roughly two hours from dairy, antacids and mineral supplements. The milk instruction is the tempting one because milk genuinely does settle the stomach, but it is also the single most effective way to chelate the dose; a full glass of water while staying upright gives the same comfort and also protects the esophagus, which is why the dose is not taken lying down at bedtime. Doxycycline is also photosensitizing, so sun precautions are part of the counseling rather than something that can be skipped.

Sumatriptan (Imitrex) tablets are prescribed for which purpose?

• a.Daily prophylaxis to prevent migraine attacks from occurring
• b.Relief of an acute migraine attack✓
• c.Long-term control of chronic neuropathic pain
• d.Relief of tension-type headache

Triptans are serotonin 5-HT1 agonists taken at the onset of a headache to abort that attack, and patients are told there is a limit to how many doses may be taken in 24 hours. Daily prevention is the tempting choice because migraine prophylaxis is real therapy, but it uses different drugs such as propranolol, topiramate or amitriptyline; a triptan taken every day leads to medication-overuse headache rather than prevention. Tension-type headache is the other close call: sumatriptan acts on the 5-HT1B/1D receptors of the trigeminal-vascular system that drives migraine, and it is not indicated for ordinary tension headache, which is treated with simple analgesics.

Enoxaparin (Lovenox) is dispensed in prefilled syringes. Which description of its class and route is correct?

• a.Unfractionated heparin, given only by continuous IV infusion
• b.Low molecular weight heparin, given subcutaneously✓
• c.Vitamin K antagonist, taken by mouth
• d.Direct thrombin inhibitor, taken by mouth

Enoxaparin is a low molecular weight heparin injected subcutaneously, usually into the fat of the abdomen, and it is dosed by weight without routine aPTT monitoring. Unfractionated heparin is the tempting description since both are heparins, but unfractionated heparin is a different product that is titrated by aPTT and can also be given subcutaneously, so the word 'only' makes that description wrong twice over.

Which medication is a histamine-2 (H2) receptor antagonist used to reduce stomach acid?

• a.Calcium carbonate
• b.Famotidine✓
• c.Metoclopramide
• d.Pantoprazole

Famotidine blocks histamine-2 receptors on the gastric parietal cell and lowers acid output; it is sold both by prescription and over the counter as Pepcid. Pantoprazole is the tempting selection because it also lowers acid, but it is a proton pump inhibitor that blocks the H+/K+-ATPase itself. Calcium carbonate is an antacid that neutralizes acid already in the stomach, and metoclopramide is a prokinetic that speeds gastric emptying.

A patient is dispensed a dry powder inhaler (DPI). Which instruction fits this device?

• a.Press down on the canister while inhaling slowly
• b.Shake the inhaler well and attach a valved holding chamber before inhaling
• c.Rinse the mouthpiece under running water after each dose and air-dry it
• d.Exhale away from the device, then inhale quickly and deeply✓

A DPI has no propellant, so the patient's own fast, deep breath is what pulls the powder out of the device; the patient breathes out away from the mouthpiece first, because exhaling into it adds moisture that clumps the powder. Shaking, a spacer, and pressing a canister while inhaling slowly all describe a pressurized metered-dose inhaler, and washing a DPI with water is exactly what must not be done.

What does the enteric coating on a tablet such as enteric-coated aspirin accomplish?

• a.To protect the drug from stomach acid so it dissolves in the intestine✓
• b.To make the tablet easier to swallow by smoothing it
• c.To spread the drug's release evenly over a 12- to 24-hour dosing interval
• d.To mask a bitter taste for patients who chew their tablets

An enteric coating is acid-resistant: it holds the tablet together through the stomach, which protects an acid-labile drug and spares the gastric lining, and it dissolves at the higher pH of the small intestine. Extended release is the tempting description because both are special coatings that must never be crushed, but extended release controls the rate over time while an enteric coat controls the place of dissolution. A coating can also smooth a tablet or hide a bitter taste, but those are properties of ordinary film and sugar coatings, not the reason a tablet is made enteric-coated.

A patient is dispensed a transdermal patch that is changed every 72 hours. Which counseling point is correct?

• a.Apply the patch to the same spot each time so absorption stays consistent
• b.Remove the old patch before applying a new one✓
• c.Apply the new patch over the old one to keep the drug level steady
• d.Cut the patch in half when a lower dose is wanted

Only one patch should be on the skin at a time: the old patch is peeled off and folded onto itself for disposal, and the new one goes on a clean, dry, hairless site that is rotated each time. Leaving the old patch on stacks two doses on one patient, reusing the same site is what produces local irritation, and cutting a patch can destroy the rate-controlling membrane, so patches are not cut unless the manufacturer's labeling says they may be.

A tablet is labeled for buccal administration. Which is the correct way to take it?

• a.Beneath the tongue, held there until it fully dissolves
• b.Between the cheek and the upper gum✓
• c.Chewed and then swallowed
• d.Swallowed whole with a full glass of water

Buccal means the tablet is tucked between the cheek and the gum, where it dissolves and is absorbed through the mucosa straight into the bloodstream. Sublingual placement under the tongue is the tempting answer because both routes bypass first-pass liver metabolism, but they are separate directions that print differently on the label, and swallowing or chewing the tablet sends it through the stomach and defeats the mucosal route entirely.

A patient asks whether an ophthalmic (eye) product could be used in the ear, and whether an otic (ear) product could be used in the eye. Which statement is correct?

• a.An otic product may be placed in the eye, but an ophthalmic product may not be used in the ear
• b.An ophthalmic product must never be used in the ear, and an otic product must never be used in the eye
• c.The two are interchangeable, since both are supplied as sterile solutions buffered to the same pH
• d.An ophthalmic product may be used in the ear if the prescriber directs it, but an otic product is not acceptable for use in the eye✓

Ophthalmic products are manufactured sterile and adjusted to a pH and tonicity the eye tolerates, so they already meet everything the ear canal requires, and prescribers do order an ophthalmic solution for use in the ear. Otic products are not held to the sterility and tonicity standards of an eye product and can injure the cornea, which is why the substitution runs in one direction only. A ban in both directions is the tempting answer because refusing to substitute is the safer habit, but it is stricter than the actual rule; what does hold is that the substitution comes from the prescriber and not from the patient.

A bottle of amoxicillin oral suspension is reconstituted with water at the pharmacy. What storage and discard information belongs on the label?

• a.Keep it refrigerated and use it until the expiration date printed on the bottle
• b.Refrigerate it and discard any unused portion after 7 days
• c.Store at room temperature and discard after 30 days
• d.Refrigerate it and discard any unused portion after 14 days✓

Once water is added, amoxicillin suspension carries a 14-day in-use period stated in the manufacturer's labeling, and refrigeration is preferred because it improves palatability and stability. A 7-day discard date is the closest call, because reconstituted antibiotics do not all share one in-use period, so the number has to be read off the labeling of the product actually being dispensed rather than assumed from a general rule. The expiration date printed on the bottle is the other classic error: it applies to the dry powder, and reconstitution starts a new and much shorter clock.

Which practice belongs to correct cold-chain handling of vaccines stored in a refrigerator at 2-8 °C?

• a.Keep vaccines in the refrigerator door, the easiest place to reach in a busy clinic
• b.Record the temperature once a week and adjust the thermostat as needed
• c.Keep water bottles out of the unit so that air can circulate freely
• d.Keep vaccines in the center of the unit with a continuous temperature log✓

Refrigerated vaccines belong in the middle of the storage unit, away from walls, vents, floor and door, with a digital data logger recording continuously so any excursion is detected. The door is the tempting spot because it is convenient, but it is the warmest and least stable part of the unit; water bottles are actually encouraged in the door and empty bins, since they buffer the temperature when the door is opened.

A patient is dispensed NPH insulin, a cloudy suspension. How should the vial be prepared before each dose?

• a.Draw the dose without mixing, since the particles redissolve in the syringe
• b.Shake the vial hard for about ten seconds until the liquid looks uniform
• c.Gently roll the vial between the palms✓
• d.Warm the vial under hot running water before drawing the dose

NPH is a suspension whose particles settle, so it is resuspended by gently rolling or tipping the vial until the liquid is evenly cloudy. Vigorous shaking is the tempting choice because it clearly mixes the vial, but it froths the insulin and can clump the protein, which makes an accurate dose hard to draw, and hot water is never used to warm insulin.

A prescription is written for Lamictal. Which product is the classic look-alike/sound-alike that could be selected in error?

• a.Lantus (insulin glargine)
• b.Levaquin (levofloxacin)
• c.Lamisil (terbinafine)✓
• d.Lanoxin (digoxin)

Lamictal (lamotrigine, an anticonvulsant and mood stabilizer) and Lamisil (terbinafine, an oral antifungal) share their first four letters and appear together on published confused-drug-name lists, which is why many pharmacies separate them on the shelf and confirm the indication. Lanoxin is the tempting distractor because it also begins with 'La' and is a narrow-therapeutic-index drug, but it shares only the first two letters with Lamictal, while Lamisil shares four and is the name paired with Lamictal on those lists.

A patient taking simvastatin asks whether grapefruit juice is a problem. What is correct?

• a.Grapefruit juice speeds elimination of the drug, so the dose must be doubled
• b.Grapefruit juice raises simvastatin levels and should be avoided✓
• c.Grapefruit juice binds the tablet in the gut and blocks absorption
• d.Only the juice matters; eating the whole fruit is safe

Grapefruit juice inhibits intestinal CYP3A4, so more simvastatin survives into the bloodstream and the risk of muscle toxicity rises; the same warning applies to lovastatin and to several calcium channel blockers. The furanocoumarins responsible are in the fruit itself, so eating grapefruit segments counts the same as drinking the juice, which is why limiting the warning to the juice is wrong. The 'speeds elimination' claim reverses the mechanism, since inhibiting the enzyme raises drug levels rather than lowering them, and grapefruit does not bind the tablet in the gut the way an antacid or a binding resin does.

A patient is starting phenelzine, a monoamine oxidase inhibitor. Which dietary counseling is essential?

• a.Avoid tyramine-rich foods such as aged cheese, cured meats and tap beer✓
• b.Avoid bananas and citrus fruit, the main sources of tyramine
• c.Avoid grapefruit juice, which raises the drug level
• d.Avoid dark green leafy vegetables, which reverse the drug's effect

MAO inhibitors block the enzyme that normally breaks tyramine down, so a tyramine load can release a surge of norepinephrine and cause a hypertensive crisis with severe headache and dangerously high blood pressure. Tyramine forms as protein ages, so the foods that matter are the aged, cured, fermented, smoked or spoiled ones - aged cheese, dry sausage, sauerkraut, soy sauce, tap beer - while fresh fruit such as bananas and oranges is not a significant source, which makes that list tempting but wrong. The leafy-green warning is the vitamin K counseling that belongs to warfarin, and grapefruit juice is a CYP3A4 issue unrelated to monoamine oxidase.

How should a patient take levothyroxine so that absorption stays consistent?

• a.With breakfast and a calcium supplement, so the stomach is not empty
• b.With a full glass of milk each morning
• c.At bedtime together with the evening iron tablet
• d.On an empty stomach with water, 30 to 60 minutes before breakfast✓

Levothyroxine is absorbed best from an empty stomach, so it is taken with water 30 to 60 minutes before the first food of the day, and calcium, iron and antacids are separated by about four hours because they bind it. Taking it with breakfast is the tempting choice since it helps patients remember, but food, and calcium in particular, cuts the amount absorbed and destabilizes the TSH the dose was titrated to.

A patient stabilized on warfarin asks about eating salad and spinach. What is the correct advice?

• a.Keep vitamin K intake steady from week to week rather than eliminating it✓
• b.Stop eating all green vegetables while on warfarin, because vitamin K cancels the drug
• c.Eat as much leafy green as possible to balance the blood thinner
• d.Take an extra dose on any day with a large salad

The warfarin dose is titrated against the patient's usual vitamin K intake, so steadiness is what protects the INR; big swings in either direction destabilize it. Cutting out greens entirely is the tempting advice because vitamin K really does oppose warfarin, but a sudden drop pushes the INR up and raises bleeding risk just as a sudden increase pushes it down toward clotting. Loading up on greens and adding a dose because of one meal are dangerous for the same reason: the dose is changed by the prescriber on the basis of an INR, not by the patient on the basis of dinner.

Which product may a customer buy in a United States pharmacy without a prescription?

• a.Montelukast 10 mg tablets (Singulair)
• b.Albuterol HFA inhaler (Ventolin)
• c.Loratadine 10 mg tablets✓
• d.Promethazine 25 mg tablets

Loratadine 10 mg is a second-generation antihistamine sold over the counter as Claritin and store brands. Montelukast is the tempting choice because allergy products are often OTC, but it is an oral leukotriene modifier available only by prescription. Albuterol inhalers are prescription-only in the United States, and promethazine tablets are prescription-only as well.

A customer wants an oral antihistamine for seasonal allergies that is least likely to cause drowsiness. Which is the best choice?

• a.Chlorpheniramine maleate (Chlor-Trimeton)
• b.Fexofenadine (Allegra)✓
• c.Diphenhydramine (Benadryl)
• d.Cetirizine hydrochloride (Zyrtec)

Fexofenadine is a second-generation H1 antihistamine that crosses the blood-brain barrier poorly, so it is the one labeled non-drowsy. Cetirizine is the genuinely close call: it is also second-generation, but it is the second-generation agent most associated with sedation and its labeling carries a drowsiness warning, so it is not the best answer when the customer's stated priority is staying alert. Diphenhydramine and chlorpheniramine are first-generation antihistamines that cause sedation plus anticholinergic effects such as dry mouth and urinary retention.

Percocet tablets contain which two active ingredients?

• a.Tramadol with acetaminophen
• b.Oxycodone with aspirin
• c.Oxycodone with acetaminophen✓
• d.Hydrocodone with acetaminophen

Percocet is oxycodone with acetaminophen, and its strength is written as the two ingredients together, for example 5/325 mg. Oxycodone with aspirin is the closest trap: it is the same opioid combined with aspirin instead, it is sold as Percodan, and that brand name differs from Percocet by two letters. Hydrocodone with acetaminophen is sold as Norco or Lortab, and tramadol with acetaminophen is Ultracet.

A prescription calls for a 0.125 mg dose. The tablets on hand are labeled 250 mcg. How much is one dose?

• a.One-half tablet✓
• b.Two tablets
• c.One-quarter tablet
• d.One tablet

Convert the units first: 0.125 mg x 1,000 mcg/mg = 125 mcg. Then 125 mcg divided by 250 mcg per tablet = 0.5 tablet. Checking it the other way round, 250 mcg = 0.25 mg and 0.125 mg divided by 0.25 mg = 0.5, the same answer. Two tablets comes from dividing in the wrong direction, 250 divided by 125; a whole tablet comes from assuming 0.125 mg and 250 mcg are the same amount; a quarter tablet comes from moving the decimal one place too far and treating the order as 62.5 mcg. Because the tablet on hand is larger than the dose ordered, the answer has to be less than one whole tablet.

A prescription is transmitted to the pharmacy carrying the code DAW 1. What does that code communicate?

• a.The patient asked for the brand-name product even though substitution was allowed.
• b.State law requires the brand-name product for this drug.
• c.The prescriber has required that the brand-name product be dispensed.✓
• d.The pharmacist selected the product that was dispensed.

DAW 1 records the prescriber's own instruction that no substitution be made, so the brand must be dispensed. The state-law wording describes DAW 7, which is used when a brand product is mandated by law rather than chosen by the prescriber; a patient's request for the brand is DAW 2; and pharmacist product selection is DAW 3.

What is an authorized generic?

• a.A generic approved under an abbreviated application after the brand's patent expired.
• b.An imported version of the brand product sold at a lower price.
• c.The first generic to reach the market after a successful patent challenge, during its exclusivity period.
• d.The brand-name product itself, marketed without the brand name on the label under the innovator's own FDA approval.✓

An authorized generic is the brand-name product itself, sold without the brand name under the innovator's own application, so no abbreviated application and no separate bioequivalence study are involved. The ordinary generic is the tempting choice, but that is a different manufacturer's product approved through an abbreviated application. The first generic to win exclusivity after a patent challenge is also an abbreviated-application product, and the brand company often launches an authorized generic precisely to compete with it during that exclusivity.

A biologic has been designated by the FDA as an interchangeable biosimilar. What does that designation permit?

• a.It has been shown to be chemically identical to the reference biologic, not merely highly similar.
• b.It may be substituted at the pharmacy without prescriber intervention, where state law allows.✓
• c.It may be dispensed only after the prescriber authorizes the change.
• d.It carries an AB therapeutic-equivalence rating in the FDA's Orange Book.

Interchangeability is the additional standard that permits substitution at the pharmacy without contacting the prescriber, subject to state pharmacy law; a biosimilar without that designation does not carry the same permission, which is why requiring prescriber authorization is the tempting answer. Biosimilars are highly similar rather than chemically identical, and licensed biologics are listed in the Purple Book, not the Orange Book.

Two products are pharmaceutical equivalents, but the FDA has not rated them therapeutically equivalent. What does that tell the technician?

• a.They have the same active ingredient, strength and dosage form, but bioequivalence has not been established.✓
• b.The FDA has compared the two products in a study and concluded that they are not bioequivalent to each other.
• c.They contain different active ingredients that are used for the same indication.
• d.They are made by the same company at two different plants.

Pharmaceutical equivalence covers the same active ingredient, strength, dosage form and route; therapeutic equivalence adds proof of bioequivalence, so a pharmaceutically equivalent product without that proof is not automatically substitutable. The tempting answer is that the FDA studied the pair and found them not bioequivalent — that does happen, but an unrated product may equally be one for which the data are simply insufficient, so all the technician may conclude is that equivalence has not been established.

A vial is labeled epinephrine 1:1000. Expressed as a metric concentration, what does that ratio strength mean?

• a.1 mg/mL✓
• b.10 mg/mL
• c.0.1 mg/mL
• d.1 mcg/mL

For a solution, a ratio strength means grams of drug in that number of milliliters: 1:1000 is 1 g in 1,000 mL = 1,000 mg in 1,000 mL = 1 mg/mL. The other three values are the concentrations of other ratios. 0.1 mg/mL is 1:10,000, that is 1 g in 10,000 mL — a different epinephrine presentation, which is why the two labels must never be read interchangeably. 10 mg/mL would be 1:100, and 1 mcg/mL would be 1:1,000,000. All four options are bare values of similar length, so nothing about their wording favors one over another.

A technician dissolves 25 g of a drug in enough water to make 500 mL of finished solution. What is the percentage strength (w/v)?

• a.0.05% w/v
• b.25% w/v
• c.5% w/v✓
• d.2.5% w/v

Percentage strength w/v is grams of solute per 100 mL: 25 g ÷ 500 mL = 0.05 g/mL, and 0.05 g/mL × 100 mL = 5 g per 100 mL, so the solution is 5% w/v. Checked the other way, 5% w/v means 5 g per 100 mL, which in 500 mL is 5 × 5 = 25 g. The wrong values each come from a specific slip: 0.05% is the grams per 500 mL read as a percentage, which is 100 times too dilute; 25% is simply the number of grams in the container; and 2.5% comes from dividing the 25 g by 1,000 mL, as though a full liter had been prepared.

Approximately how much sodium does one liter of 0.9% sodium chloride injection contain?

• a.77 mEq
• b.130 mEq
• c.154 mEq✓
• d.513 mEq

0.9% w/v means 0.9 g per 100 mL, or 9 g of sodium chloride per liter; 9 g ÷ 58.5 g per mole ≈ 0.154 mole, which gives roughly 154 mEq of sodium and 154 mEq of chloride per liter. Every other value is a real figure for a different fluid, which is what makes them tempting: 77 mEq is the sodium in a liter of 0.45% (half-normal) saline and is the hardest to resist because it is exactly half; 130 mEq is the sodium in lactated Ringer's; and 513 mEq is the sodium in a liter of 3% sodium chloride.

An order calls for 0.4 mg of a drug. The vial on the shelf is labeled 400 mcg/mL. What volume contains the ordered dose?

• a.0.4 mL
• b.0.1 mL
• c.10 mL
• d.1 mL✓

0.4 mg × 1,000 mcg/mg = 400 mcg, and 400 mcg ÷ 400 mcg/mL = 1 mL. Checked the other way, 1 mL of a 400 mcg/mL vial delivers 400 mcg = 0.4 mg. The 0.4 mL value is the trap: it comes from using the milligram number as the volume, as though the vial were labeled 1 mg/mL. Drawing 0.1 mL would deliver only 40 mcg, and the 10 mL value comes from mistakenly converting 0.4 mg to 4,000 mcg.

A potassium chloride oral solution is labeled 20 mEq per 15 mL. A dose of 40 mEq is ordered. What volume should be measured?

• a.60 mL
• b.30 mL✓
• c.15 mL
• d.7.5 mL

The solution supplies 20 mEq in each 15 mL, so 40 mEq is two of those volumes: 40 ÷ 20 = 2, and 2 × 15 mL = 30 mL. Checked by concentration, 20 mEq ÷ 15 mL = 1.33 mEq/mL, and 40 mEq ÷ 1.33 mEq/mL = 30 mL. The 60 mL value doubles the volume a second time by pairing 15 mL with 10 mEq instead of 20 mEq; 15 mL is one labeled dose volume and would give only 20 mEq; and 7.5 mL is half the labeled volume, which would give 10 mEq.

A vial of powdered antibiotic directs the technician to add 4.5 mL of diluent, and states that the resulting solution measures 5 mL. Why is the final volume larger than the volume of diluent added?

• a.The label rounds the 4.5 mL of diluent up to 5 mL for convenience.
• b.Air injected into the vial adds to the volume.
• c.The diluent expands as the vial warms to room temperature during mixing.
• d.The dry powder itself occupies volume once it dissolves.✓

Final volume equals diluent volume plus the space the powder occupies once dissolved — its powder volume, or displacement — which is why the label gives both numbers and why the concentration must be calculated from the 5 mL final volume, not the 4.5 mL of diluent. Two competing explanations are worth weighing: thermal expansion is real but warming a few milliliters of water changes its volume by a negligible amount, far too little to account for 0.5 mL, and the label is not rounding, since it deliberately states the two volumes separately because the difference matters to the concentration. Air injected to equalize pressure does not add to the liquid volume.

A vial containing 1 g of powdered antibiotic is reconstituted to a final volume of 4 mL. What volume delivers a 250 mg dose?

• a.0.25 mL
• b.4 mL
• c.1 mL✓
• d.0.4 mL

1 g = 1,000 mg in 4 mL, so the reconstituted concentration is 1,000 ÷ 4 = 250 mg/mL, and 250 mg ÷ 250 mg/mL = 1 mL. Checked the other way, 1 mL of a 250 mg/mL solution contains 250 mg. Drawing the whole 4 mL is the dangerous error — it would deliver the full 1,000 mg, four times the ordered dose. The 0.25 mL value comes from reading 250 mg as a quarter of a milliliter, and 0.4 mL from dividing the 4 mL by 10.

A technician must blend 50 mg of a potent powdered drug uniformly into 100 g of ointment base. Which description matches geometric dilution?

• a.Add the whole 100 g of base to the drug at once and mix vigorously until the color of the mixture looks uniform.
• b.Mix the drug with an approximately equal amount of base, then keep doubling the quantity of base added and mixing until all of it is incorporated.✓
• c.Divide the base into ten equal portions and add one portion at a time, mixing thoroughly after each addition.
• d.Wet the drug with a small amount of mineral oil to form a smooth paste, then stir that paste into the base.

Geometric dilution keeps the two quantities being combined roughly equal at every step, which is what makes a very small amount of potent drug distribute evenly through a much larger mass. Wetting the drug with mineral oil is levigation, a genuine technique but one that reduces particle size rather than guaranteeing uniform distribution; adding equal tenths of the base is the closest imitation but the first addition already overwhelms the 50 mg of drug with 10 g of base; and adding all the base at once leaves pockets of concentrated drug.

Before incorporating a gritty powdered drug into an ointment base, a technician grinds it in a mortar with a few drops of mineral oil. What is this step called?

• a.Levigation✓
• b.Geometric dilution
• c.Trituration
• d.Fusion

Levigation is the reduction of particle size by grinding a powder together with a small amount of a liquid in which the drug is not soluble — here, mineral oil as the levigating agent. Trituration is the closest competitor because it also reduces particle size by grinding, but it is done on the dry powder; the added liquid is exactly what makes this levigation. Geometric dilution is a mixing sequence rather than a grinding step, and fusion melts the components together.

Why is a compounded nonsterile preparation given a beyond-use date rather than the expiration date printed on the manufacturer's stock bottle?

• a.It is the last day the pharmacy may dispense the preparation, though the patient may keep using it afterward.
• b.The beyond-use date is simply the earliest expiration date printed on any of the ingredients used in the preparation.
• c.The manufacturer's expiration date applies only to the unopened original container, and the stability of the newly compounded preparation has not been tested.✓
• d.A beyond-use date is always shorter than an expiration date because compounded preparations are less pure than manufactured ones.

An expiration date is supported by the manufacturer's stability testing of that exact product in that exact container; once the drug is combined into a new preparation that testing no longer applies, so a beyond-use date is assigned instead. The earliest expiration among the ingredients is the tempting answer because it genuinely caps the dating, but it is a ceiling on the beyond-use date rather than the reason one exists. A beyond-use date usually is shorter than a manufacturer's expiration date, but that reflects untested stability of the new preparation, not any assumption that compounded products are impure; and it is the date beyond which the preparation should not be used, not merely a last day to dispense it.USP <795>

An intravenous order specifies D5NS. Which solution does that abbreviation name?

• a.5% dextrose in 0.45% sodium chloride
• b.5% dextrose in sterile water with no added sodium
• c.5% dextrose in 0.9% sodium chloride✓
• d.5% dextrose in lactated Ringer's solution

NS stands for normal saline, which is 0.9% sodium chloride, so D5NS is 5% dextrose in 0.9% sodium chloride. The 0.45% version is the tempting near-miss: that is half-normal saline, written D5 1/2NS, so reading NS loosely as any saline concentration would halve the sodium the patient receives. Dextrose in sterile water alone is D5W, and dextrose in lactated Ringer's is written D5LR.

Which statement correctly describes lactated Ringer's solution?

• a.A hypertonic electrolyte solution given to raise serum sodium quickly in symptomatic hyponatremia.
• b.An isotonic crystalloid containing sodium, potassium, calcium, chloride and lactate.✓
• c.A protein-containing colloid used to expand plasma volume.
• d.Sodium chloride 0.9% to which the manufacturer has added 5% dextrose.

Lactated Ringer's is an isotonic electrolyte (crystalloid) solution, and its calcium content is the reason it is incompatible with some drugs that plain saline tolerates. Hypertonic sodium chloride, not lactated Ringer's, is the fluid used to raise serum sodium quickly; 0.9% sodium chloride with 5% dextrose added is D5NS; and a protein-containing volume expander such as albumin is a colloid, a different category of fluid altogether.

Why are strongly hypertonic intravenous solutions usually infused through a central venous catheter rather than a small arm vein?

• a.They irritate the lining of small peripheral veins and can cause phlebitis.✓
• b.The high osmolarity would pull water out of red blood cells and make them shrink.
• c.A peripheral vein cannot deliver the flow rate that a hypertonic solution requires.
• d.A hypertonic solution must be given by pump, which peripheral lines lack.

A solution far more concentrated than blood inflames the wall of a small vein and can cause phlebitis and thrombosis, whereas the rapid blood flow through a large central vein dilutes it almost immediately. Two distractors deserve weighing: red cells do shrink transiently in a hypertonic solution, but that happens wherever the solution is infused and is not what limits peripheral use — damage to the vein wall is. Flow rate is the other tempting alternative, but peripheral lines can run quickly and can be run on the same infusion pumps, so neither achievable rate nor pump availability drives the choice of access.

A technician repackages tablets from a bulk bottle into unit-dose blisters for a hospital's automated cabinets. What must the repackaged label carry at a minimum?

• a.The drug name and strength, a lot or control number, and a beyond-use date.✓
• b.The drug name and strength only; the lot number stays in the log.
• c.The patient's name, prescription number and directions for use, as on a dispensed label.
• d.Only the manufacturer's original expiration date, copied unchanged.

A repackaged unit-dose label has to identify the product and let it be traced and dated: drug name and strength, a lot or control number tying it back to the source container, and a beyond-use date for the new package. Keeping the lot number only in the repackaging log is the tempting answer, but a single blister found in a cabinet has to be traceable on its own when a recall lands. The original expiration date does not carry over to a new container, and a patient name and directions belong on a dispensed prescription label, not on floor stock repackaged in advance for whichever patient later needs it.

A pharmacy sets a par level for each fast-moving product. What does the par level represent?

• a.The number of times the pharmacy's whole inventory is sold and replaced in a year.
• b.The largest quantity of a product the pharmacy is permitted to keep on hand.
• c.The stock quantity at which the product is reordered.✓
• d.The quantity ordered on each purchase order.

A par level is the on-hand quantity that triggers an order, so routine purchasing keeps the shelf between the par level and the intended maximum. Counting how often the whole inventory is sold and replaced in a year is the turnover rate — a related and tempting choice, but it measures how hard the money in inventory is working rather than when to reorder a single item. How much to buy each time is the order quantity, a separate decision from the level that triggers the order, and nothing caps how much of an ordinary product a pharmacy may keep on hand.

A pharmacy rotates stock using first-expired-first-out. How does that differ from shelving by the date each package was received?

• a.The package with the earliest expiration date is placed in front, even if it arrived later.✓
• b.Short-dated stock is moved to the back so it is not dispensed by mistake.
• c.Packages are arranged by lot number so recalls can be pulled quickly.
• d.The package that arrived first is always placed in front, regardless of its expiration date.

First-expired-first-out shelves stock by expiration date, so a box received today that expires in three months goes in front of one received last month that expires in a year. Ordering by arrival date is first-in-first-out, the closest competitor: it usually gives the same result, but it fails exactly when a newer shipment carries the shorter dating. Moving short-dated stock to the back guarantees it will expire unused, and arranging by lot number helps with recalls but does nothing about dating.

A pharmacy's vaccine refrigerator is found in the morning reading outside its required temperature range. What should be done with the vaccine inside?

• a.Discard every dose at once, because any temperature excursion makes vaccine unusable.
• b.Mark it 'do not use', keep it stored properly, and seek viability guidance.✓
• c.Put it back into routine use as soon as the refrigerator holds the correct temperature.
• d.Move it to the freezer until the refrigerator has been repaired.

Vaccine exposed to an out-of-range temperature is separated and labeled so nobody administers it, but it is not automatically thrown away — the manufacturer or the immunization program decides whether the exposure has affected it. Simply resuming use once the temperature recovers is the tempting shortcut, but it ignores the exposure that has already happened; discarding everything immediately wastes doses that may still be viable; and a freezer is not an approved storage condition for a refrigerated vaccine.

The pharmacy receives a Class I recall notice naming specific lot numbers of an injectable product. What is the pharmacy's immediate responsibility?

• a.Wait for the wholesaler to collect the recalled product on its next scheduled delivery run.
• b.Notify the FDA in writing that the recalled lot was received.
• c.Identify and immediately quarantine every unit of the affected lots still in the pharmacy.✓
• d.Remove every strength and lot of that drug from the shelves, whatever the lot number.

A Class I recall means use of the product could cause serious harm or death, and the pharmacy's first job is to find the named lots and take them out of dispensable stock before another dose reaches a patient. Pulling every lot of the drug is the tempting over-correction: it is not what the notice requires and it creates a shortage of product that is still safe to dispense. Waiting for the wholesaler leaves the recalled units in reach of a dispensing error, and the recalling firm, not each pharmacy, reports back to the FDA.

Which FDA resource lists licensed biological products, including biosimilar and interchangeable products?

• a.The Orange Book, the therapeutic-equivalence list
• b.The Green Book, the animal-drug approval list
• c.The Purple Book✓
• d.The Red Book

Licensed biologics, including biosimilars and interchangeable biosimilars, are listed in the Purple Book. The Orange Book is the closest competitor because it is also an FDA listing used for substitution decisions, but it covers drugs approved under new and abbreviated drug applications and carries the therapeutic-equivalence codes; the Green Book is the FDA's animal-drug listing; and the Red Book is a commercial drug-pricing reference rather than an approval list.

A technician needs to know whether two injectable drugs may be combined in the same intravenous solution. Which reference is built to answer that question?

• a.The FDA Orange Book, which rates therapeutic equivalence
• b.The Red Book
• c.The USP-NF, which sets identity and purity standards
• d.Trissel's Handbook on Injectable Drugs✓

Trissel's Handbook on Injectable Drugs is the standard compatibility and stability reference for parenteral products, tabulating which injectables can share a syringe or a bag and for how long. The USP-NF is the tempting alternative because it is also an official standard, but it defines identity, strength, quality and purity — it does not tabulate drug-to-drug admixture compatibility. The Orange Book rates therapeutic equivalence for substitution, and the Red Book is a pricing reference.

A drug is described as having a half-life of about six hours. What does half-life measure?

• a.The time from administration until the drug first begins to produce an effect.
• b.The time for the plasma concentration to fall by half.✓
• c.The fraction of an oral dose that reaches the systemic circulation.
• d.The length of time the drug's effect lasts after a single dose.

Half-life is the time required for the amount of drug in the plasma to drop to 50% of its previous value, which is what shapes the dosing interval and how long a drug takes to clear. The time until an effect first appears is onset and how long the effect lasts is duration — both describe the patient's response rather than the fall in drug concentration, and the fraction of an oral dose reaching the circulation is bioavailability.

A patient has taken metoprolol for high blood pressure for two years and asks whether she can simply stop it now that her home readings are normal. Which counselling point applies to beta blockers?

• a.It may be stopped whenever the readings return to normal for a full week
• b.It is only needed on days when blood pressure feels high
• c.It can be switched to every other day once home readings are normal
• d.It should not be stopped suddenly; the prescriber tapers the dose✓

Long-term beta blockade up-regulates beta receptors, so stopping the drug abruptly can produce rebound tachycardia and hypertension and, in a patient with coronary disease, angina or infarction; prescribers step the dose down instead. Normal readings mean the drug is working, not that it is no longer needed. Moving to alternate days is self-tapering by another name and leaves the pressure uncovered on the off days, and beta blockers are never taken as needed for how blood pressure 'feels' — hypertension has no reliable symptoms.

Swelling of the ankles and feet that is not caused by fluid overload is a recognized, dose-related effect of which cardiovascular drug class?

• a.Calcium channel blockers such as amlodipine✓
• b.ACE inhibitors such as enalapril
• c.Loop diuretics such as furosemide
• d.Thiazide diuretics such as hydrochlorothiazide

Amlodipine, nifedipine and the other dihydropyridine calcium channel blockers dilate arterioles far more than veins, which raises pressure in the capillary bed and pushes fluid into the tissue, producing dose-related ankle edema that is not heart failure and responds poorly to a diuretic. ACE inhibitors are the tempting answer because bradykinin build-up is a well-known class effect, but bradykinin produces a dry cough and angioedema of the face and airway rather than gradual ankle swelling. Loop and thiazide diuretics remove fluid rather than causing swelling; thiazides do lower potassium, but potassium loss does not cause edema.

A woman of childbearing age was switched from lisinopril to losartan because of a persistent dry cough. Which precaution still applies after the switch?

• a.Potassium levels no longer need monitoring on losartan
• b.Losartan may be used safely during pregnancy, unlike lisinopril
• c.Both classes carry a boxed warning against use in pregnancy✓
• d.The cough should resolve within a few days

ACE inhibitors and ARBs both carry a boxed warning for fetal toxicity and are stopped as soon as pregnancy is detected, so moving from lisinopril to losartan removes the cough but not that risk. Assuming an ARB is safe in pregnancy because it is a different class is the misconception this question targets. Both classes also raise serum potassium, so monitoring continues, and ACE-inhibitor cough typically fades over one to several weeks after stopping, not within days.

A patient starting spironolactone should be cautioned about routinely using which everyday grocery product?

• a.Bananas and other high-potassium fruit
• b.Aged cheese and cured meats
• c.Salt substitutes✓
• d.Cranberry juice cocktail

Spironolactone is a potassium-sparing diuretic: it holds potassium back rather than wasting it, so an extra potassium load can push the serum level high enough to cause dangerous arrhythmias. Most supermarket salt substitutes replace sodium chloride with potassium chloride and are then shaken freely over food at every meal, so the amount taken in is unmeasured and repeated — which is why salt substitutes, along with potassium supplements, are the products named in the counselling. High-potassium foods such as bananas are the defensible second answer and are worth raising, but a portion of fruit is a fixed, self-limiting amount that most patients with normal kidney function tolerate. Aged cheese and cured meats carry the tyramine caution taught for MAO inhibitors, and cranberry juice is the product patients associate with warfarin; neither affects spironolactone.

Digoxin is a narrow-therapeutic-index drug. Which set of complaints is classically associated with digoxin toxicity?

• a.Dry cough, hoarseness, and a metallic taste in the mouth
• b.Ringing in the ears and hearing loss developing over several days
• c.Nausea, loss of appetite, and visual disturbances such as yellow-green halos✓
• d.Swollen gums and unusual hair growth on the arms

Because the toxic and therapeutic concentrations of digoxin sit so close together, technicians are taught the early picture: gastrointestinal upset with nausea and anorexia, confusion or fatigue, and the characteristic visual changes of blurred or yellow-green tinted vision with haloes around lights. Tinnitus with hearing loss points instead to salicylate or aminoglycoside toxicity, while gum overgrowth with increased body hair is the classic phenytoin picture.

A patient's profile shows both insulin lispro and insulin glargine. How do the two products differ in category?

• a.Lispro is intermediate-acting and glargine is short-acting mealtime insulin
• b.Both are basal insulins, so the pair duplicates therapy
• c.Lispro is basal; glargine is given with meals
• d.Lispro is rapid-acting; glargine is long-acting basal✓

Insulin lispro is a rapid-acting analogue given around meals to cover the carbohydrate in that meal, while insulin glargine is a long-acting analogue that supplies steady background coverage; a basal-plus-mealtime pair on one profile is a normal regimen, not a duplication, which is why the duplicate-therapy answer is tempting but wrong. Reversing the two roles is the dangerous error, because glargine is not sized to a meal and lispro cannot hold glucose steady overnight.

Which class of oral antidiabetic drugs most often requires the patient to be counselled on recognizing and treating low blood sugar?

• a.Sulfonylureas such as glipizide and glyburide✓
• b.Biguanides such as metformin
• c.Alpha-glucosidase inhibitors such as acarbose and miglitol
• d.SGLT2 inhibitors such as empagliflozin

Sulfonylureas stimulate the pancreas to release insulin whether or not blood glucose is high, so a missed meal, extra exercise or a dose taken twice can drop blood sugar too far — the patient needs to recognize the shakiness-and-sweating picture and keep glucose tablets to hand. Metformin is the tempting choice because it is the most-dispensed oral diabetes drug, but it works by lowering hepatic glucose output and does not force insulin release, so on its own it rarely causes hypoglycemia. Acarbose and miglitol slow the digestion of carbohydrate and empagliflozin sends glucose out in the urine; neither pushes insulin out of the pancreas, so hypoglycemia with them is uncommon unless they are combined with insulin or a sulfonylurea.

Which administration instruction belongs on a levothyroxine prescription label?

• a.Take together with the morning calcium and iron supplements
• b.Take in the morning on an empty stomach✓
• c.Take at bedtime with a snack to prevent insomnia
• d.Take with the largest meal of the day to reduce nausea

Levothyroxine absorption is reduced by food and cut sharply by calcium salts, iron salts and some antacids, so the standard direction is to take it in the morning on an empty stomach with water and to separate those products by several hours. Taking the tablet alongside the morning calcium and iron is the specific habit that produces unexplained treatment failure and repeated dose increases. Levothyroxine is not a sedating drug and is not given with a snack.

A patient who has taken prednisone daily for several weeks is given a new prescription written as a stepwise decreasing dose. Why is the dose stepped down instead of simply stopped?

• a.The taper prevents the allergic reactions that follow sudden steroid withdrawal
• b.The falling dose is needed to stop the drug from accumulating in fat tissue
• c.The taper prevents opioid-style withdrawal and craving
• d.Abrupt withdrawal can leave adrenal hormone output suppressed✓

Weeks of an oral corticosteroid suppress the hypothalamic-pituitary-adrenal axis, so the adrenal glands need time to resume making cortisol; stepping the dose down lets that recovery happen. Stopping abruptly risks adrenal insufficiency — fatigue, weakness, nausea and low blood pressure — which candidates often mislabel as an allergic reaction, but this withdrawal is a hormone problem, not an immune one, and it is not opioid-type dependence with craving either. Prednisone is not stored in fat tissue in a way that would dictate the schedule.

A patient is dispensed doxycycline capsules. Which counselling point matters most?

• a.Store the capsules in the refrigerator
• b.Take each dose with a glass of milk to prevent stomach upset from the drug
• c.Take it with an antacid to protect the stomach
• d.Separate it from dairy, antacids and iron, and avoid strong sun✓

Tetracyclines bind calcium, magnesium, aluminium and iron, so milk, antacids and iron salts sharply reduce how much doxycycline is absorbed and must be separated from the dose; the class also causes photosensitivity, so sun protection is advised. Taking it with milk is the intuitive answer for a drug that upsets the stomach, and it is exactly what defeats the antibiotic. Doxycycline is stored at controlled room temperature, not refrigerated.

Which adverse effect is the subject of a boxed warning shared by fluoroquinolones such as levofloxacin and ciprofloxacin?

• a.Permanent blue-grey discoloration of the skin and nails
• b.Tendinitis and tendon rupture✓
• c.Aortic aneurysm and aortic dissection
• d.Irreversible hearing loss with prolonged treatment

The fluoroquinolone boxed warning covers tendinitis and tendon rupture — most often the Achilles tendon — with the risk highest in older patients, in those also taking a corticosteroid and in transplant recipients, so patients are told to report new tendon pain or swelling and to rest the limb. The same boxed warning also names peripheral neuropathy, central-nervous-system effects and worsening of myasthenia gravis. Aortic aneurysm and dissection is the defensible second answer, because the FDA did add that risk to fluoroquinolone labelling, but it sits in Warnings and Precautions rather than in the boxed warning. Blue-grey skin and nail discoloration belongs to minocycline, and hearing loss to the aminoglycosides.

Why is amoxicillin/clavulanate prescribed instead of plain amoxicillin for some infections?

• a.Clavulanate is a second antibiotic that kills organisms amoxicillin cannot reach
• b.Clavulanate inactivates bacterial beta-lactamase enzymes✓
• c.Clavulanate slows kidney clearance so amoxicillin levels stay higher
• d.Clavulanate reduces the diarrhea amoxicillin can cause

Clavulanate has almost no useful antibacterial activity of its own; it binds and inactivates the beta-lactamase enzymes that resistant organisms use to destroy amoxicillin, which restores the amoxicillin's effect. Calling it a second antibiotic is the tempting answer because the product name lists two ingredients, but the roles are drug and protector, not two drugs. Blocking renal clearance to raise penicillin levels describes probenecid, and clavulanate does not settle the gut — it is the component most associated with the extra diarrhea the combination causes.

Nystatin oral suspension is dispensed to an adult for oral thrush. Which patient direction is correct?

• a.Dilute the dose in a full glass of water and drink it quickly
• b.Apply the dose to the gums with a cotton swab only
• c.Take the dose with a meal to improve absorption
• d.Swish in the mouth, then swallow✓

Nystatin is essentially not absorbed from the gastrointestinal tract; it works by direct contact with the yeast, so the dose is held and swished around the mouth as long as possible to coat the lesions before it is swallowed. Diluting it and drinking it straight down destroys that contact time, which is the whole mechanism. Painting the dose onto the mucosa with a swab is a technique used for an infant who cannot swish, not the direction for an adult, and taking it with food cannot improve absorption because systemic absorption is not how the drug works.

A patient starting sertraline for depression asks when she should expect to feel better. What is the accurate counselling point?

• a.No change in the first week means the drug has failed
• b.Mood should lift within two or three doses; if not, the dose is too low
• c.Full antidepressant benefit usually takes several weeks✓
• d.The drug works best taken only on bad days

SSRIs are taken every day, and while sleep, appetite and anxiety often improve first, the full effect on mood builds over several weeks — which is why patients are urged to keep taking the drug through an unchanged first week instead of concluding that it has failed. Expecting relief within two or three doses is the misconception that drives early discontinuation, and it also pushes patients to demand dose increases the prescriber has not judged necessary. An SSRI taken only on bad days will not work at all.

A patient stabilized on lithium asks whether she can buy ibuprofen for her sore back. Why does this combination matter?

• a.Ibuprofen inactivates lithium in the stomach, so the mood benefit is lost
• b.NSAIDs can reduce lithium clearance and push lithium levels into the toxic range✓
• c.Lithium blocks the pain relief that ibuprofen would give
• d.NSAIDs speed lithium removal, so the level falls below the effective range

Lithium is cleared almost entirely by the kidney and has a narrow therapeutic range, so anything that cuts renal excretion can raise the level into toxicity; NSAIDs reduce the prostaglandin-mediated renal blood flow that lithium clearance depends on. Dehydration, a low-salt diet and thiazide diuretics act the same way, which is why lithium patients are told to keep fluid and salt intake steady. The direction of the interaction is what has to be right: NSAIDs push the lithium level up, not down. Ibuprofen does not chemically destroy lithium, and lithium does not block analgesia.

Patients taking atypical (second-generation) antipsychotics such as olanzapine or quetiapine are routinely monitored for which class effect?

• a.Loss of kidney and thyroid function needing periodic labs
• b.Weight gain with rises in blood glucose and lipids✓
• c.A drop in white cells needing weekly counts
• d.Falling potassium levels that require ongoing supplementation

Second-generation antipsychotics are associated with metabolic effects, so weight, waist measurement, fasting glucose or A1c and a lipid panel are followed on a schedule; olanzapine and clozapine carry the greatest metabolic burden and aripiprazole and ziprasidone the least. Regular white-cell counts are the defensible second answer, but mandatory absolute-neutrophil-count monitoring belongs to clozapine under its REMS program, not to the class as a whole. Periodic kidney and thyroid testing is the monitoring pattern taught for lithium, and these drugs do not waste potassium.

A patient picking up hydrocodone/acetaminophen tablets also brings a multi-symptom OTC cold product to the register. Which risk should be raised?

• a.Duplicate hydrocodone, because most cold products contain an opioid
• b.Duplicate acetaminophen from two products, risking liver injury✓
• c.The cold product will block the opioid from being absorbed
• d.The two products cancel each other's pain relief

Acetaminophen is hidden inside many combination prescription analgesics and inside most multi-symptom cold and flu products, so taking both can add up to an unintended overdose and liver injury; patients are taught to read the active-ingredient panel before combining anything with a prescription analgesic. Worrying about duplicate opioid is the tempting parallel, but hydrocodone is never sold over the counter in a shelf cold remedy. Neither product blocks the absorption or the analgesic effect of the other.

A patient taking naproxen twice daily for arthritis asks about adding ibuprofen for a headache. What is the correct counselling point?

• a.Adding ibuprofen is safe when both are taken with food
• b.Ibuprofen may be added because it works by a different mechanism
• c.Combining them is fine if the doses are taken 6 hours apart
• d.Two NSAIDs should not be combined✓

Naproxen and ibuprofen are both non-selective NSAIDs working through the same cyclo-oxygenase pathway, so stacking them multiplies the gastrointestinal bleeding, kidney and cardiovascular risks without adding useful pain relief; acetaminophen is the usual add-on instead. Spacing the doses by a few hours or taking them with food eases stomach upset but does nothing about the additive risk, which is why those answers are tempting and still wrong.

How is sumatriptan used in the management of migraine?

• a.It is taken on a fixed daily schedule regardless of symptoms
• b.It is saved until the headache becomes severe
• c.It is taken every night to prevent attacks from developing
• d.It is taken to treat a migraine attack once it starts✓

Triptans are abortive, or acute, migraine treatments: the dose is taken when an attack begins and works best when taken early, and the patient is given a limit on how many doses to use in a period. Migraine prevention uses a different group of drugs taken daily whether or not a headache is present — propranolol, topiramate and amitriptyline are typical examples — which is what makes the daily-dosing answers tempting. Waiting until the pain is severe is the common patient habit that makes a triptan work less well, which is why the counselling is to treat as soon as the attack is recognized.

A patient with asthma is dispensed both an albuterol inhaler and a fluticasone inhaler. Which statement describes their roles correctly?

• a.Albuterol relieves attacks; fluticasone prevents them✓
• b.Albuterol is the daily controller and fluticasone is the rescue drug
• c.Both are rescue inhalers, so either may be used during an attack
• d.Fluticasone is used first at the onset of wheezing to open the airways

Albuterol is a short-acting beta-2 agonist that relaxes bronchial smooth muscle within minutes, so it is the rescue inhaler, while inhaled fluticasone is a corticosteroid that reduces airway inflammation over days to weeks and is used every day whether or not the patient has symptoms. Reaching for the steroid inhaler during an attack is the dangerous reversal, because it does nothing quickly. Needing the rescue inhaler often is a signal that the controller regimen should be reviewed.

Why is a patient using an inhaled corticosteroid told to rinse the mouth and spit after each dose?

• a.Rinsing washes the propellant away before it stains the teeth
• b.Rinsing prevents the bitter taste from lingering
• c.Rinsing stops the inhaler from clogging
• d.Residual steroid in the mouth can cause oral thrush✓

Much of an inhaled corticosteroid dose lands on the mouth and throat rather than the lung, where it locally suppresses defences and lets Candida overgrow, producing oral thrush and hoarseness; rinsing and spitting after each dose removes that residue and also lowers the amount swallowed. Clearing the taste is a genuine side benefit of rinsing but not the reason the direction is given, and the propellant does not stain teeth or block the actuator in a way that rinsing the mouth would fix.

A patient who drives a delivery van asks which antihistamine on the shelf is least likely to make him drowsy. Which product fits?

• a.Chlorpheniramine (Chlor-Trimeton)
• b.Diphenhydramine (Benadryl)
• c.Loratadine (Claritin)✓
• d.Promethazine (Phenergan)

Loratadine is a second-generation antihistamine that crosses into the brain poorly, so it is among the least sedating options along with fexofenadine; cetirizine is also second-generation but causes drowsiness in some people. Diphenhydramine, chlorpheniramine and promethazine are all first-generation agents whose sedation is pronounced — diphenhydramine is sold as an over-the-counter sleep aid for exactly that reason. Any antihistamine can still impair driving, so the patient should judge his own response before a shift.

When should a once-daily proton pump inhibitor such as omeprazole be taken for the best acid-suppressing effect?

• a.At bedtime, several hours after the last meal of the day
• b.Before the first meal of the day✓
• c.Only when heartburn is felt
• d.Immediately after the largest meal of the day

A proton pump inhibitor can only shut down pumps that are actively secreting acid, and the largest pool of active pumps is switched on by the first meal of the day, so the dose is taken before eating in the morning. Taking it right after the meal misses that window, and a PPI is a poor as-needed remedy because full acid suppression builds over several days; an antacid or an H2 blocker is what works on demand.

Ondansetron orally disintegrating tablets are dispensed to a patient who cannot keep liquids down. Which handling instruction is correct?

• a.Peel the foil back and place the tablet on the tongue; do not push it through✓
• b.Push the tablet through the foil and swallow it with a full glass of water
• c.Crush the tablet and mix it into applesauce before each dose
• d.Dissolve the tablet in water and drink the solution

The orally disintegrating tablet is deliberately fragile and crumbles if it is forced through the blister backing, so the foil is peeled open with dry hands and the tablet is laid on the tongue, where it disintegrates in seconds and is swallowed with saliva — no water needed, which is the whole point for a patient who is vomiting. Pushing it through the foil or dissolving it in a glass of water defeats that design and risks losing part of the dose.

Which direction belongs on a prescription for once-weekly oral alendronate?

• a.Take at bedtime with milk so the calcium is absorbed at the same time
• b.Take with juice at any convenient time of day
• c.Take with breakfast, then lie down to rest
• d.Take on rising with plain water and stay upright afterwards✓

Oral bisphosphonates are very poorly absorbed and can irritate or ulcerate the esophagus, so alendronate is taken first thing after getting up with a full glass of plain water, and the patient stays sitting or standing and takes nothing else by mouth for at least 30 minutes. Milk, juice, coffee and calcium supplements all block absorption, so the milk answer is doubly wrong, and lying down after the dose is the specific behavior that causes esophageal injury.

While a technician is entering a new prescription, the system fires a drug-interaction alert that the technician's log-in cannot bypass. What does this hard stop mean?

• a.The technician may key in the pharmacist's override code kept at the workstation
• b.The technician should delete one of the interacting drugs from the profile so the alert clears
• c.Only the pharmacist may review the alert and clear it before the fill continues✓
• d.The alert is informational and may simply be documented

A hard stop is built so that the clinical judgement behind an override is made and documented by the pharmacist; the technician's role is to leave the order in the queue and hand it over. Keying in a borrowed override code is the closest wrong answer because it does move the queue along, but it puts the technician's hands on a clinical decision and falsifies who reviewed the interaction. Deleting a drug from the profile destroys the very data the interaction check runs on.

Two strengths of the same manufacturer's product arrive in cartons that are identical except for a small color band. Which practice best reduces wrong-carton selection?

• a.Store the two strengths in separate labelled bins with an auxiliary warning on each✓
• b.Cover the manufacturer's color band with the pharmacy's own strength label
• c.Apply tall man lettering to both shelf labels, since that is the standard fix for look-alike products
• d.Shelve them side by side in strength order so the difference is obvious

When the confusable feature is the packaging rather than the name, the control has to be physical: separate the strengths and add a warning that forces a second look. Tall man lettering is the tempting answer because it is the standard look-alike remedy, but it differentiates spelling, and here the two names are identical, so it changes nothing. Shelving them adjacently in strength order actually raises the risk, because the near-identical cartons then sit within one reach, and covering manufacturer labelling obscures information the pharmacist needs at verification.

A community pharmacy runs an automatic refill program for maintenance prescriptions. Which control matters most to the safety of that program?

• a.Enrolling every maintenance prescription automatically so that no chronic therapy ever lapses
• b.Adding Schedule II prescriptions to the program so that patients do not run out between visits
• c.Letting the pharmacist catch any discontinued drug at the final verification step
• d.Confirming with the patient each cycle that the drug is still being taken as prescribed✓

The characteristic auto-refill harm is a drug that the prescriber stopped or changed being filled, delivered and then taken again, so the program needs a live confirmation from the patient at each cycle. Waiting for the pharmacist's final verification is the closest wrong answer, because that check does happen, but it compares the label to the prescription on file and cannot see a change the pharmacy was never told about. Auto-enrolling everything removes the patient's consent, and Schedule II prescriptions cannot be refilled at all under federal law, so they can never be part of a refill program.

A recall notice arrives naming one specific lot number of a tablet the pharmacy stocks. What should the technician do with the pharmacy's stock of that drug?

• a.Pull the named lot, quarantine it away from active stock, and follow the notice✓
• b.Leave the lot on the shelf but flag the computer record so that it is never dispensed
• c.Pull every bottle of the drug regardless of lot and send all of it back
• d.Discard the affected bottles in the pharmaceutical waste bin

A lot-specific recall is handled by removing that lot from where anyone can reach it, holding it in a marked quarantine area separate from dispensable stock, and doing exactly what the notice instructs about return or destruction. Flagging the computer record is the closest wrong answer because it does block the sale, but the physical bottle stays within arm's reach of the fill station, and a computer flag cannot stop a hand. Pulling every lot destroys usable inventory the notice never covered, and discarding the bottles gives up the documented return the manufacturer needs.

A patient returns a sealed, unopened bottle of tablets the pharmacy dispensed last week and asks that it be restocked and credited. In most states, what should the pharmacy do?

• a.Decline to restock it; medication that has left the pharmacy cannot be verified✓
• b.Repackage the tablets into a new vial for the next patient on the same drug
• c.Restock it after the pharmacist inspects the tablets and matches the lot
• d.Restock it, because the manufacturer's seal is unbroken and the fill is under 30 days old

Once a dispensed medication leaves the pharmacy's control, nobody can confirm how it was stored or handled, so in most states it cannot go back into dispensable stock even if the seal looks untouched. Pharmacist inspection is the closest wrong answer, because inspection and lot matching are real controls, but neither reconstructs the temperature history of a bottle that spent a week in a car or a bathroom. Repackaging it for another patient carries the same unverifiable product forward under a new label.

A refrigerated biologic has to reach a patient's home by pharmacy courier. Which practice best protects the product in transit?

• a.Send it by ordinary courier and tell the patient to refrigerate it on arrival
• b.Pack it in an insulated bag with ice cubes and leave it at the door if nobody answers
• c.Freeze the product before it leaves so that it stays cold for the entire trip
• d.Pack it in a validated insulated shipper with a temperature indicator and obtain a signature on delivery✓

Cold-chain transport is only defensible when the container has been validated to hold the range for the expected trip time and the indicator lets someone read afterwards whether it actually did, with a signature proving the product was not left in the sun. Ice cubes plus a doorstep drop is the closest wrong answer because the insulation is at least present, but melting ice gives no record and an unattended package has no controlled temperature at all. Freezing is worse than doing nothing for most refrigerated biologics, which are damaged by it.

In a long-term-care pharmacy a technician fills unit-dose medication carts for the next 24 hours. Which check best keeps a cart-fill error from reaching a resident?

• a.Filling from the previous cycle's cart list, since residents' regimens rarely change much
• b.Filling from the current medication administration record and having the pharmacist verify the cart before it leaves✓
• c.Having a second technician confirm that the drawer count matches the resident census
• d.Relying on the nurse's check at the bedside as the last chance to catch the error

Cart fill is only as good as the document it is filled from, so the fill must start from the current medication administration record and end with a pharmacist verification while the cart is still in the pharmacy and errors are cheap to fix. The bedside nurse check is the closest wrong answer, because it is a genuine last line of defense, but it happens after the cart has travelled and it is the control the pharmacy cannot manage. Counting drawers against the census confirms quantity, not that the right drug reached the right resident.

A prescription reads: instill 1 drop into each eye three times daily. One 5 mL bottle is dispensed, and the manufacturer states the bottle delivers 20 drops per mL. Rounded down to whole days, what is the day supply?

• a.8 days
• b.33 days
• c.16 days✓
• d.17 days

The bottle holds 5 mL x 20 drops/mL = 100 drops, and the patient uses 1 drop x 2 eyes x 3 times daily = 6 drops a day, so 100 / 6 = 16.7, reported as 16 whole days. Reading 'each eye' as a single drop per dose leaves 3 drops a day and 100 / 3 = 33 days; doubling the dose to two drops in each eye gives 12 drops a day and 100 / 12 = 8 days. The 17-day figure is the same 16.7 rounded the wrong way, and that rounding is the call worth pausing over, since 16.7 sits closer to 17: a day supply is always rounded down, because on the seventeenth day there is not a full day of drops left.

An inhaler canister is labelled 200 metered actuations. The sig reads: inhale 2 puffs by mouth four times daily. One canister is dispensed. What is the day supply?

• a.100 days
• b.25 days✓
• c.12 days
• d.50 days

The patient uses 2 puffs x 4 times daily = 8 actuations a day, so 200 / 8 = 25 days exactly. Dividing 200 by the 4 daily doses while forgetting that each dose is 2 puffs gives 50 days, and counting only the 2 actuations of a single daily dose gives 200 / 2 = 100 days. Doubling the daily use to 16 actuations gives 200 / 16 = 12.5, reported as 12 days, but nothing in the sig supports 16 puffs a day.

A box of five insulin pens is dispensed. Each pen holds 3 mL of insulin labelled 100 units/mL. The sig reads: inject 35 units subcutaneously twice daily. Rounded down to whole days, what is the day supply?

• a.42 days
• b.7 days
• c.21 days✓
• d.22 days

Each pen holds 3 mL x 100 units/mL = 300 units, so five pens hold 1,500 units; the patient uses 35 x 2 = 70 units a day, and 1,500 / 70 = 21.4, reported as 21 whole days. Treating 100 units/mL as 100 units per pen ignores the 3 mL volume and leaves 500 units, or 500 / 70 = 7 days. Counting only one 35-unit dose a day gives 1,500 / 35 = 42 days. The 22-day figure is that same 21.4 rounded up, and a day supply is rounded down because the final partial day is not a full day of therapy.

A patient is directed to apply 0.5 g of a cream to the affected area three times daily. One 45 g tube is dispensed. What is the day supply?

• a.90 days
• b.10 days
• c.30 days✓
• d.15 days

The patient uses 0.5 g x 3 = 1.5 g a day, so 45 g / 1.5 g per day = 30 days. Treating 1.5 g as the amount per application rather than per day triples the daily use to 4.5 g and gives 45 / 4.5 = 10 days. Counting a single 0.5 g application a day gives 45 / 0.5 = 90 days, and using 3 g a day gives 45 / 3 = 15 days.

A prednisone taper is written with 20 mg tablets: 60 mg daily for 5 days, then 40 mg daily for 5 days, then 20 mg daily for 5 days. What quantity should be dispensed?

• a.60 tablets
• b.18 tablets
• c.6 tablets
• d.30 tablets✓

With 20 mg tablets the three steps are 3, 2 and 1 tablets a day, so the totals are 3 x 5 = 15, 2 x 5 = 10 and 1 x 5 = 5 tablets, giving 15 + 10 + 5 = 30 tablets. The 60-tablet figure is what the same taper needs if 10 mg tablets are used, since the steps would be 6, 4 and 2 a day; the strength written on the prescription decides which applies, and this one says 20 mg. Adding 3 + 2 + 1 without ever multiplying by the 5 days gives 6 tablets, and multiplying that 6 by 3 days instead of 5 gives 18 tablets.

An antineoplastic is ordered at 75 mg/m2 for a patient whose body surface area is documented on the order as 1.6 m2. The vial is labelled 6 mg/mL. What volume contains the ordered dose?

• a.7.8 mL
• b.12.5 mL
• c.20 mL✓
• d.120 mL

The dose is 75 mg/m2 x 1.6 m2 = 120 mg, and 120 mg / 6 mg/mL = 20 mL. The 12.5 mL figure is the most tempting because it uses the right vial concentration but never applies the body surface area, dividing the bare 75 mg by 6 mg/mL. Dividing by 1.6 instead of multiplying gives 46.9 mg and 46.9 / 6 = 7.8 mL, and carrying the milligram number straight across as a volume gives 120 mL, which would only be right if the vial were 1 mg/mL.

A child weighing 33 lb is ordered an antibiotic at 40 mg/kg/day divided every 8 hours. The suspension supplied is 250 mg/5 mL. What volume should be given per dose?

• a.12 mL
• b.6 mL
• c.8.8 mL
• d.4 mL✓

The child weighs 33 lb / 2.2 = 15 kg, so the daily dose is 15 kg x 40 mg/kg = 600 mg; every 8 hours means 3 doses, so each dose is 600 / 3 = 200 mg, and 200 mg / (250 mg per 5 mL, that is 50 mg/mL) = 4 mL. The 6 mL figure is the most tempting because every step is right except the last, splitting the day into two doses of 300 mg. Taking the 33 lb as kilograms gives 33 x 40 = 1,320 mg a day, 440 mg a dose and 8.8 mL, and giving the whole 600 mg at once is 12 mL.

How many milligrams of lidocaine are contained in 20 mL of a 2% (w/v) lidocaine solution?

• a.400 mg✓
• b.20 mg
• c.4,000 mg
• d.40 mg

A percentage strength expressed w/v means grams of drug per 100 mL, so 2% is 2 g per 100 mL, which is 2,000 mg / 100 mL = 20 mg/mL, and 20 mg/mL x 20 mL = 400 mg. Reading the 2 as 2 mg/mL without converting the grams first gives 2 x 20 = 40 mg, and inflating that same conversion tenfold to 200 mg/mL gives 4,000 mg. The 20 mg figure stops at the per-millilitre strength and never multiplies by the 20 mL volume.

An epinephrine solution is labelled with the ratio strength 1:1,000. What concentration does that ratio strength represent?

• a.1,000 mg/mL
• b.10 mg/mL
• c.1 mg/mL✓
• d.0.1 mg/mL

A ratio strength for a solution means grams of drug in that many millilitres, so 1:1,000 is 1 g in 1,000 mL, which is 1,000 mg / 1,000 mL = 1 mg/mL, the same as 0.1% w/v. The 0.1 mg/mL figure is the one worth pausing over, because it is a real epinephrine concentration a technician handles, but it belongs to the 1:10,000 label, where the same 1 g is spread through ten times the volume. Reading the label as 1 g in 100 mL gives 10 mg/mL, and reading it as 1,000 mg in each millilitre gives 1,000 mg/mL.

You must prepare 500 mL of 60% isopropyl alcohol using a 90% and a 40% isopropyl alcohol. What volume of each is required?

• a.250 mL of 90% and 250 mL of 40%
• b.200 mL of 90% and 300 mL of 40%✓
• c.300 mL of 90% and 200 mL of 40%
• d.100 mL of 90% and 400 mL of 40%

By alligation the 90% contributes 60 - 40 = 20 parts and the 40% contributes 90 - 60 = 30 parts, giving 50 parts in all, so the 90% supplies 20/50 x 500 = 200 mL and the 40% supplies 30/50 x 500 = 300 mL. Checking by mass balance, 200 x 0.90 = 180 g plus 300 x 0.40 = 120 g is 300 g of alcohol in 500 mL, which is 60%. Reversing the parts to 300 mL and 200 mL is the commonest error and yields 270 + 80 = 350 g in 500 mL, or 70%. Mixing 250 mL of each averages the two strengths to 65%, and the 1-to-4 split yields 90 + 160 = 250 g in 500 mL, or 50%.

A vial of lyophilised antibiotic powder is reconstituted with 8.6 mL of sterile water and the resulting solution measures 10 mL. What is the powder volume?

• a.1.4 mL✓
• b.18.6 mL
• c.10 mL
• d.8.6 mL

Powder volume is the space the dry drug itself occupies, found as final volume minus diluent volume: 10 mL - 8.6 mL = 1.4 mL. The 8.6 mL figure is the most tempting because that number is the one printed on the reconstitution instructions, but it is the diluent, not the powder. The 10 mL figure is the final volume the label concentration is based on, and adding the two volumes to reach 18.6 mL counts the diluent twice.

An order reads: infuse 1,500 mL of 0.9% sodium chloride over 12 hours using an administration set calibrated at 20 gtt/mL. What is the drip rate in gtt/min?

• a.42 gtt/min✓
• b.31 gtt/min
• c.125 gtt/min
• d.21 gtt/min

The infusion delivers 1,500 mL x 20 gtt/mL = 30,000 drops over 12 x 60 = 720 minutes, so 30,000 / 720 = 41.7, rounded to 42 gtt/min. Checking the other way, 1,500 / 12 = 125 mL/hr and 125 / 60 x 20 = 41.7 gtt/min. The 125 figure is the most tempting because that number really does appear in the working, but it is the hourly volume, not a drip rate. A 15 gtt/mL set would give 125 / 60 x 15 = 31 gtt/min and a 10 gtt/mL set 125 / 60 x 10 = 21 gtt/min, but this order specifies a 20 gtt/mL set.

A 1,000 mL bag is started at 100 mL/hr. After 4 hours the prescriber lowers the rate to 60 mL/hr. How much longer will the bag run?

• a.6 hours
• b.16.7 hours
• c.14 hours
• d.10 hours✓

In the first 4 hours the pump delivered 4 x 100 = 400 mL, leaving 1,000 - 400 = 600 mL, and 600 mL / 60 mL/hr = 10 more hours. The 16.7-hour figure is the most tempting because it applies the new rate correctly but to the whole 1,000 mL, ignoring the 400 mL already infused. Running the remaining 600 mL at the old 100 mL/hr gives 6 hours, and adding the 4 hours already elapsed onto the 10 gives 14 hours, which answers total run time rather than the time still to go.

A plan charges a $10.00 copay plus 20% coinsurance on the balance of the prescription price. The total price of the prescription is $210.00. What does the patient pay?

• a.$52.00
• b.$50.00✓
• c.$42.00
• d.$10.00

The copay comes off first, leaving $210.00 - $10.00 = $200.00; the coinsurance is 20% x $200.00 = $40.00, so the patient owes $40.00 + $10.00 = $50.00. The $52.00 figure is the most tempting because it also adds the copay, but it takes the 20% from the full $210.00 instead of from the balance, charging the patient twice on that first $10.00. Taking 20% of $210.00 and forgetting the copay altogether gives $42.00, and $10.00 assumes the plan absorbs everything above the copay.

A pharmacy acquires a bottle for $80.00 and sells it for $100.00. What are the gross profit and the percentage markup on cost?

• a.$20.00 gross profit and a 25% markup✓
• b.$20.00 gross profit and a 125% markup
• c.$20.00 gross profit and a 20% markup
• d.$100.00 gross profit and a 25% markup

Gross profit is selling price minus cost, $100.00 - $80.00 = $20.00, and markup on cost divides that profit by the cost: $20.00 / $80.00 = 0.25, or 25%. The 20% figure is the hardest to discard, because $20.00 / $100.00 really is 20%, but dividing by the selling price gives the gross margin; this question asks for markup on cost, so the denominator has to be the $80.00. The 125% figure is $100.00 / $80.00, the price as a percentage of cost rather than the increase over it, and the $100.00 profit figure mistakes the whole selling price for the profit and never subtracts what the bottle cost.

A prescription sig reads: ii gtts AU tid. Which set of patient directions is correct?

• a.Instill 2 drops into the left ear three times daily
• b.Instill 2 drops into each eye three times daily
• c.Instill 2 drops into both ears three times daily✓
• d.Instill 2 drops into both ears twice daily

The Roman numeral ii is 2, gtts is drops, AU is auris uterque or both ears, and tid is three times daily. The each-eye version is the trap worth thinking about, because AU and OU differ by one letter and both mean the paired organ; the A stands for auris, the ear, while OU would be oculus uterque, both eyes. AS would be the left ear alone, and twice daily would be written bid.

A prescriber writes 'dispense as written' on a prescription for a brand-name drug that has an AB-rated generic. Which DAW code should be transmitted on the claim?

• a.DAW 1✓
• b.DAW 0
• c.DAW 2
• d.DAW 4

A dispense-as-written instruction from the prescriber on the face of the prescription is DAW 1, which is defined as substitution not allowed by the prescriber. DAW 2 is the closest call, because it also ends with the brand being dispensed, but it records the patient as the source of the request; billing it that way misstates who made the decision and often shifts the extra cost onto the patient. DAW 0 means no product selection was indicated by anyone, and DAW 4 means substitution was allowed but the generic was not in stock.

A claim for a 90-day supply of a maintenance drug is rejected as 'plan limitations exceeded'. The plan covers this drug in 30-day quantities at retail. What is the correct resolution?

• a.Bill the whole 90-day supply as a cash sale
• b.Resubmit the same 90-day claim with a DAW 1 code
• c.Split the 90 tablets into three claims submitted the same day
• d.Rebill the claim for a 30-day quantity and dispense that amount✓

A plan-limitation rejection is a quantity problem, so the fix is to cut the fill back to the quantity the plan actually covers, bill that, and let the patient decide about mail order for the longer supply. Splitting the fill into three same-day claims is the closest wrong answer because it does reach the same 90 days, but the second and third claims reject as refill-too-soon or duplicates, and deliberately structuring claims to defeat a plan limit is a billing offense. A DAW code addresses brand substitution and has no effect on a quantity limit, and moving the patient to cash without telling them takes away a choice that is theirs to make.

A prescriber writes 'QD' on an order for a once-daily medication. Why does ISMP's list of error-prone abbreviations ask that this be written out as 'daily'?

• a.QD is easily misread as QID or QOD✓
• b.QD gives no route, so the order cannot be filled
• c.QD resembles OD, the abbreviation for the right eye
• d.QD is banned only in handwriting

The letters and the period in QD are readily read as QID or as QOD, so a once-daily drug can end up given four times a day or every other day. Confusion with OD, the abbreviation for the right eye, is a genuine hazard that ISMP also lists, but it is a route error rather than the frequency error that put QD on the list. A missing route is a separate defect, and the abbreviation is discouraged in typed orders as well as handwritten ones.

An order for an oral liquid is written as '.5 mg'. How should that dose have been expressed, and why?

• a.0.50 mg, because a second decimal place records that the dose was checked
• b.500 mcg, because ISMP bars stating a dose as a fraction of a milligram
• c.0.5 mg, because a bare decimal point can be missed and read as 5 mg✓
• d.1/2 mg, because a fraction cannot be read as a whole number

A decimal point with nothing in front of it disappears on a fax, a carbon copy or a smudged page, so .5 mg is read as 5 mg — a tenfold overdose. Rewriting the dose in micrograms is the tempting alternative and is a reasonable way to avoid decimals, but the reason given is false: ISMP does not forbid sub-milligram doses, it requires the leading zero. A trailing zero such as 0.50 mg is the opposite error and is also on the do-not-use list, because a lost decimal point makes it read as 50 mg.

A handwritten hospital order reads 'MS 4 mg IV q4h PRN pain.' Why is the order returned to the prescriber before it is processed?

• a.MS is a brand abbreviation, and brands are barred from inpatient orders
• b.MS orders must also carry a concentration expressed in mg per mL
• c.MS can mean morphine sulfate or magnesium sulfate✓
• d.MS is an oral-only abbreviation

MS and MSO4 have been read as magnesium sulfate when morphine sulfate was meant, and the reverse, which is why ISMP requires the drug name to be spelled out in full. The missing concentration is a real labeling concern and is the closest call here, but a concentration would not resolve which of the two drugs was ordered — the ambiguity is in the name itself. MS is not a brand name, and it is not limited to the oral route.

A pharmacy requires an independent double check on every insulin infusion prepared in the IV room. What makes the second check 'independent'?

• a.The second person repeats the calculation aloud while the first person confirms it
• b.The second check is recorded on a separate log sheet
• c.The second check is done by staff from a different department
• d.The second person checks the work alone, without seeing the first result✓

Independence means the second person works from the original order and reaches a conclusion without being told what the first person concluded; only then can the check catch the first person's error. Reading the calculation aloud together is the tempting choice because it feels like verification, but the second person is anchored to a result already spoken and tends to confirm it. Neither the checker's department nor where the record is filed has any bearing on independence.

Concentrated potassium chloride injection has killed patients who received it undiluted. Which system change did hospitals widely adopt in response?

• a.Concentrated vials stayed in floor stock but were sealed in a red high-alert overwrap
• b.Concentrated vials were removed from floor stock in favor of premixed bags✓
• c.Nurses were required to dilute the concentrate at the bedside before every dose
• d.Only pharmacists were allowed to sign the vials out

The concentrated vials were taken off nursing units altogether and commercially premixed, ready-to-hang bags were supplied instead, because undiluted potassium chloride given by IV push causes cardiac arrest within seconds. Adding warning stickers while leaving the vials on the unit is the plausible-sounding option, and it was tried — it did not stop the deaths, because a hurried nurse still had a lethal vial within reach. Bedside dilution is exactly the step this change was designed to eliminate.

On a hospital unit a nurse asks whether an insulin pen already used for one patient may be used for a second patient if a fresh needle is attached and the pen barrel is wiped with alcohol. What is correct?

• a.Yes, provided a new needle is attached at the bedside and the pen is relabeled
• b.Yes, because the cartridge is a closed system the needle never touches
• c.No, an insulin pen is dedicated to a single patient✓
• d.Only if the pen holds a long-acting insulin rather than a rapid-acting one

Insulin pens are single-patient devices: blood and tissue can be drawn back into the cartridge during an injection, so changing the needle does not make the pen safe for anyone else. The closed-system argument is the tempting one, but backflow into the cartridge has been demonstrated, which is why the FDA and CDC warned against sharing pens even with a new needle each time. The insulin inside the pen has no bearing on the rule.

A hospital expands the traditional five rights to eight by adding right documentation, right reason and right response. What does 'right response' require?

• a.Checking whether the drug produced the effect it was given for✓
• b.Checking that the order matches the diagnosis recorded in the chart
• c.Checking that the dose was charted within the required time
• d.Checking that the patient consented before the dose

Right response closes the loop: after the dose, someone confirms that the pain score fell, the blood pressure came down or the fever broke, and that no adverse effect appeared. Matching the order to the recorded diagnosis is the close call, but that is right reason — it asks why the drug was ordered, not what it did. Charting the dose on time is right documentation, and consent is not one of the eight rights.

Two finished prescriptions sit in the will-call bin for a father and a son who share the same first and last name. Which practice best prevents handing over the wrong bag?

• a.Ask which drug the patient expects and match it to the label
• b.Sort the two bags into separate bins by middle initial
• c.Staple the two bags together and hand over both
• d.Confirm the date of birth as well as the name✓

Two identifiers are the standard: the name plus a second item such as date of birth or street address, which is what separates a father from a son with the same name. Asking which drug the patient expects sounds practical and is the closest alternative, but a family member frequently collects for both and can name either drug, so it confirms nothing about identity. Bin sorting only helps the staff find the bag, and releasing both bags at once is the wrong-patient handoff the check exists to stop.

A technician scans the barcode on the stock bottle and the dispensing system accepts it as a match for the label. Which error does that scan still leave undetected?

• a.That the bottle holds a strength other than the one the label calls for
• b.That the package size differs from the quantity dispensed
• c.That the prescription was entered under the wrong patient's name✓
• d.That the manufacturer differs from the previous fill

The barcode carries the NDC, and the NDC identifies the labeler, the product — drug, strength and dosage form — and the package size, so all of those are compared against what was entered. The NDC says nothing about who the prescription is for, so a wrong-patient data-entry error passes the scan cleanly and has to be caught by verifying identity at entry and again at the point of sale.

A wholesaler's invoice lists the NDC 0093-0058-01 in the 10-digit 4-4-2 format. To convert it to the 11-digit 5-4-2 format used on claims, where is the leading zero inserted?

• a.At the end of the package code
• b.In front of the product code, making it a five-digit segment
• c.In front of the package code, making a three-digit segment
• d.In front of the labeler code✓

A 4-4-2 number is short one digit in the labeler segment, so the zero is placed at the front of that segment and 0093-0058-01 becomes 00093-0058-01. Padding the product or package segment instead produces a number in 4-5-2 or 4-4-3 shape, which is not a valid NDC configuration and will either reject at the processor or, worse, match a different product than the one dispensed.

Which published resource names the specific drug pairs a pharmacy should display using tall man lettering?

• a.The manufacturer's package insert for each affected product
• b.The FDA Orange Book therapeutic equivalence codes
• c.The FDA Purple Book
• d.The ISMP List of Confused Drug Names✓

ISMP maintains the List of Confused Drug Names, which pairs look-alike and sound-alike products and marks the pairs for which tall man lettering such as buPROPion and busPIRone is recommended. The Orange Book rates therapeutic equivalence between generics and their reference products, and the Purple Book lists licensed biologics; neither addresses name confusion. A package insert describes one product and cannot tell you which other product it is mistaken for.

In most states a pharmacist must counsel, or offer to counsel, at the point of sale. For which of these four patients is counseling most clearly indicated?

• a.A patient refilling the same lisinopril strength he has taken for two years
• b.A neighbor collecting a housebound patient's refill
• c.A patient buying an OTC pain reliever at the register
• d.A patient starting weekly oral methotrexate for the first time✓

A first fill of weekly oral methotrexate is the clearest trigger: it is a new prescription, and taking the tablets daily instead of once a week has killed patients, so the directions themselves are the hazard being counseled on. An unchanged refill of a long-standing drug is the close call, since an offer is usually still made, but nothing about the therapy has changed. Counseling can be left for the patient when an agent collects a routine refill, and a plain over-the-counter purchase carries no counseling duty.

A manufacturer recalls a lot of tablets that assayed subpotent, and the FDA classifies it as a Class II recall. What does that classification say about the health risk?

• a.Use carries a reasonable probability of serious harm or death
• b.Use is unlikely to cause any adverse effect
• c.Use may cause temporary or medically reversible harm✓
• d.The firm removes the product voluntarily

Class II covers products whose use may cause temporary or medically reversible adverse health consequences, with only a remote probability of serious harm — a subpotent lot fits, because the patient is underdosed for a period but the consequence is generally reversible. Class III, reserved for products unlikely to cause any adverse effect such as a lot with a label typo, is the tempting near miss. Class I requires a reasonable probability of serious injury or death, and a market withdrawal is not an FDA recall class at all.

A patient who received an influenza vaccine at the pharmacy calls two days later with a large, swollen, painful arm and a fever. To which federal system should this reaction be reported?

• a.MedWatch, the FDA program for drug and device problems
• b.The Vaccine Adverse Event Reporting System✓
• c.The ISMP national medication error reporting program
• d.The CDC's National Healthcare Safety Network

Adverse events following immunization go to VAERS, the reporting system co-managed by the FDA and CDC specifically for vaccines, and reports are accepted from pharmacists, other clinicians and patients alike. MedWatch is the close call because it is the FDA's general safety-reporting program, but vaccine reactions are routed to VAERS instead. ISMP's program collects medication errors rather than reactions, and NHSN collects healthcare-associated infection data from facilities.

After correcting a dispensing error internally, a pharmacy also submits a de-identified account of it to ISMP's national medication errors reporting program. What is the purpose of that external report?

• a.To share the hazard nationally so other pharmacies can avoid it✓
• b.To satisfy a federal requirement that every dispensing error be reported
• c.To create a record the pharmacy can use if the patient later sues
• d.To shift responsibility for the error onto the manufacturer

The ISMP program is voluntary and confidential, and its value is that a hazard discovered in one pharmacy is analyzed and published so that pharmacies everywhere can change a label, a shelf or a workflow before the same error reaches their patients. The federal-requirement option is the tempting one, but no federal rule compels reporting of every dispensing error; state boards set their own, much narrower duties. The report is not built as a legal defense and does not transfer responsibility to anyone.

A hospital convenes a root cause analysis after a patient receives a tenfold insulin overdose. What distinguishes a root cause analysis from a failure mode and effects analysis?

• a.It scores each step of a process for how likely it is to fail
• b.It identifies the individual whose action caused the event
• c.It looks back at an event that already happened to find the system failures behind it✓
• d.It is conducted before a new process is put into use

A root cause analysis is retrospective: it starts from an event that already harmed someone and works backward through the process to the system weaknesses that allowed it. A failure mode and effects analysis is the mirror image in time — it is done prospectively, before or during a process change, and scores each step for how it could fail and how badly. Stopping at the individual whose hand was on the syringe is exactly what a root cause analysis is designed not to do.

During a long queue a technician knowingly skips the required barcode scan because the scanner is slow and the product looks obviously right. Under a just-culture model, how is that behavior classified and answered?

• a.Human error, met with consoling and a redesign of the scanning step
• b.Reckless behavior, met with disciplinary action up to termination
• c.A knowledge gap, met with mandatory retraining
• d.At-risk behavior, met with coaching and a fix to the workflow✓

Skipping a required step because it feels slow and the risk feels small is at-risk behavior: the technician drifted from the rule without seeing the danger, so the response is coaching plus removing what makes the shortcut attractive, such as fixing the slow scanner. Reckless behavior is the close call and is the label many people reach for, but it means consciously disregarding a substantial and unjustifiable risk — here the technician believed the risk was negligible. Human error is an unintended slip, which a deliberate choice is not, and the technician already knew the rule.

A prescriber orders 250 mg of an antibiotic every 8 hours, the pharmacy dispenses the correct 250 mg product to the floor, and the nurse gives one dose four hours late. How is this event classified?

• a.A dispensing error, because the pharmacy is accountable for timely delivery to the floor
• b.A prescribing error, because no clock time was written
• c.An administration error, because the deviation occurred when the dose was given✓
• d.A near miss, because the ordered dose still reached the patient

The order was appropriate and the pharmacy supplied the right drug and strength, so the deviation first appears at the point of administration and belongs to the nursing step of the medication-use process. Calling it a dispensing error is the tempting choice when the pharmacy delivers to the unit, but nothing about the product or the label was wrong. It is not a near miss either: a near miss is caught before it reaches the patient, and this dose reached the patient at the wrong time.

Under CDC hand-hygiene guidance, in which situation is an alcohol-based hand rub NOT an acceptable substitute for washing with soap and water?

• a.When hands are visibly soiled or the patient has C. difficile✓
• b.When gloves will be put on immediately afterward for a nonsterile task
• c.When more than one hour has elapsed since the last hand hygiene
• d.When the technician has a small cut on the hand

Alcohol rubs do not remove visible soil and do not kill Clostridioides difficile spores, so soap and water is required when hands are dirty and after contact with a patient or environment involving C. difficile. Time elapsed since the last hand hygiene does not change which product is appropriate, only whether hand hygiene is due. Gloves are worn in addition to hand hygiene, never as a reason to change the method, and a small cut is covered rather than treated with a different product.

A technician is stuck by a needle while disposing of a used syringe in the pharmacy. Under the OSHA Bloodborne Pathogens Standard, what should be done?

• a.Wash the site and report it at once for evaluation✓
• b.Squeeze the wound to express blood and apply bleach to the site
• c.Report it only if the source patient is known to be infected
• d.Recap the needle, finish the task, and report at the end of the shift

The standard requires the exposed employee to wash the site and report the incident immediately, so that a confidential post-exposure medical evaluation can begin and prophylaxis, if indicated, can start within the window in which it works. Waiting for the end of the shift closes that window, and recapping is one of the commonest ways sticks happen in the first place. Squeezing the wound or applying bleach damages tissue and is not recommended, and the source patient's status is determined by the evaluation rather than being a condition for reporting.29 CFR 1910.1030

Which practice best controls cross-contamination between products when tablets and capsules are counted in a community pharmacy?

• a.Keep one tray for penicillins and cephalosporins and clean all trays weekly
• b.Wipe the tray and spatula with 70% isopropyl alcohol between products✓
• c.Change gloves for every prescription and leave the tray as it is
• d.Pour tablets from the stock bottle straight into the vial

Dust and residue transfer from one product to the next on the counting surface, so the tray and spatula are wiped with 70% isopropyl alcohol between prescriptions — that is what protects the patient whose drug is counted next. Reserving a tray for penicillins and cephalosporins is a genuine and useful practice and is the close call here, but cleaning only once a week leaves residue from every other drug counted on the general tray in the meantime. Gloves protect the technician, not the next patient's tablets, and pouring straight from the bottle makes an accurate count impossible.

Which reference does a pharmacy use to decide whether a drug must be handled with hazardous-drug precautions?

• a.The manufacturer's stability and compatibility chart
• b.The Safety Data Sheet supplied with the product
• c.The FDA Orange Book equivalence ratings
• d.The NIOSH hazardous drug list✓

USP <800> requires each entity to build its own hazardous drug list from the NIOSH list of antineoplastic and other hazardous drugs and to keep that list current. The Safety Data Sheet is the close call, because it genuinely describes the chemical's hazards and handling, but it is written product by product by the manufacturer and is not the source that decides whether a drug belongs on the entity's hazardous list. Compatibility charts and equivalence ratings answer entirely different questions.USP <800>

A technician must count methotrexate tablets, a drug on the NIOSH hazardous drug list, for an outpatient prescription. Which handling applies?

• a.Count on the general tray, then wipe it with alcohol afterward
• b.Use a dedicated tray and chemotherapy-rated gloves✓
• c.Count inside the horizontal laminar airflow hood to trap the dust
• d.Wear a surgical mask and count at the open back counter

Non-sterile handling of a hazardous drug still needs containment: a counting tray and spatula reserved for hazardous products, chemotherapy-rated gloves, and cleaning after use, because methotrexate tablet dust contaminates the surfaces it touches. Wiping the general tray afterward is the close call, but it does nothing for the residue already carried by the tray during that count and the equipment itself is what has to be dedicated. A horizontal laminar airflow hood blows air outward across the work surface toward the operator, so it would spread the dust rather than contain it.USP <800>

A 50 mL bag of an antineoplastic drug is dropped in the pharmacy and splits open on the floor. What is the correct first response?

• a.Blot the liquid with paper towels and discard them in the regular trash
• b.Restrict access to the area and open the hazardous spill kit✓
• c.Flush the spill toward the nearest floor drain with running water
• d.Cover the spill until housekeeping arrives

A hazardous drug spill is handled with the spill kit: keep people out of the area, put on the PPE the kit contains, contain the liquid with its absorbent pads, and place everything in the kit's hazardous waste bag. Ordinary paper towels in the regular trash send chemotherapy waste into the municipal stream and expose whoever handles the bag later. Flushing to a drain contaminates the water supply, and waiting for housekeeping exposes staff who are neither trained nor equipped for a hazardous drug.USP <800>

A product's carton directs 'store in a freezer.' Under USP's standard storage definitions, which temperature range does that describe?

• a.Between -80 °C and -60 °C, the ultra-cold storage range
• b.Between -10 °C and 0 °C, just below the freezing point of water
• c.Between -25 °C and -10 °C✓
• d.Any temperature at or below 0 °C

USP's storage definitions place a freezer between -25 °C and -10 °C, which is what a carton reading 'store in a freezer' expects; a refrigerator at 2 °C to 8 °C will not hold such a product. Treating anything at or below 0 °C as a freezer is the common assumption and fails in both directions, because a household frost-free unit can cycle warmer than -10 °C while an ultra-cold freezer runs far below -25 °C. Ultra-cold storage is a separate, specifically labeled condition used for only a few products.

A Category 1 compounded sterile preparation is made in an ISO Class 5 device that sits in an unclassified segregated compounding area. Under the 2023 revision of USP <797>, what beyond-use dates may be assigned to it?

• a.30 days refrigerated once sterility testing has been completed
• b.48 hours at controlled room temperature, 14 days when refrigerated, or 45 days in a freezer
• c.4 hours from the start of compounding, whatever the storage temperature
• d.12 hours or less at controlled room temperature, or 24 hours or less refrigerated✓

A Category 1 CSP is made in an ISO Class 5 primary engineering control that is not surrounded by a cleanroom suite, so USP <797> caps its beyond-use date at 12 hours at controlled room temperature or 24 hours refrigerated. The 48-hour, 14-day and 45-day set is the most tempting wrong answer because those were the low-risk figures in the earlier version of the chapter, which the risk-level system no longer uses. Dating measured in days or weeks belongs to Category 2 and Category 3 preparations, which require a classified cleanroom suite and, for the longest dates, sterility testing.USP <797>

A single-dose antibiotic syringe is prepared at the bedside as an immediate-use CSP. Under the 2023 revision of USP <797>, when must administration begin?

• a.Within 12 hours if the syringe is kept at controlled room temperature
• b.Within 4 hours of the start of preparation✓
• c.Within 24 hours if the syringe is refrigerated right away
• d.Within 1 hour of preparation

Immediate-use compounding is a limited exemption for urgent single-patient doses prepared outside an ISO Class 5 environment, and the 2023 revision of USP <797> requires administration to begin within 4 hours of the start of preparation. The 1-hour answer is the closest trap because that was the limit in the previous version of the chapter, and many older references still print it. Refrigeration does not extend an immediate-use preparation at all; anything needing longer storage must be compounded as a Category 1, 2 or 3 CSP.USP <797>

A technician compounds an oral suspension from crushed tablets in a water-containing vehicle, and no stability information exists for the formulation. What default beyond-use date does USP <795> allow?

• a.14 days, refrigerated✓
• b.30 days at room temperature in a tight container
• c.180 days at controlled room temperature
• d.6 months, or 25% of the time remaining on the shortest-dated ingredient

A water-containing oral preparation compounded without supporting stability data gets a default beyond-use date of 14 days under USP <795>, and it has to be refrigerated, because water is what allows microbial growth. The 180-day figure is the tempting wrong answer: that is the default for a nonaqueous preparation, and the presence of water in this suspension is exactly what disqualifies it. The manufacturer's expiration date on the tablets never carries over to a compounded preparation.USP <795>

During the compounding of a Category 2 CSP, where must ISO Class 5 air quality be maintained?

• a.In the ante-room where hand hygiene and garbing take place
• b.In the pass-through chamber that connects the ante-room to the buffer room
• c.Throughout the entire buffer room, including its floor and walls
• d.In the direct compounding area inside the primary engineering control✓

ISO Class 5 is the air quality required inside the primary engineering control — the laminar airflow workbench, biological safety cabinet or isolator — because that is where critical sites such as vial septa and needle hubs are exposed. The buffer room is the closest wrong answer: it must be ISO Class 7, one class less clean, since people and carts move through it. Ante-rooms for nonhazardous compounding are ISO Class 8, and a pass-through is a transfer device, not a compounding space.USP <797>

A technician snaps open a glass ampule inside the ISO Class 5 hood. How should the drug be moved from the ampule into the final container?

• a.Withdraw it through a 5-micron filter needle, then change the needle to inject✓
• b.Withdraw it with a regular needle and inject through a 0.22-micron sterilizing filter
• c.Withdraw it with a 5-micron filter needle and inject the dose through that needle
• d.Withdraw it with a regular needle and add a vent to equalize the pressure

Snapping an ampule showers glass fragments into the solution, so the contents are drawn up through a 5-micron filter needle or filter straw that traps the glass, and that filter is then swapped for a plain needle before the dose is injected. Injecting through the same filter needle is the closest wrong answer and a common shortcut, but it pushes the trapped glass straight into the bag. An ampule has no vacuum to equalize, so venting is pointless, and a 0.22-micron filter is a sterilizing filter rather than the particulate device intended for ampule withdrawal.USP <797>

A technician applies sterile 70% isopropyl alcohol to gloved hands and immediately reaches into the hood. What is wrong with this practice?

• a.The alcohol must be allowed to dry, because the contact time is what kills organisms✓
• b.The alcohol must be wiped off with a low-lint wipe before sterile supplies are touched
• c.Sterile water for irrigation should be used on gloves instead of alcohol
• d.Gloved hands are sanitized only when re-entering the buffer room

Alcohol only kills microorganisms while it is wet and in contact with the surface, so gloves must be allowed to air dry before compounding continues. Wiping the alcohol off is the tempting alternative, because wiping is correct for spills and for drying a work surface, but here it removes the alcohol before it has had the contact time it needs. Sterile 70% isopropyl alcohol, not sterile water, is the required agent, and gloves are sanitized frequently throughout compounding rather than only on re-entry.USP <797>

How should the work surface of a horizontal laminar airflow workbench be wiped down before compounding begins?

• a.From the top of the sash downward, finishing at the grille at the front of the deck
• b.Starting at the front opening and wiping backward to the face of the HEPA filter
• c.In circles from the center of the deck outward to all four edges
• d.In overlapping strokes, from the HEPA filter outward toward the front✓

In a horizontal workbench the HEPA filter is at the back and clean air flows toward the operator, so cleaning starts at the cleanest surface nearest the filter and moves outward, using overlapping strokes so no area is skipped. Wiping from the front toward the filter is the tempting mirror image and is exactly wrong: it drags contamination from the dirtiest edge back toward the critical area. Circular strokes leave untouched gaps between the circles, and a downward sash-to-grille pattern describes a vertical-flow biological safety cabinet, not this hood.

A case of IV bags arrives in a corrugated shipping carton. How should the bags enter the buffer room?

• a.Unpacked in the ante-room and wiped down with sterile 70% IPA✓
• b.Opened inside the hood so the contents meet only ISO Class 5 air first
• c.Carried in inside the sealed carton so the bags are never touched
• d.Sprayed with a germicidal detergent while still in the carton, then shelved

Corrugated cardboard sheds fibers and cannot be disinfected, so shipping cartons are opened outside the classified area and each item is wiped with sterile 70% isopropyl alcohol as it is transferred in through the pass-through. Carrying the sealed carton in is the tempting answer because the bags themselves stay untouched, but the carton is the contamination source. Opening a shipping carton inside the primary engineering control puts particles directly into the ISO Class 5 air, and spraying the outside of cardboard disinfects nothing.USP <797>

A compounding technician reports for a shift with an oozing rash on one forearm. Under USP <797>, what does this mean for that shift?

• a.The technician must stay out of the compounding areas until it resolves✓
• b.The technician may compound if the forearm is covered by the gown and double gloves
• c.The technician may compound after covering the rash with an occlusive dressing
• d.The technician may compound Category 1 preparations but not Category 2 CSPs

USP <797> excludes personnel with conditions that increase shedding — weeping sores, rashes, sunburn, conjunctivitis and active respiratory infections — from the compounding areas until the condition resolves, because garb reduces shedding but does not stop it. Covering the arm with the gown and a second pair of gloves is the tempting answer since the site would not be visible, but skin scales and organisms still escape at the cuffs and neckline. The exclusion is not graded by CSP category; it applies to all sterile compounding.USP <797>

A compounder leaves the buffer room for a break and removes the gown. Under USP <797>, what may be re-donned when the compounder returns during the same shift?

• a.Nothing; every item of garb must be replaced after any exit from the buffer room
• b.The gown, the hair cover and the face mask, but not the gloves
• c.The gown, if it is not visibly soiled and was left in the ante-room✓
• d.The gown and the gloves, if neither is soiled or torn

USP <797> permits the gown alone to be re-donned during the same work shift, provided it is not visibly soiled and has been stored inside the ante-room where it cannot be contaminated. Reusing the hair cover and mask along with it is the closest wrong answer, and it is what many people assume, but all garb other than the gown must be replaced with new items. Gloves are single-use without exception and are followed by a fresh application of sterile 70% isopropyl alcohol.USP <797>

Which requirement applies to the gloves worn while compounding an antineoplastic hazardous drug?

• a.A single pair of nitrile examination gloves is enough inside a closed-system isolator
• b.Sterile latex gloves changed each time a new vial is entered
• c.Powder-free vinyl gloves changed at the end of each batch
• d.Gloves meeting ASTM D6978, changed every 30 minutes✓

USP <800> requires chemotherapy gloves that have been tested for permeation by chemotherapy drugs under ASTM D6978, worn as two pairs and changed every 30 minutes unless the manufacturer documents a longer use time, and immediately if torn or contaminated. Relying on one pair inside an isolator is the closest wrong answer, because the containment device protects the room but not the hands that reach into it. Vinyl offers poor chemical resistance, and sterility, while needed for asepsis, is not what makes a glove a chemotherapy glove.USP <800>

How often must the disposable gown worn for hazardous-drug compounding be changed when the manufacturer provides no permeation information?

• a.Every 12 hours, matching the beyond-use date of the preparations
• b.Every 30 minutes, on the same schedule as chemotherapy gloves
• c.Once per shift, unless it becomes visibly contaminated
• d.Every 2 to 3 hours, and immediately after a spill or splash✓

USP <800> sets a default gown change of every 2 to 3 hours when no permeation data are available, and any splash or spill means the gown comes off at once. The 30-minute answer is tempting because it is the correct interval for chemotherapy gloves, but gloves are thinner, handle the drug directly and are therefore changed far more often than the gown. Waiting for visible contamination is unsafe, since hazardous-drug residue is usually invisible.USP <800>

What conditions does USP <800> require for the containment secondary engineering control in which antineoplastic drugs are compounded?

• a.Neutral pressure, with the exhaust recirculated through a HEPA filter
• b.Positive pressure of 0.02 inches of water column toward the ante-room, with 30 air changes per hour
• c.Negative pressure of 0.2 inches of water column with at least 6 air changes per hour
• d.Negative pressure of 0.01 to 0.03 inches of water column and at least 12 air changes per hour✓

The containment room is held at negative pressure of 0.01 to 0.03 inches of water column relative to adjacent spaces, with at least 12 air changes per hour, so that drug-contaminated air is pulled inward and exhausted rather than escaping to the rest of the pharmacy. Positive pressure with 30 air changes describes a nonhazardous ISO Class 7 buffer room, which is the closest wrong answer and the reason candidates mix the two up: protecting the product calls for positive pressure, protecting the personnel calls for negative. Recirculating hazardous-drug exhaust is not permitted; it must be vented externally.USP <800>

A 250 mL bag of an antineoplastic solution splits and spills on the pharmacy floor. What must happen first?

• a.Absorbent pads from the spill kit are laid over the spill from the outside inward
• b.Housekeeping is called to mop the floor with a germicidal detergent
• c.The area is restricted and the responder dons the spill-kit PPE✓
• d.The spill is wiped up with sterile 70% alcohol and low-lint wipes

Containment begins by keeping people away and protecting the responder: the chemotherapy spill kit supplies two pairs of chemotherapy gloves, a gown, eye protection, shoe covers and a NIOSH-approved respirator, and these go on before anything is touched. Laying absorbent pads from the outside inward is the correct next step and is the tempting answer, but doing it unprotected exposes the responder's skin and airway to the drug. Alcohol does not deactivate a hazardous drug, and mopping spreads the contamination across the floor.USP <800>

An emptied cyclophosphamide vial and the gown, gloves and wipes used to compound the dose are ready for disposal. Where do they belong?

• a.In regular pharmacy trash, because the vial is empty
• b.In a black container for RCRA hazardous waste
• c.In a red biohazard sharps container
• d.In a yellow chemotherapy waste container✓

Trace-contaminated hazardous-drug waste — an emptied vial plus the gown, gloves and wipes used with it — goes into the yellow chemotherapy waste stream for incineration. The black container is the closest wrong answer and is reserved for bulk hazardous waste, such as a partially used vial or a drug listed as hazardous waste by the EPA under RCRA. Red biohazard containers are for bloodborne-pathogen waste, and nothing that contacted an antineoplastic drug may go in the ordinary trash.USP <800>

A technician has just drawn a dose from a vial and is holding the used needle and syringe. What is the correct handling?

• a.Recap the needle with both hands before placing it in the sharps container
• b.Drop the assembly uncapped into the sharps container✓
• c.Recap using the one-handed scoop technique, then discard the assembly
• d.Break the needle off the hub and discard the syringe in the trash

OSHA's bloodborne pathogens standard requires contaminated sharps to be discarded immediately into a closable, puncture-resistant, leak-proof container that is labeled or color-coded, without recapping. The one-handed scoop is the closest wrong answer because it is a genuine technique, but it is permitted only when a specific medical procedure makes recapping unavoidable and no mechanical device is available — routine disposal is not that situation. Shearing or breaking a needle is expressly prohibited, and the container is replaced at its fill line rather than being pushed down.29 CFR 1910.1030

Which device does CDC recommend for monitoring the temperature of a pharmacy's vaccine refrigerator?

• a.A digital minimum/maximum thermometer that reads the air in the unit
• b.An alcohol or bimetal-stem thermometer on the middle shelf
• c.An infrared thermometer aimed at the vaccine cartons twice a day
• d.A digital data logger with a buffered probe✓

CDC recommends a digital data logger whose probe sits in a buffered material such as glycol, sand or glass beads, because the buffer responds like a vial of vaccine instead of like the air, and the logger records a continuous history rather than a single reading. An air-reading minimum/maximum digital thermometer is the closest wrong answer: it does capture the extremes, but the swings it reports every time the door opens are not the temperature the vaccine actually experienced. Bimetal-stem, alcohol and infrared devices are not accurate or continuous enough for vaccine storage.

A pharmacy stocks heparin 1,000 units/mL vials and heparin 10,000 units/mL vials. Which storage practice most reduces the chance that the wrong concentration is drawn up?

• a.Separate the two concentrations and highlight the strength on each bin✓
• b.Store both strengths in one bin and rely on the barcode scan at the point of fill
• c.Shelve them side by side in strength order so that the difference is visible
• d.Stock only 10,000 units/mL vials and dilute at the point of use

Heparin errors are classically wrong-concentration errors between vials that look nearly identical, so the two strengths are physically separated and the differing part of the strength is made to stand out on the bin label and on the vial. Shelving them side by side in strength order is the tempting answer because it feels orderly, but adjacency is precisely what lets a hand reaching by habit land on the wrong vial. Barcode scanning is a strong second control and should also be in place, yet it verifies after selection and cannot substitute for separation; keeping only the concentrated vial adds a dilution step and makes a large overdose easier.

What makes the verification of a compounded dose an independent double check?

• a.A second person confirms that the first person's calculation and selection were right
• b.A second person verifies the drug, concentration and calculation without seeing the first person's work✓
• c.The pharmacist checks the finished syringe against the label before release
• d.The same person repeats the calculation after a break and signs the label twice

In an independent double check the second practitioner works from the original order and reaches a conclusion before ever seeing what the first person did, and only then are the two results compared. Confirming someone else's arithmetic is the tempting answer because it is what most people actually do, but seeing the first result anchors the checker and lets the same error pass twice. One person checking their own work cannot be independent no matter how long the pause, and the pharmacist's final verification, while required, is a single check on its own.

Before the gown is donned in the ante-room, how does USP <797> require hand hygiene to be performed?

• a.Wash to the wrist with an antimicrobial soap for at least 15 seconds
• b.Rub the hands with an alcohol-based hand rub for at least 30 seconds and let them dry
• c.Scrub hands and forearms with a sterile brush and a povidone-iodine surgical scrub
• d.Wash hands and forearms to the elbow with soap and water for at least 30 seconds✓

USP <797> requires washing the hands and forearms up to the elbows with soap and water for at least 30 seconds, followed by drying with a low-lint towel, before the gown goes on; the sterile alcohol-based hand rub comes later, applied to clean dry hands just before sterile gloves. The alcohol rub is the tempting answer because it is the right agent at the wrong step — it disinfects but does not remove the soil, skin scales and debris that washing physically removes. A brush-and-iodine surgical scrub is an operating-room practice, and washing only to the wrist leaves the forearms that will be inside the gown sleeves untouched.USP <797>

A hospital pharmacy and therapeutics committee has approved a therapeutic interchange protocol for proton pump inhibitors. What does that protocol permit?

• a.Dispensing a different drug in the same class under the approved protocol✓
• b.Dispensing the same drug from a different manufacturer at the same strength
• c.Dispensing a different drug in the same class whenever the ordered one is unavailable
• d.Dispensing an AB-rated generic of the drug the prescriber ordered

Therapeutic interchange substitutes a chemically different drug expected to give a comparable outcome — one proton pump inhibitor for another at the protocol's equivalent dose — under authority the prescribers granted in advance through the approved protocol. Making the swap because the ordered product is unavailable is the closest wrong answer: a shortage may trigger the conversation, but the authority comes from the protocol, not from the stock situation, and without a protocol the prescriber must approve each change. Dispensing an AB-rated generic or the same molecule from another manufacturer is generic substitution, which involves the identical active ingredient.

A patient cannot swallow a delayed-release capsule that contains enteric-coated pellets, and the product labeling addresses this situation. What does such labeling typically direct?

• a.Crush the pellets with the capsule shell and mix the powder into applesauce
• b.Dissolve the whole capsule in warm water until the shell breaks apart
• c.Chew the pellets thoroughly so the coating breaks before swallowing
• d.Sprinkle the intact pellets on applesauce, swallowed whole✓

In this dosage form the protection is on each individual pellet, not on the capsule shell, so the labeling allows the shell to be opened and the pellets sprinkled on a spoonful of soft food and swallowed without chewing. Crushing is the tempting answer because it also gets the drug out of the capsule, but it destroys the enteric coating and dumps the whole dose into the stomach, where acid degrades the drug and can cause irritation. Chewing does the same damage, and soaking the capsule in warm water is not a labeled administration method.

A prescription is filled for regular insulin U-500. Which statement about this product is correct?

• a.It is diluted by the pharmacy to U-100 before being dispensed
• b.It is a long-acting analog that may not be mixed with other insulins
• c.It contains five times as much insulin per mL as a U-100 product✓
• d.It contains 500 units in the vial rather than 100 units

The 'U' number always states units per milliliter, so U-500 regular insulin holds 500 units/mL — five times the concentration of U-100 — which is why it is a high-alert product dispensed with its own dedicated U-500 syringe or pen so units are never misread as volume. The idea that the number describes the total content of the vial is the classic misconception and the most tempting wrong answer. U-500 is regular human insulin, short-acting rather than a long-acting analog, and it is dispensed as supplied rather than diluted by the pharmacy.

A patient who regularly fills sildenafil brings in a new prescription for sublingual nitroglycerin, and the system fires an interaction alert. Why does this combination matter?

• a.Together they can cause severe, life-threatening hypotension✓
• b.Nitroglycerin blocks the enzyme that clears sildenafil, causing priapism
• c.Together they raise blood pressure enough to trigger a hypertensive emergency
• d.Sildenafil makes nitroglycerin lose potency in the bottle

Both drugs act on the same nitric-oxide pathway and amplify vasodilation, so a nitrate taken by someone who has recently used a PDE-5 inhibitor can drop blood pressure catastrophically; this is a contraindication rather than a caution, and the alert belongs in front of the pharmacist before the prescription goes out. The hypertensive-emergency answer inverts the mechanism, since both agents lower blood pressure rather than raise it. Sildenafil does not degrade nitroglycerin tablets, and priapism with PDE-5 inhibitors is not produced by nitrate-induced enzyme blockade.

A lyophilized vaccine is supplied with a separate diluent. How should that diluent be handled in the pharmacy?

• a.Store it in the refrigerator door so it cannot freeze at the back wall
• b.Use any manufacturer's sterile water, since vaccine diluents are interchangeable
• c.Store it at room temperature or refrigerated, and keep it out of the freezer✓
• d.Store it in the freezer with the lyophilized vaccine it belongs to

Diluents are stored as their own labeling directs — at room temperature or refrigerated — and must never be frozen, because freezing can crack the vial and damage the stabilizers the diluent carries. Freezing it alongside the vaccine is the tempting answer, since some lyophilized vaccines are themselves stored frozen, but only the vaccine goes into the freezer. Each diluent is formulated for its specific vaccine and may not be swapped for another product or for plain sterile water, and the refrigerator door is not an acceptable storage location for any vaccine component.

A prescription sig reads: 1 tab PO qid ac & hs. Which set of patient directions is correct?

• a.Take 1 tablet by mouth every six hours around the clock with food
• b.Take 1 tablet by mouth after each meal and again at bedtime
• c.Take 1 tablet by mouth four times a day as needed for symptoms
• d.Take 1 tablet by mouth before each meal and at bedtime✓

qid is four times daily, ac is ante cibum or before meals, and hs is hora somni or at bedtime, so the four doses fall before each of the three meals and once at bedtime. Reading the doses as coming after meals swaps ac for pc, post cibum, which moves every dose to the wrong side of the meal and matters for drugs that must be taken on an empty stomach. Doses spaced every six hours around the clock would be written q6h, which detaches them from meals, and nothing in this sig makes the drug an as-needed one.

A prescription reads: hydrocortisone 1% ung, apply to the affected area bid. The shelf holds both a cream and an ointment of that drug and strength. Which product should be pulled?

• a.Either product, because a cream and an ointment of the same strength are interchangeable
• b.The ointment, because ung abbreviates unguentum✓
• c.The lotion, because ung indicates a pourable topical preparation
• d.The cream, because ung marks a water-washable topical base

ung is the abbreviation for unguentum, the Latin word for ointment, so the ointment is the dosage form the prescriber ordered. Treating the cream as equivalent is the tempting error, because both are semisolid topicals of the same drug and strength, but the base changes how the drug is delivered and how long it stays on the skin, and a change of dosage form needs the prescriber's authorisation. A cream would be written crm, and a lotion is a separate pourable dosage form altogether.

Why must the NDC transmitted on a third-party claim match the NDC on the stock bottle actually used to fill the prescription?

• a.A mismatched NDC changes the product's therapeutic equivalence rating and blocks substitution
• b.Federal law requires the dispensing label to print the same NDC that the claim carries
• c.The NDC sets the price the pharmacy paid the wholesaler
• d.The plan pays for the exact package billed and audits compare it to the stock used✓

The NDC on a claim is the pharmacy's statement of whose package, in what size, was dispensed; reimbursement is calculated from that number and an auditor reconciles it against the bottles on the shelf and the purchase invoices, so billing one manufacturer's NDC while dispensing another's produces a recoverable overpayment even when the drug is identical. The labelling answer is the closest wrong one, because the NDC often does print on the dispensing label, but that is pharmacy and state practice rather than what makes the match matter on the claim. Therapeutic equivalence ratings come from the Orange Book, and the NDC identifies a package rather than a price.

A prescriber leaves the substitution line open on a brand-name prescription that has an AB-rated generic, the patient asks for nothing in particular, and the pharmacy dispenses the generic. Which DAW code belongs on the claim?

• a.DAW 3, substitution allowed and the pharmacist selected the brand
• b.DAW 0, no product selection indicated✓
• c.DAW 2, substitution allowed but the patient requested the brand
• d.DAW 1, substitution not allowed by the prescriber

DAW 0 is the code for a claim on which nobody indicated a product selection, which is exactly what a routine generic fill is. The pharmacist-selected code is the closest wrong answer, because a pharmacist did choose the product here, but that code is reserved for the case where the pharmacist dispenses the brand although substitution was allowed. The prescriber code applies only when the prescriber blocks substitution, and the patient code only when the patient asks for the brand and pays the difference.

A prescriber wants to transmit controlled-substance prescriptions to the pharmacy electronically. Under the federal EPCS rules, what must be true of that transmission?

• a.The prescription must be followed by a signed paper copy delivered to the pharmacy within seven days
• b.The prescriber signs each prescription with two-factor authentication in a certified application✓
• c.Office staff may transmit the prescription under the prescriber's shared log-in
• d.Only Schedule III through V prescriptions may be sent electronically

Electronic prescribing of controlled substances is open to every schedule the prescriber may write, but the practitioner has to sign the record inside an application certified for the purpose, using two of the three permitted identity factors. The paper follow-up is the closest wrong answer, because an emergency oral order for a Schedule II drug really does have to be covered by a written prescription within seven days, while a compliant electronic prescription is the legal record on its own. A shared log-in defeats the whole point of the signing credential, which is personal to the prescriber and may not be delegated.21 CFR part 1311

A patient asks a second pharmacy to pick up the remaining refills on an alprazolam prescription. The two pharmacies do not share a real-time online database. What does federal law allow?

• a.The remaining refill information may be transferred one time only✓
• b.The refill information may be transferred as often as refills remain
• c.Transfer is barred for every controlled substance, whatever its schedule
• d.Transfer requires a new prescription from the prescriber

Alprazolam is a Schedule IV drug, and federal rules let the refill information on a Schedule III, IV or V prescription be transferred between pharmacies on a one-time basis. Repeated transfers are the closest wrong answer, because pharmacies that share a real-time online database may indeed transfer up to the number of refills authorised, and this pair does not qualify for that exception. A blanket ban would be right only for Schedule II, which carries no refills at all, and asking the prescriber for a new prescription is always an option but is not what the transfer rule permits.21 CFR 1306.25

A patient leaving the country for a month asks to refill a maintenance drug early, and the claim rejects as refill too soon. What is the correct step?

• a.Contact the plan and request a vacation supply override✓
• b.Change the day supply on the claim until the refill goes through
• c.Resubmit the claim each morning until it pays
• d.Sell the early refill as a cash prescription without telling the plan

Plans build a vacation or extended-travel override into their refill-too-soon edits, and the pharmacy obtains it by calling the help desk with the travel dates. The cash sale is the closest wrong answer, because a patient may legitimately choose to pay cash, but doing it silently costs the patient a benefit they are entitled to and leaves the early supply off the plan's profile. Altering the day supply to force payment is a false claim, and resubmitting an unchanged claim does not move the refill date the plan is measuring against.

A new prescription rejects with the message that the product is not on the plan's formulary. Which step by the technician is most likely to resolve it?

• a.Submit a prior authorisation request, since every non-formulary reject is cleared that way
• b.Substitute a drug from the same class that the plan does cover and bill for it
• c.Send the plan's preferred alternatives to the prescriber and ask for a new prescription✓
• d.Tell the patient the drug is not covered and charge the cash price

A formulary reject is a coverage decision the pharmacy cannot overturn; what it can do is look up what the plan covers in that class and put those options in front of the prescriber, who is the only person able to write the new prescription. Prior authorisation is the closest wrong answer, and some plans do cover a non-formulary drug through an exception request, but that request also has to come from the prescriber with clinical justification and many plans exclude non-formulary products outright. Switching the drug inside the pharmacy dispenses something that was not prescribed, and quoting the cash price without offering a covered route gives the patient nowhere to go.

A claim rejects with 'prior authorisation required'. Which statement describes how that authorisation is actually obtained?

• a.The pharmacist approves it after documenting the need in the profile
• b.The prescriber submits clinical justification to the plan✓
• c.The patient telephones the plan and requests the authorisation
• d.The pharmacy forwards the patient's chart notes to the plan

Prior authorisation is a coverage decision the plan makes on the prescriber's clinical evidence, so the prescriber's office is the only party that can complete it; a technician may start the paperwork, notify the office and track the outcome. The patient's call is the closest wrong answer, because members can and do reach the plan's help desk, but the plan still turns to the prescriber for the clinical information before approving anything. The pharmacy does not hold the chart notes, and no pharmacist has authority over a plan's coverage decisions.

A claim rejects with a message that the patient must first try a preferred agent in the same class before this product will be covered. What is this plan requirement called?

• a.A prior authorisation requirement
• b.Therapeutic interchange by the pharmacy
• c.A step-therapy requirement✓
• d.A quantity limit

Step therapy makes coverage of the requested product conditional on a documented trial of the plan's preferred agent first. Prior authorisation is the closest wrong answer, and the two are often worked through the same help desk, but a prior authorisation asks for clinical justification of this drug while step therapy asks for evidence that a cheaper one was tried and failed. A quantity limit caps how much may be dispensed in a period, and therapeutic interchange is a substitution made under a protocol inside a health system rather than a claim reject.

Which piece of information belongs on the label of a prescription dispensed to a patient but is not required on the manufacturer's stock bottle it was counted from?

• a.The patient's name and the directions for use✓
• b.The product's National Drug Code in 11-digit format
• c.The name and address of the drug's manufacturer
• d.The lot number the manufacturer assigned to the production run

A dispensing label is a patient-specific document: it names the patient and carries the directions the prescriber wrote, and neither can appear on a manufacturer's bulk container that has no patient attached to it. The lot number is the closest wrong answer, because pharmacies do record lot numbers for repackaged products and immunizations, but the manufacturer must print it on the stock bottle while a retail dispensing label is not required to show it. The National Drug Code and the manufacturer's name and address are elements of the manufacturer's own labelling.

A pharmacy's cost of goods sold for the year was $1,200,000 and its average inventory value was $100,000. What is the inventory turnover rate?

• a.0.08 times a year
• b.12 times a year✓
• c.120 times a year
• d.1 time a year

Inventory turnover is the cost of goods sold divided by the average inventory value: $1,200,000 / $100,000 = 12, so the pharmacy sells and replaces the value of its shelf stock twelve times a year. Checking the same figure another way, $100,000 of stock turned twelve times supplies $1,200,000 of goods. Dividing in the opposite direction, $100,000 / $1,200,000, gives 0.08, using one month's cost of goods, $100,000 / $100,000, gives 1, and shifting the decimal one place gives 120.

What does a perpetual inventory of Schedule II drugs give a pharmacy?

• a.A record the wholesaler keeps for the pharmacy's audits
• b.A monthly reconciliation of purchases against the DEA Form 222 file
• c.A count of the entire controlled stock taken once every two years
• d.A running balance updated with every transaction✓

A perpetual inventory is a live running balance: every receipt adds, every dispensing subtracts, and the recorded quantity of a Schedule II drug can be compared with the shelf at any moment. The biennial count is the closest wrong answer, because federal law does require a complete controlled-substance inventory every two years, but that is a snapshot taken once every two years and it cannot show a loss in the week it happens. Reconciling against the Form 222 file covers only what was ordered, and the wholesaler's records document what was shipped rather than what left the pharmacy.

A stock bottle is labelled EXP 09/2026, with no day shown. What does that date mean for dispensing?

• a.Once the bottle is opened the printed date no longer applies and a six-month limit takes over
• b.The product may be dispensed through the last day of September 2026✓
• c.The product should have been pulled at the end of August 2026
• d.The product may be dispensed only through 1 September 2026

A manufacturer's expiration date printed as a month and a year runs through the last day of that month, so this bottle may be used up to and including 30 September 2026. Reading it as the first of the month is the closest wrong answer, and it errs on the safe side, but it discards a month of usable stock on every bottle in the pharmacy. An unopened manufacturer's container stored as labelled keeps its printed date; the shorter dating that starts when a container is opened belongs to products the pharmacy repackages or compounds.

A pharmacy sends expired Schedule II tablets to a DEA-registered reverse distributor. What documents that transfer of the drugs?

• a.A DEA Form 41 completed by the pharmacy when the courier collects them
• b.A signed inventory sheet kept in the pharmacy for two years
• c.A DEA Form 222 issued to the pharmacy by the reverse distributor✓
• d.The credit memo the reverse distributor returns

A transfer of a Schedule II substance moves on a DEA Form 222, executed by the registrant receiving the drugs, and that applies to expired stock going to a reverse distributor just as it does to a purchase. Form 41 is the closest wrong answer, because it is the controlled-substance disposal record, but it documents the actual destruction and is completed by the registrant who destroys the drugs rather than by the pharmacy handing them over. A credit memo and an internal inventory sheet are business records with no standing under the controlled-substance rules.

A technician repackages tablets from a bulk bottle into unit-dose blisters for a hospital's cabinets. Besides the blister labels, what must the repackaging record capture?

• a.The name of every patient who later receives one of the repackaged doses
• b.The source lot number and expiration date and the run's control number
• c.The drug name, strength and the number of packages produced
• d.The wholesaler's invoice number for the bulk bottle✓

A repackaging record has to make it possible to walk any unit-dose package back to the container it came from, so it captures the manufacturer's lot number and expiration date of the source bottle together with the internal control number placed on the run. Recording drug, strength and count is the closest wrong answer, because those details do belong in the log, but without the source lot number a recall cannot be traced and every package from that run has to be destroyed. Patient names belong to dispensing records, and an invoice number tracks a purchase rather than a package on a cart.

A hospital outpatient pharmacy fills prescriptions from 340B-purchased inventory. What has to be true before a given prescription may be filled from that stock?

• a.The patient must be enrolled in Medicaid on the day of the fill
• b.The prescription must be for a generic product with an AB rating
• c.The patient must be an eligible patient of the covered entity✓
• d.The patient must be uninsured, or below a stated income level

340B pricing follows the patient relationship: the drug has to go to a patient of the covered entity on a prescription arising from care the entity provided, and diverting that inventory to anyone else is exactly what program audits look for. Income or insurance status is the closest wrong answer, because 340B entities do serve low-income populations, but the discount is conditioned on the patient relationship and not on the patient's means. Medicaid enrolment matters only for the separate rule that stops a manufacturer paying a rebate on a drug already sold at the 340B price, and the program covers brand products as well as generics.

A mail-order pharmacy located in one state ships maintenance prescriptions to patients in thirty others. What does shipping into those states require?

• a.A nonresident pharmacy license in each state served✓
• b.Nothing beyond the license held in the pharmacy's home state
• c.Registration with the FDA as an out-of-state dispenser of drugs
• d.A staffed pharmacy location inside every state served

Pharmacy licensure follows the patient, so a mail-order operation needs a nonresident or out-of-state pharmacy license from the board of every state it ships into, on top of the license where it physically sits. Relying on the home-state license is the common misreading, and it is precisely what boards pursue when an unlicensed pharmacy ships across a border. The FDA registers manufacturers, repackagers and outsourcing facilities rather than dispensing pharmacies, and no state makes a physical location a condition of shipping in.

Electronic prescribing takes the prescriber's handwriting out of the process. Which new error should the technician watch for when an e-prescription arrives?

• a.A drug or strength picked from the wrong line of the prescriber's drop-down list✓
• b.The same prescription transmitted twice, so the patient is set up with a duplicate supply
• c.A decimal point misread because the dose was written with a trailing zero
• d.A transcription slip made as the pharmacy re-keys the directions

The characteristic e-prescribing error is a selection error: the prescriber clicks the line above or below the intended product and the pharmacy receives a clean, legible prescription for the wrong drug or the wrong strength, with nothing on its face to signal the mistake. Duplicate transmission is the closest wrong answer, and it does happen, but a duplicate arrives as two identical orders and is caught by the system's duplicate-therapy and refill-too-soon edits. Trailing-zero misreads and re-keying slips belong to handwritten and telephoned orders, which an e-prescription bypasses.

A non-controlled prescription is written for #30 with the note 'refill prn'. In most states, how should the refills be entered?

• a.As refills for two years, the federal limit for non-controlled drugs
• b.As refills sufficient to cover one year from the date written✓
• c.As unlimited refills until the prescriber cancels the prescription
• d.As five refills within six months of the date written

A note to refill as needed is not a license for perpetual refills: in most states a non-controlled prescription may be refilled for one year from the date it was written, so the entry is capped at that horizon, commonly eleven refills on a thirty-day quantity. Unlimited refills is the closest wrong answer, because the prescriber did write prn, but the prescription itself expires under state law whatever the note says. Five refills in six months is the federal limit for Schedules III and IV, and there is no federal two-year refill limit for non-controlled drugs.

Cefdinir 125 mg/5 mL oral suspension is prescribed as 3.75 mL by mouth twice daily for 10 days. What quantity should be dispensed?

• a.112.5 mL
• b.37.5 mL
• c.75 mL✓
• d.7.5 mL

Each day the patient takes 3.75 mL x 2 = 7.5 mL, and over 10 days that is 7.5 mL x 10 = 75 mL. Checking the same figure another way, twice daily for 10 days is 20 doses in all, and 3.75 mL x 20 = 75 mL. Counting one dose a day gives 37.5 mL and counting three a day gives 112.5 mL, while 7.5 mL is a single day's total rather than the quantity for the course.

Warfarin 5 mg tablets are prescribed as: take 1 tablet by mouth on Monday, Wednesday and Friday, and one-half tablet by mouth on each of the other days. Ninety tablets are dispensed. What is the day supply?

• a.90 days
• b.126 days✓
• c.18 days
• d.60 days

One week uses 3 x 1 tablet + 4 x 0.5 tablet = 3 + 2 = 5 tablets, so 90 tablets last 90 / 5 = 18 weeks, and 18 x 7 = 126 days. Checking the same figure another way, 5 tablets per 7 days is 0.714 tablets a day, and 90 / 0.714 = 126 days. Averaging the two dose sizes into 1.5 tablets a day gives 90 / 1.5 = 60 days, counting a whole tablet every day gives 90 days, and 18 is the number of weeks left unconverted.

A wholesaler delivery includes one bottle that expires in six weeks, of a drug the pharmacy dispenses about twice a year. What should the technician do with it?

• a.Shelve it behind the existing stock, which was received earlier
• b.Shelve it in front of the existing stock so it is used first
• c.Return the short-dated bottle to the wholesaler✓
• d.Move it to the quarantine shelf until the date passes

Wholesalers take short-dated stock back within a stated window, and returning it now recovers the money while that credit is still available; at roughly two dispensings a year this bottle will expire untouched on the shelf. Shelving it in front is the closest wrong answer, because first-expired-first-out is the correct rotation rule, but rotation only helps when the product will actually move before the date, which it will not here. Shelving by receipt date ignores expiration altogether, and holding it in quarantine until it expires turns a returnable bottle into waste.

A plan's contract says it pays the lower of the contracted rate or the pharmacy's usual and customary price. What is the usual and customary price?

• a.The average wholesale price less the plan's contracted discount
• b.The maximum allowable cost the plan sets for a multi-source generic
• c.The price a cash customer pays for that prescription✓
• d.The pharmacy's acquisition cost

The usual and customary price is what the pharmacy would charge a cash-paying customer walking in for that same prescription, and the plan pays that figure whenever it is lower than the contracted rate. Maximum allowable cost is the closest wrong answer, because it also caps what a plan will pay, but it is a ceiling the plan sets for a multi-source generic rather than a price the pharmacy sets. Acquisition cost is what the pharmacy paid for the drug and average wholesale price is a published list figure, and a cash customer is charged neither of them.

Which federal law required pharmacies to offer counselling and to carry out a prospective drug utilization review for Medicaid patients?

• a.The Health Insurance Portability and Accountability Act of 1996
• b.The Omnibus Budget Reconciliation Act of 1990✓
• c.The Drug Quality and Security Act of 2013
• d.The Poison Prevention Packaging Act of 1970

The Omnibus Budget Reconciliation Act of 1990 tied federal Medicaid funding to a prospective drug utilization review and an offer to counsel, and the states then extended both duties to patients generally. The privacy statute is the closest wrong answer, because it also governs what happens at the counter, but it controls the use and disclosure of health information rather than requiring any counselling offer. Child-resistant packaging comes from the 1970 packaging law, and drug supply-chain track-and-trace requirements from the 2013 statute.

Under the federal Controlled Substances Act, which of these prescription products is placed in Schedule V?

• a.Methylphenidate tablets for attention-deficit disorder
• b.Diphenoxylate with atropine tablets for diarrhea✓
• c.Alprazolam tablets for anxiety
• d.Buprenorphine film for opioid use disorder

Diphenoxylate combined with a subtherapeutic amount of atropine is a Schedule V product; the atropine is added specifically to discourage abuse of the opioid. Buprenorphine is the closest trap because it is also an opioid used in low doses under tight control, but it is Schedule III. Alprazolam is Schedule IV and methylphenidate is Schedule II.21 CFR 1308.15

Which statement correctly describes how Schedule III differs from Schedule IV under the Controlled Substances Act?

• a.Schedule III substances may be refilled five times, while Schedule IV substances may not be refilled
• b.Schedule III substances must be ordered on a DEA Form 222, while Schedule IV substances need no order form
• c.Schedule III substances have a greater potential for abuse than Schedule IV substances✓
• d.Schedule III substances have no currently accepted medical use in the United States

The schedules are ranked by abuse potential and dependence liability, so Schedule III sits above Schedule IV. Both have accepted medical uses, both are limited to five refills within six months, and only Schedule I and II substances require a DEA Form 222 or a CSOS order. Testosterone and acetaminophen with codeine are typical Schedule III products; alprazolam and zolpidem are Schedule IV.21 USC 812

While preparing a paper DEA Form 222 for a Schedule II order, a technician writes the wrong number of packages on one line. What does federal regulation require?

• a.The technician may line through the entry and initial the change, provided the pharmacist signs the form afterward
• b.The form must be voided and a new one prepared, because a supplier may not fill an order form that shows any alteration or erasure✓
• c.The line may be left as written, and the correct quantity noted on the packing slip when the order is received
• d.The entry may be corrected in ink and initialed if the supplier is telephoned before the form is mailed

A supplier is forbidden to fill an order form that is incomplete, illegible, or that shows any alteration, erasure or change, so the only remedy is to void the defective form and execute a fresh one; the voided form is retained with the pharmacy's Schedule II records. Crossing out and initialing is the tempting answer because that is how most other pharmacy records are corrected, but on an order form it is exactly what makes the document defective.

A pharmacy orders Schedule II products electronically through the Controlled Substance Ordering System (CSOS) instead of on paper. What does federal law require of the person who signs those orders?

• a.The signer must enter the pharmacy's shared CSOS password, which the wholesaler reissues each year
• b.The signer must be the pharmacist-in-charge listed on the pharmacy's DEA registration
• c.The signer must hold an individual CSOS digital certificate issued by the DEA✓
• d.The signer must fax a paper DEA Form 222 to the supplier

A CSOS digital certificate is issued by the DEA to a named individual — the registrant, or a person who holds power of attorney for ordering — and that certificate, not a shared store password, signs the electronic order. Naming the pharmacist-in-charge is tempting because that person usually does hold the power of attorney, but the rule is about who holds a certificate, not about the title. No paper form accompanies a CSOS order.

A pharmacy destroys expired Schedule II tablets on site and records the destruction on DEA Form 41. What does the DEA require about how that destruction is carried out?

• a.A DEA diversion investigator must be present in the pharmacy during the destruction
• b.The pharmacist-in-charge may destroy the drugs alone if their acquisition cost is under five hundred dollars
• c.A licensed reverse distributor must take possession before any Schedule II drug may be destroyed
• d.Two authorized employees must witness the destruction and sign the record✓

The destruction must render the substance non-retrievable, and the Form 41 record is witnessed and signed by two employees the registrant has authorized. Sending expired stock to a licensed reverse distributor is the tempting answer because it is what most community pharmacies actually do, but it is one lawful option rather than a requirement — a registrant may destroy on site and document it on Form 41.

A pharmacy confirms that a significant quantity of controlled substances has been stolen. In addition to completing DEA Form 106, what does federal regulation require?

• a.Written notice to the DEA field division office within one business day of discovering the loss✓
• b.Completing an internal audit first and notifying the DEA once the exact missing quantity is known
• c.Written notice to the DEA field division office within thirty days of discovering the loss
• d.Notifying the local police only, since Form 106 itself serves as notice to the DEA

On discovering a theft or significant loss the registrant must notify the DEA field division office in writing within one business day, and Form 106 follows. Waiting for the audit is the tempting answer, because Form 106 does ask for exact quantities and the pharmacy usually cannot state them on day one — but the notification clock runs from discovery, not from the completed count.21 CFR 1301.76

When a pharmacy takes its biennial controlled substance inventory, how must the quantities on hand be counted?

• a.Schedule II items must be counted exactly; Schedule III through V items may be estimated✓
• b.Every schedule may be estimated as long as a pharmacist signs and dates the inventory record
• c.Only Schedule II items are inventoried; Schedule III through V items are counted when ownership changes
• d.Every schedule must be counted exactly, including opened Schedule V syrups

Federal rules require an exact count of every Schedule II substance on hand. For Schedule III through V an estimated count is acceptable, except that a container holding more than 1,000 tablets or capsules must be counted exactly. Estimating everything is the tempting answer because it is true for most of the shelf, but it fails on the Schedule II requirement.21 CFR 1304.11

Federal law sets a minimum period for keeping controlled substance records at the registered location. What is that period, and how do state requirements interact with it?

• a.Two years, and a state board may require a longer period✓
• b.Two years, and no state may require longer because federal law preempts state record rules
• c.Five years in every state, because HIPAA extended the federal period
• d.Seven years, matching the federal retention period for business tax records

The federal floor is two years, and the records must be kept at the registered location and be readily retrievable. Federal law does not preempt stricter state rules here: many boards of pharmacy require three, five or more years, and the pharmacy follows whichever period is longer. HIPAA governs privacy documentation and does not set the retention period for controlled substance records.21 CFR 1304.04

Federal regulations govern how a pharmacy files the paper prescriptions it has dispensed. How must Schedule II prescriptions be filed?

• a.Interfiled with Schedule III through V prescriptions in one controlled substance file
• b.In a separate file that holds Schedule II prescriptions and nothing else✓
• c.In any arrangement the pharmacy chooses, provided the records can be produced within 72 hours of a DEA request
• d.Interfiled with non-controlled prescriptions and stamped with a red C

Schedule II prescriptions must be maintained in a file separate from every other prescription record. The red C answer describes the alternative available for Schedule III through V prescriptions, which may be kept in their own file or interfiled with non-controlled prescriptions if marked with a red C at least one inch high — an option that does not extend to Schedule II. Pharmacies using an electronic system that makes the records readily retrievable are excused from the red C marking.21 CFR 1304.04

A prescriber telephones an emergency oral prescription for a Schedule II drug and the pharmacist dispenses only the amount needed for the emergency period. What must happen next under federal regulations?

• a.The prescriber must deliver a written, signed prescription to the pharmacy within seven days✓
• b.The pharmacist must obtain a written prescription before the patient leaves the pharmacy
• c.The prescriber must deliver a written, signed prescription to the pharmacy within seventy-two hours
• d.No further paperwork is required once the oral order is entered in the profile

The prescriber has seven days to deliver the written, signed prescription covering the emergency oral order, and if it does not arrive the pharmacist must notify the DEA. Seventy-two hours is the closest wrong answer because that figure does appear in the Schedule II rules — it is the window for supplying the balance of a partially filled prescription, a different situation.21 CFR 1306.11

A pharmacy can supply only part of the quantity written on a Schedule II prescription because of a stock shortage. Under federal rules, what applies to the remaining quantity?

• a.It may be supplied whenever the wholesaler delivers, since the prescription is already on file
• b.It must be supplied within 72 hours, or the pharmacist must notify the prescriber✓
• c.It must be supplied within 30 days of the date the prescription was issued
• d.It requires a new prescription, since Schedule II prescriptions may not be partially filled

When the pharmacist cannot supply the full quantity, the balance may be dispensed within 72 hours; if that passes, the pharmacist must notify the prescriber and no further quantity may go out on that prescription. The 30-day answer is genuinely close, because a partial fill requested by the patient or the prescriber does allow the remainder to be filled up to 30 days after the prescription was written — but that is a requested partial fill, not a stock shortage.21 CFR 1306.13

A resident of a long-term care facility has a Schedule II prescription that the pharmacy dispenses in small amounts as the resident needs them. For how long do federal rules allow that prescription to be partially filled?

• a.Up to 72 hours from the first partial fill, as in a community pharmacy
• b.Up to 90 days from the date it was issued, matching a typical maintenance supply
• c.Up to six months from the date it was issued, as with Schedule III refills
• d.Up to 60 days from the date it was issued✓

For a patient in a long-term care facility, and for a patient the prescriber has documented as terminally ill, a Schedule II prescription may be partially filled for up to 60 days from the issue date unless it is terminated sooner. The 72-hour answer is the tempting one because that limit does govern partial fills in a community pharmacy that is simply out of stock; the long-term care provision is a separate, longer allowance.21 CFR 1306.13

Under federal law, how long after it is written may a Schedule II prescription still be filled?

• a.Federal rules set no fixed limit, and many state boards impose one of their own✓
• b.Federal rules allow six months, as with Schedule III refills
• c.Federal rules allow 90 days when the prescription is for a chronic condition
• d.Federal rules allow 30 days, after which the prescriber must write a new prescription

The DEA has not set a federal expiration date for filling a Schedule II prescription; it must be presented within a reasonable time and the prescriber's intent must still be current, but no number of days appears in the federal rule. Many state boards do set a limit, commonly 30, 60, 90 or 180 days, and the pharmacy follows its own state's rule. The six-month figure belongs to Schedule III through V refills, not to filling a Schedule II.

A patient asks a pharmacy to transfer the remaining refills on a Schedule IV prescription to a different pharmacy. What does federal law allow?

• a.Unlimited transfers, provided both pharmacists record the date and their initials
• b.No transfer at all, since prescriptions for any controlled substance may never be transferred between pharmacies
• c.One transfer of the remaining refills, unless the two pharmacies share a real-time online database✓
• d.Transfers back and forth between the pharmacies as often as the patient asks

Refill information for a Schedule III, IV or V prescription may be transferred one time only, and both pharmacists must document the transfer. Where the two pharmacies share a real-time, online database, transfers may be made up to the maximum number of refills authorized. The blanket no-transfer answer describes Schedule II prescriptions, which carry no refills to transfer in the first place.21 CFR 1306.25

Federal regulations permit certain Schedule V products that are not prescription drugs to be sold at retail without a prescription. What does federal law require of that sale, and what may a state do?

• a.A pharmacist must make the sale to a buyer at least 18 years old; a state may forbid it✓
• b.Any pharmacy employee may make the sale once the buyer signs the pseudoephedrine logbook and shows a photo ID
• c.Any pharmacy employee may make the sale to a buyer at least 21 years old, and no state may forbid it
• d.A pharmacist must make the sale, and only to a buyer already known to the pharmacy

Federal rules let a pharmacist personally sell a limited quantity to a purchaser at least 18 years of age, obtain identification from a purchaser not known to the pharmacist, and record the sale in a bound book. Federal law is only a floor here: many states require a prescription for these products, and where the state is stricter the state rule controls. Requiring the buyer to be already known to the pharmacy inverts the identification rule, which exists precisely for buyers who are not known.21 CFR 1306.26

A customer buys a pseudoephedrine product under the Combat Methamphetamine Epidemic Act. What does federal law require of the record of that sale?

• a.A logbook entry with photo identification, kept until the end of the calendar year
• b.A logbook entry signed by the pharmacist who made the sale, kept six months
• c.A logbook entry with photo identification, kept for two years✓
• d.An electronic record transmitted to the DEA within one business day of each sale

The seller records the product, the quantity, the purchaser's name and address and the date and time of sale, verifies photo identification, obtains the purchaser's signature, and keeps the logbook for at least two years after the last entry. Nothing is transmitted to the DEA at the point of sale, and federal law does not require a pharmacist to ring up the sale, although several states are stricter on that point.

A patient asks that all of her prescriptions be dispensed in easy-open containers because she has arthritis. Under the Poison Prevention Packaging Act, what may the pharmacy do?

• a.Honor the request for one prescription at a time, with a new request at each fill
• b.Refuse, because federal law waives child-resistant packaging only for named exempt drugs
• c.Honor a standing request from the patient that covers all of her prescriptions, and keep it on file✓
• d.Honor the request only if the prescriber writes a waiver on each prescription

The Act, enforced by the Consumer Product Safety Commission rather than the FDA, allows the patient to give a blanket request covering all of her prescriptions, and the pharmacy documents it. A prescriber's request is the narrower one — it applies only to the prescription on which it appears. Exempt products such as sublingual nitroglycerin are a separate provision and do not limit the patient's right to ask.

A manufacturer recalls several lots of a tablet because the outer carton misspells the company's mailing address. The drug itself and the directions for use are unaffected. How does the FDA classify this recall?

• a.Class III, a defect that is not likely to cause an adverse health consequence✓
• b.Class II, a defect that may cause temporary or medically reversible health harm
• c.Class I, since any labeling error creates a reasonable probability of serious harm
• d.A market withdrawal, since the FDA does not regulate carton printing

Class III covers situations where use of the product is not likely to cause any adverse health consequence, which fits a cosmetic misprint that does not touch the drug, its strength or its directions. Class II is the closest wrong answer and would apply if the labeling error could lead to a temporary or reversible harm, such as a wrong strength on the carton. A market withdrawal involves a minor issue that is not a violation the FDA would act on, and printed labeling is very much regulated.

Under the Drug Supply Chain Security Act, a pharmacy receives transaction information and a transaction statement with each shipment of prescription drugs. What must the pharmacy do with those records?

• a.Keep them for six years from the date of the transaction and produce them on request✓
• b.Keep them for two years, which is the period that applies to controlled substance records
• c.Return them to the wholesaler once the shipment has been checked in
• d.Keep them only for the products that are controlled substances

A dispenser must retain the transaction information and transaction statement for at least six years from the date of the transaction and be able to produce them, particularly when investigating a suspect or illegitimate product. The two-year answer is tempting because it is a real retention period in a pharmacy — it is the DEA's period for controlled substance records, a different law with its own clock. The Act covers prescription drug purchases generally, not only controlled substances.

A health plan telephones a pharmacy to ask about one patient's claim for a single medication. Which principle of the HIPAA Privacy Rule governs how much the technician may disclose?

• a.The patient authorization requirement, which bars disclosure without a signed release
• b.The treatment exception, which permits disclosure of the entire medication profile
• c.The minimum necessary standard✓
• d.The public health exception, which permits disclosure to any payer

Disclosures for payment are permitted without patient authorization, but they are limited to the minimum information necessary for the purpose — here, the single claim in question rather than the patient's whole medication history. The authorization answer is the tempting one because a signed authorization really is required for uses such as marketing; it is not required for payment activities.45 CFR 164.502

A patient reports high fever and extensive arm swelling that began the day after receiving an influenza vaccine at the pharmacy. Which federal system is used to report this event?

• a.The FDA MedWatch program, which receives reports on every FDA-regulated product
• b.The Vaccine Adverse Event Reporting System✓
• c.The state board of pharmacy, which forwards vaccine reports to the CDC
• d.The DEA field division office, using its adverse event report form

Adverse events following immunization go to VAERS, which the FDA and the CDC run jointly, and federal law requires health care providers to report certain post-vaccination events. MedWatch is the closest wrong answer because it genuinely does collect adverse events for drugs, biologics and devices, but vaccine events are routed to VAERS instead. The DEA has no role in adverse event reporting.

A pharmacy technician's duties include assisting with immunizations, so the OSHA Bloodborne Pathogens Standard applies. What must the employer make available?

• a.Hepatitis B vaccination at a cost shared equally by the employer and the employee
• b.Hepatitis B vaccination, but only after a documented needlestick injury
• c.Hepatitis B and hepatitis C vaccination at no cost to the employee
• d.Hepatitis B vaccination at no cost to the employee✓

The employer must offer hepatitis B vaccination free of charge, within 10 working days of the employee's initial assignment to work with occupational exposure; an employee who declines signs a declination form and may still accept the vaccine later. The needlestick answer inverts the rule, since the point of the standard is protection before an exposure occurs, and there is no hepatitis C vaccine to offer.29 CFR 1910.1030

The OSHA Hazard Communication Standard covers the hazardous chemicals a pharmacy keeps, such as disinfectants and compounding chemicals. What does it require of the safety data sheets?

• a.They must be kept in a locked cabinet with the pharmacist-in-charge holding the key
• b.They must be requested from the manufacturer only when an exposure occurs
• c.They must be readily accessible to employees on every shift✓
• d.They must be mailed to OSHA each year

Safety data sheets must be available to employees in their work area throughout each work shift, without having to ask permission or wait for someone with a key, which is why locking them away fails the standard even though the sheets are on the premises. Requesting a sheet only after an exposure defeats the purpose, since the sheet is what tells the employee how to respond.29 CFR 1910.1200

A drug's Risk Evaluation and Mitigation Strategy includes elements to assure safe use (ETASU). What does that add beyond a medication guide?

• a.The manufacturer must supply the drug to any pharmacy that orders it and pay for all patient monitoring
• b.Prescribers, pharmacies and patients may have to be certified or enrolled before dispensing✓
• c.The FDA reviews each individual prescription before it may be filled
• d.The drug is placed in a DEA schedule matching the seriousness of the risk it carries

ETASU can require prescriber certification, pharmacy certification, patient enrollment in a registry, documented laboratory monitoring, or dispensing only in certain settings, so a pharmacy that is not certified simply cannot dispense the product. A REMS is an FDA requirement and has no connection to DEA scheduling, and the FDA does not review individual prescriptions.

Two products carry the same AB therapeutic equivalence code in the Orange Book. What determines whether the pharmacy may actually dispense one in place of the other?

• a.The FDA's approval letter, which names the products that may be dispensed in place of the brand
• b.The wholesaler's purchasing contract, which lists the products a pharmacy may interchange
• c.The AB rating by itself, which authorizes substitution in every state
• d.State substitution law, since the AB rating by itself does not authorize a substitution✓

An AB code tells the pharmacy that the FDA considers the products therapeutically equivalent, but the authority to dispense one for the other comes from state substitution law, which varies on points such as patient notification, prescriber consent, and whether substitution is mandatory or permissive. The AB rating is a necessary condition in most states rather than the permission itself, which is why relying on the rating alone is the tempting error.