Chapter 21 Hypertension

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1. KMJ, a 50-year-old man approaches you at the pharmacy to seek your advice
regarding home blood pressure monitoring. He was diagnosed with mild
hypertension two months ago and has been using hydrochlorothiazide (HCTZ) 25
mg po daily since. KMJ does not have any other medical conditions and does not
take any over the counter medications. He smokes 4 to 6 cigarettes daily and
drinks a glass of wine daily at supper and drinks 1 to 2 cups coffee daily. As
pharmacist, you will provide him all of the following information regarding home
blood pressure monitoring, EXCEPT:*

1. A. An important aspect of home blood pressure monitoring is having the correct cuff
size.
2. B. Patients should lie down quietly for at least 30 minutes before taking reading.
3. C. Avoid smoking at least 30 min before taking blood pressure reading.
4. D. Avoid drinking coffee at least 30 min before taking blood pressure reading.

Answer
Ans: B
Tips: Patients should be advised to be seated quietly in a chair for at least 5 min utes with their
feet uncrossed on the floor and their arm supported at heart level. An important aspect of
home blood pressure monitoring is having the correct cuff size. The standard -size cuff is
recommended for patients with an arm circumference of 9 to 13 inches. For patients with arms
measuring 14 to 17 inches, a larger-size cuff should be used. Patients should lie down quietly
for at least 30 minutes before taking reading. Avoid caffeine and smoking at least 30 to 45 min
before measuring blood pressure. There are 3 major types of blood pressure monitors, the
mercury sphygmomanometer, the aneroid manometer, and the digital/electronic device, of
these three the mercury sphygmomanometer is the most accurate.
2. The blood pressure goal for most patients like KMJ without comorbid disease
is?

1. A. 120/80 mm Hg
2. B. <140/90 mm Hg
3. C. <130/80 mm Hg
 4. D. <160/90 mm Hg

Answer
Ans: B
Tips: According to Joint National committee on Prevention, Detection and Treatment of High
blood pressure, the blood pressure for most patients without comorbid disease is <140/90 mm
Hg. Patients with other medical conditions like diabetes or chronic kidney disease, goal is
<130/80 mm Hg.
3. The pharmacy technician prepared KMJ’s medication. Which of the following
would you include in your counselling of Hydrochlorothiazide 25 mg po qd with
KMJ?

1. A. Do not wear contact lenses.

2. B. Take it in the morning.
3. C. Take with a glass of orange juice or banana (K+ supplement)
4. D. Avoid combining with other antihypertensives.

Answer
Ans: B
Tips: As mentioned in Thiazide Class monograph, during the first week of thiazide therapy, if
given as once daily dose, thiazide should be taken in the morning to avoid nocturnal urination.
If given in multiple doses, last dose should be taken 6 hours before bedtime, preferably before
4 pm. This effect subsides 1-2 weeks of continuous therapy.
4. Continuing KMJ’s case, as part of your counselling, it is important to mention
few side effects KMJ should expect from the drug. Which of the following is/are
the side effects of hydrochlorothiazide?

1. A. Metabolic acidosis
2. B. Gout arthritis
3. C. Hyperlipidemia
4. D. B & C

Answer
Ans: D
Tips: Combination: HCTZ/amiloride, HCTZ/Triamterene, HCTZ/Spironolactone
5. MKT is a 60 year old man with high cholesterol, controlled stable angina,
experiencing < 1 angina attack per month secondary to coronary artery disease. On
his visit to his family physician his blood pressure was 165/[Link] doctor provides
diagnosis of hypertension. His current medication is rosuvastatin 10 mg daily. No
known allergies. At this time, doctor could consider adding?

1. A. Metoprolol
2. B. Lisinopril
3. C. Losartan
4. D. Hydrochlorothiazide

Answer
Ans: A
6. A patient of yours has the following on his profile:
Medical condition: hypertension and diabetes.
Lifestyle: drinks 1 glass of wine per day and smokes about 15 cigarettes per day.
His diet includes high fat and cholesterol.
Which from this patient’s risk factors has the LEAST effect on his hypertension?

1. A. Smoking cessation
2. B. Eating healthy food, balanced diet
3. C. Eating low-fat diet
4. D. Decreasing alcohol consumption

Answer
Ans: D
7. In evaluating the above patient’s overall cardiovascular risks, which of the
following has the highest risk?

1. A. Smoking
2. B. Diabetes
3. C. Hypercholesterolemia
4. D. All of the above

Answer
Ans: C
Tips: Two major drivers of elevated BP are obesity (especially in the young) and vascular
stiffness (especially in the old). Elevated BP leads to cardiovascular and renal complications.
Important sequelae are stroke, myocardial infarction, atrial fibrillation, heart failure, chronic
kidney disease and dementia
8. When assessing a patient’s hypertension treatment plan, which of the following
should be included in your evaluation?

1. A. Asses any secondary complications to his treatment plan.

2. B. Asses any complication secondary to high blood pressure.
3. C. Asses MP’s compliance
4. D. All of the above

Answer
Ans: D
9. A 57-year-old patient who is a regular customer of your pharmacy approaches
the pharmacy counter complaining of side effects from his medication. He is
currently using hydrochlorothiazide. Which of the following side effects is not
caused by his medication?

1. A. Gout
2. B. Erectile dysfunction
3. C. Hyperglycemia
4. D. Hypocalcemia
Answer
Ans: D
Tips: HyperGLUC (Increased in glyucose, lipids[LDL and TG], uric acid and Calcium.
10. MB presented to his family doctor complaining of increased blood sugar level.
MB has diabetes and was recently diagnosed with hypertension. He then was
prescribed an antihypertensive medication which he started taking few days ago.
Which of following antihypertensive drugs is most likely the cause of MB’s
hyperglycemia?

1. A. Angiotensin Converting Enzyme Inhibitor (ACEi)

2. B. Calcium Channel Blocker (CCB)
3. C. Hydrochlorothiazide
4. D. Verapamil

Answer
Ans: C
11. Continuing MB’s case, his doctor then switched him to another
antihypertensive. Weeks later, MB went back to the doctor complaining this time
of sexual dysfunction. Which of the following medications could MB he be possibly
taking?

1. A. Diuretics
2. B. Beta blockers
3. C. Angiotensin Converting Enzyme Inhibitor (ACEi)
4. D. Calcium Channel Blocker (CCB)

Answer
Ans: B
Tips: Beta blockers have erectile dysfunction side effect. Hydrochlorothiazide has (2% men)
erectile dysfunction. Potassium-sparing diuretics have erectile dysfunction.
12. Following MB’s case, he comes for refill of his medication. He wants to
seriously take over his condition because he does not want to end up like his
friend who died of all the complications. You will mention MB damage of all the
following organs as a result of hypertension complications, EXCEPT:

1. A. Heart
2. B. Eyes
3. C. Liver
4. D. Large vessels

Answer
Ans: C
13. MM is a 72-year-old female who was admitted to the hospital due to acute
pulmonary edema. Chest x-ray was done which showed fluid buildup in her lungs.
MM’s medication history indicates she is on furosemide 60 mg daily and digoxin
112 mcg daily. CrCl: 30 mL/min. She was started on ACEi therapy, Captopril 25
mg. Which of the following can be done to minimize first dose syncope?

1. A. Give test dose.

2. B. Withhold diuretic.
3. C. Use Fosinopril instead of Captopril.
4. D. Call doctor to change other ACE inhibitor.

Answer
Ans: B
Tips: First dose syncope could result from excessive hypotension caused by the synergistic
effects on blood pressure of the diuretic and ACE inhibitor. When initiating additional drug to an
existing antihypertensive therapy, it is recommended to introduce the second drug at a low dose
and titrated upward or the established drug should be decreased or discontinued prior to adding
the second drug.
Fosinopril has less renal accumulation and requires only daily single dose.
14. A 75-year-old patient who was recently diagnosed with hypertension comes at
your pharmacy to fill her prescription of Captopril 25 mg. BP: 150/85. In your
counselling with the patient, you should mention all of these side effects, EXCEPT:

1. A. Hyperkalemia
2. B. Angioedema
3. C. Pulmonary edema
4. D. A & B

Answer
Ans: C
15. A 75-year-old man with no medical history was recently diagnosed with MI and
moderate hypertension. What will you choose as treatment?

1. A. Angiotensin Converting Enzyme Inhibitor (ACEi)

2. B. B-blockers
3. C. Calcium Channel Blocker (CCB)
4. D. Diuretics

Answer
Ans: A
Tips: RxTx/CTC. Post-myocardial infarction. ACE inhibitors should be considered in all post-MI
patients, especially in those with LV dysfunction (LVEF <40%), hypertension or diabetes
mellitus.
16. Following the above patient’s case, which of the following is true regarding
Angiotensin-converting enzyme (ACE) inhibitors?

1. A. Increase in Low Density Lipoprotein (LDL), decrease in triglyceride (TG)

2. B. No effect on serum lipids
3. C. Decrease High Density Lipoprotein (HDL), increase in LDL
4. D. Lowers total cholesterol
Answer
Ans: B
17. If the above patient experiences cough which he cannot tolerate and is then
switched to Angiotensin II Receptor Blockers (ARBs), which of the following
correctly describes the mechanism of action of this class of drugs?

1. A. Do not cause breakdown of bradykinin.

2. B. Do not cause dry cough as Angiotensin Converting Enzyme Inhibitor (ACEi).
3. C. Do not allow binding to the receptors.
4. D. Inhibit renin secretion

Answer
Ans: C
18. A 65-year-old patient presented to his family physician with symptoms of
swollen feet and shortness of breath. With adequate investigation, the doctor gave
a diagnosis of peripheral and pulmonary edema. The laboratory results showed he
has renal failure, CrCL: 25 mL/min. Current medication is
Triamterene/hydrochlorothiazide 25/50 mg daily po. What other treatment should
the doctor give the patient?

1. A. Furosemide (if acute renal failure).

2. B. Furosemide and Metolazone (chronic renal failure).
3. C. Increase dose of Triamterene.
4. D. Do not change the dose.

Answer
Ans: A
19. For a patient taking calcium channel blockers (CCB), what is true regarding the
side effects of this class of drug?

1. A. Steady effect on lipids

2. B. No effect on lipids
3. C. Decrease effect with liver disease
4. D. Used in congestive heart failure (CHF)

Answer
Ans: B
20. Ms. DM is a 91kg, 52-year old female who was recently diagnosed with type 2
diabetes. On physical exam her BP was 148/94, SrCr was 150 umol/L, K is
4.5mmol/L. The recommended BP target for DM is:

1. A. <130/80
2. B. <140/90
3. C. <125/75
4. D. <100/80
Answer
Ans: A
21. Ms. DM’s family doctor starts her on Ramipril 2.5mg OD and plans on titrating
the dose upward to help control her BP and to decrease the amount of albumin
being excreted in her urine. Which of the following parameters should be
monitored upon initiation of the ACE-inhibitors?

1. A. Serum potassium
2. B. Serum Creatinine
3. C. Blood Pressure
4. D. All the above

Answer
Ans: D
22. The following information should be explained to Ms. DM regarding the use of
Ramipril:

1. A. Beneficial effects of ACE-inhibitor is in reducing the risk of complications of

diabetes
2. B. Common side effects: cough, light headedness, dizziness
3. C. Has rare but serious adverse effects (allergic reactions)
4. D. All the above

Answer
Ans: D
Tips: rare but serious side effects are angioedema.
23. Ms. DM’s family doctor orders a repeat blood test 5 days after initiating
Ramipril 2.5mg OD. SrCr is 165 umol/L and K is 4.5mmol/L (3.5 mmol/L). Based on
these results, Ramipril should be:

1. A. Temporarily held and blood test repeated.

2. B. Continued and blood tests repeated once a week.
3. C. Stopped indefinitely.
4. D. Stopped and an ARB started.

Answer
Ans: B
Tips: An increase in serum creatinine can occur upon initiation of an ACE-inhibitor or ARB. This
is often reversible. In most cases, serum creatinine will stabilize without discontinuing the ACE
inhibitor or ARB. However, if creatinine clearance increases more then 30% above baseline
immediately following initiation of an ACE inhibitor or ARB, the medication should be stopped
and the patient should be reassessed.
24. Ms. DM has been experiencing headaches recently because of the “stress of
being diagnosed with chronic disease”. She would like to purchase something to
help manage the pain. You recommend:

1. A. Ibuprofen
 2. B. Acetaminophen
3. C. Naproxen
4. D. All of the above

Answer
Ans: B
Tips: RxTx. Hypertension. NSAIDS are drugs that can induce or aggravate HTN.
25. In which of the following situations would caution an additional monitoring of a
serum creatinine upon initiation of an ACE-inhibitor or ARB?

1. A. Cough
2. B. Hypotension
3. C. Hyperkalemia
4. D. All of the above

Answer
Ans: D
26. In patients suffering from Addisonian crisis, all of the following agents would
elicit diuretic actions, EXCEPT:

1. A. Furosemide
2. B. Bumetanide
3. C. Spironolactone
4. D. Chlorothiazide

Answer
Ans: C
Tips: Spironolactone competes with aldosterone and drug would have no effect in the absence
of endogenous hormone in Addison disease patients.
27. Which of the following medications causes first syncope effect?

1. A. Prazosin
2. B. Doxazosin
3. C. Terazosin
4. D. All of the above

Answer
Ans: D
Tips: First-dose syncope is a common side effect of Alpha1-Adrenergic Antagonists that
usually occurs at the start of therapy, with rapid dose titration or on addition of other agents.
Titrate slowly.
28. A physician asks you about Carvedilol. What type of medicine is this?

1. A. It is an alpha & beta-blocker.

2. B. Cardio selective beta blocker
3. C. Non-selective beta blockers
4. D. Beta blocker with intrinsic sympathomimetic activity
Answer
Ans: A
29. A 63-year-old female lives with family. Medical history hypertension, type 2
diabetes, and past medical history of bilateral invasive ductal CA status post
bilateral lumpectomy and sentinel node biopsy and currently awaiting oncology
follow up. Social: non smoker, no alcohol use. No known allergies.
Medications includes:
Januvia/metformin 50/100 twice daily
Vitamin D3 1-tab po daily
Irbesartan 150 mg daily
Her labs were reviewed by a family physician found her blood pressure 150/90 and
HbA1C 7%. What antihypertensive medication would be appropriate to add to reach
target blood pressure?

1. A. Hydrochlorothiazide
2. B. Lisinopril
3. C. Amlodipine
4. D. Atenolol

Answer
Ans: C
Tips: According to ACCOMPLISH trails in high-risk patients (hypertension with diabetes or
known cardiovascular disease), an ACE inhibitor (benazepril) with amlodipine was superior to
an ACE inhibitor with a diuretic at preventing cardiovascular events.
30. All of the following patients can take beta blockers, EXCEPT:

1. A. Patients with peripheral vascular disease.

2. B. Younger antihypertensive patients with stable angina.
3. C. Patients with systolic hypertension.
4. D. Patients with tachycardia.

Answer
Ans: A
31. Which of the following drugs can cause drug-induced impotence?

1. A. Clonidine
2. B. Methyldopa
3. C. Atenolol
4. D. All of the above

Answer
Ans: D
32. Pharmacist is going to prepare a dosette for a patient with the following
medications. For which medication he should be worried to set dose schedule?

1. A. Ramipril –OID
 2. B. Calcium carbonate – TID
3. C. Psyllium – TID
4. D. Metoprolol – OID

Answer
Ans: C
Tips: Psyllium arrange dose schedule since it requires to be spaced apart from other
medications to be taken before meals and psyllium at least 2 hrs after meals.
33. Mr. White, a 65-year-old man presents to his family physician with symptoms
of severe headache, chest pain, and visual disturbance. He further describes
pounding in his neck and ears. Upon investigation, the doctor confirmed
hypertension as the diagnosis. BP: 140/85. Other medical condition is significant
for diabetes with kidney disease. In selecting medication for Mr. White, which of
the following will be the appropriate choice?

1. A. Clonidine
2. B. Lisinopril
3. C. Chlorothiazide
4. D. Propranolol

Answer
Ans: B
34. Mr. Green, a patient with chronic obstructive pulmonary disease (COPD) has
been diagnosed with hypertension. His doctor is concerned about Mr. Green’s non -
compliance taking his medications. All of the following are possible options to give
Mr. Green, EXCEPT:

1. A. Propranolol
2. B. Atenolol
3. C. Bisoprolol
4. D. Acebutolol

Answer
Ans: A
35. MP, a 50-year-old patient is returning to his family doctor’s clinic for a follow
up check-up. Medical history indicates that he started hydrochlorothiazide 25 mg
po qd 2 months ago for HTN. After 4 months, the dose was increased to 50 mg po
qd because his BP was uncontrolled.
Other conditions: diabetes, Hypercholesterolemia, asthma
Drug allergies: Amoxicillin
Social history: Smokes half pack a day:
MP has several questions about the risks associated with HBP. Which of the
following statements is true?

1. A. Target organ affected by HBP includes brain, heart, kidney and eyes.
 2. B. Untreated HBP is a risk factor for CVD.
3. C. Isolated systolic HBP are little or no risk for developing complication secondary to
HBP.
4. D. A & B

Answer
Ans: D
Tips: SBP <140 mm Hg
36. Following MP’s case, if his current blood pressure 160/90, which of the
following is the next most appropriate step in treating Mr. John?

1. A. Discontinue HCTZ and re-evaluate BP.

2. B. Adding perindopril10 mg po qd to HCTZ 25 mg po qd and Rosuvastatin daily
3. C. Adding Atenolol 100mg po qd to HCTZ 25 mg po qd.
4. D. Increase HCTZ to 50mg po qd and ASA

Answer
Ans: B
Tips: ACEi are preferred in diabetic patient with hypertension. If blood pressure is >20 units
then can second drug for management of hypertension.
37. DC is a 50-year-old man using Doxazosin 2 mg bid for blood pressure
management. He presents a new prescription of Sildenafil 50 mg as needed at
your pharmacy. What is the appropriate action to do at this point?

1. A. Call doctor to inform about drug interactions.

2. B. Tell patient to watch for low blood pressure symptoms.
3. C. Tell patient to separate taking the drugs for 2 to 4 hours.
4. D. Call doctor to recommend low dose 25 mg Sildenafil.

Answer
Ans: D
Tips: CAT. D. Sildenafil and doxazosin.
These classes of agents can be used together with caution for erectile dysfunction. If tadalafil is
used for benign prostatic hyperplasia, discontinue any alpha 1-blocker at least 1 day prior to
initiation.
Caution is advised when Sildenafil is administered to patients taking an alpha-blocker, as the
coadministration may lead to symptomatic hypotension in a few susceptible individuals (see Drug
Interactions). In order to minimize the potential for developing postural hypotension, patients
should be hemodynamically stabilized on alpha-blocker therapy prior to initiating Sildenafil
treatment. Initiation of Sildenafil at lower doses should be considered. In addition, physicians
should advise patients what to do in the event of postural hypotensive symptoms
38. EM is a 60-year-old woman using Amiodarone and Metoprolol for the
treatment of atrial fibrillation. All of the following drugs which might be added to
the patient’s current therapy is/are a concern, EXCEPT:

1. A. Digoxin
2. B. Procainamide
3. C. Quinidine
 4. D. Ramipril

Answer
Ans: D
Tips: Medications that most likely interact with Amiodarone are beta blockers, digoxin, warfarin,
procainamide, and quinidine.
39. With EM’s current therapy, which of the following should be monitored?

1. A. Liver function test

2. B. Heart rate
3. C. Renal function test
4. D. Blood pressure

Answer
Ans: B
40. The Blood Pressure Targets in Isolated Systolic Hypertension is

1. A. < 125
2. B. < 130
3. C. < 140
4. D. < 150

Answer
Ans: C
41. Hypertensive patient taking Furosemide may experience:

1. A. Hypomagnesemia
2. B. Hypercalcemia
3. C. Hyperkalemia
4. D. Hypocalcemia

Answer
Ans: D
Tips: RxTx/CTC. Hypertension. Loop diuretics Electrolyte disturbances: hypochloremia,
hypokalemia (evident during first 1–2 wk), hyponatremia, hyperuricemia (usually
asymptomatic).
42. Ms. Rose, a female patient of yours is considering having another child in the
near future and seeks for an antihypertensive that is safe in pregnancy. Her profile
indicates that he has chronic seasonal allergies and is taking oral
pseudoephedrine twice daily. What will you recommend?

1. A. Propranolol
2. B. Atenolol
3. C. Hydrochlorothiazide
4. D. Labetalol 100 mg bid

Answer
Ans: D
Tips: Medications widely considered first-line for the management of hypertension that is not
considered severe (SBP 140–159 and/or DBP 90–109) include labetalol (100 mg BID to 800 mg
TID) and nifedipine XL (30 mg daily to 60 mg BID). Methyldopa (250 mg BID to 1000 mg TID)
43. If Ms. Rose becomes pregnant, what adjustment would you suggest for her
chronic seasonal allergies?

1. A. Discontinue Pseudoephedrine and Loratadine/intra nasal steroid

2. B. Add intranasal steroids
3. C. Add Phenylephrine nasal sprays.
4. D. Add loratadine

Answer
Ans: A
44. Mr. IG is a 65-year-old man scheduled to undergo Benign Prostatic Hyperplasia
(BPH) surgery. His wife has second thoughts about her husband proceeding for the
surgery. He has hypertension and currently on Hydrochlorothiazide 50mg po qd,
Lisinopril 40 mg po qd, Multivitamins and Vitamin E. He is a lifelong-smoker and
drinks a glass of wine at dinner. Mr. IG exercises daily. Which of the following is a
fatal but rare side effect of Lisinopril?

1. A. Stevens Johnson Syndrome

2. B. Lactic acidosis
3. C. Angioedema
4. D. Hepatotoxicity

Answer
Ans: C
45. Since Mr. IG has BPH symptoms, his physician has decided to add Prazosin to
his medications. Why should initial dose of Prazosin not exceed 1 mg at bedtime?

1. A. To maximize effect of drug.

2. B. To minimize side effect of drug.
3. C. To minimize the risk of hypersensitivity of drug.
4. D. To minimize the first dose syncope.

Answer
Ans: D
46. Which of the following is the major side effect of Prazosin?

1. A. Reflex tachycardia
2. B. Headache
3. C. Weakness
4. D. All the above

Answer
Ans: D
Tips: all of the above and drowsiness as well.
47. What other medication may be added to Mr. IG’s current medications to re -
induce atrophy of the prostate gland and reduce BPH?

1. A. Finasteride
2. B. Terazosin
3. C. Doxazosin
4. D. Testosterones

Answer
Ans: A
48. Mr. B is a 60-year-old male living with hypertension for the past 30 years. He
as well has 10-year history of Ischemic heart disease (IHD) which is not controlled
due to poor compliance. He has no family history of heart disease. Social history
indicates smoke 1 pack per day (PPD) ´ 40 years. Currently, he smokes 1-2 packs
per week and on average, drinks six packs of beer per week. Medication History as
follows:
Hydrochlorothiazide 25 mg PO daily
Nitroglycerine 0.4 mg PRN for chest pain
Ketoprofen, 75 mg PO TID
No known medical allergies, physical examination includes anxious male, BP
125/90, HR 105, wt 68 kg, 1+ ankle edema, bluish-gray skin discoloration on sun –
exposed areas.
Lab values Na 134, K 3.9, Cl 102, HCO3 28, BUN 6.1, Cr 106, Hct 0.38, Hgb 140,
MCV 88, AST 0.70, ALT 0.64, LDH 3.18, Alk Phos 0.8, Alb 38 & ESR 43 mm/hr.
Which of the following monitoring parameters is NOT important in the early
assessment of Angiotensin Converting Enzyme Inhibitor (ACEi) therapy in Mr. B?

1. A. Serum K+
2. B. Serum Creatinine
3. C. Renal function test
4. D. Serum Na+

Answer
Ans: D
Tips: RxTx/CTC. Hypertension.

• Hyperkalemia usually occurs only in those on K + supplements or drugs that cause

K+ retention, those with renal impairment or diabetics with high serum K +levels. Assess SCr
and K + after a few days, then regularly.
• An increase in serum creatinine can occur upon initiation of an ACE -inhibitor or ARB. This
is often reversible. In most cases, serum creatinine will stabilize without discontinuing the
ACE inhibitor or ARB. However, if creatinine clearance increases more then 30% above
baseline immediately following initiation of an ACE inhibitor or ARB, the medication should
be stopped and the patient should be reassessed.
49. The following Calcium Channel Blockers (CCB) would be good choices for Mr.
B to control both his hypertension and angina pectoris, EXCEPT:

1. A. Verapamil
2. B. Diltiazem
3. C. Amlodipine
4. D. Nifedipine IR

Answer
Ans: D
Tips: Nifedipine IR may cause reflex tachycardia and angina.
50. Which of the following medications is LEAST likely to affect the potassium
homeostasis?

1. A. Furosemide
2. B. Captopril
3. C. Potassium Chloride supplements (KCl)
4. D. Nitroglycerin

Answer
Ans: D
Tips: RxTx/CTC
Electrolyte Disturbances
Loop Diuretics ACEi K+ Supplements
Hyperkalemia (if using
Hypochloremia, hypokalemia
K+ supplements or
(evident during first 1–2 wk),
Potassium-sparing Elevated K+ levels
hyponatremia, hyperuricemia
diuretics
(usually asymptomatic).
Elevated Li+
51. Which of the following Angiotensin Converting Enzyme Inhibitor (ACEi) works
best if you take it on an empty stomach?

1. A. Lisinopril
2. B. Captopril
3. C. Enalapril
4. D. Ramipril

Answer
Ans: B
Tips: Captopril and perindopril are taken on an empty stomach. All other ACEi are taken with or
without meals.
52. Which of the following antihypertensives should NOT be used in a patient with
systolic dysfunction?

1. A. Ramipril
2. B. Felodipine
3. C. Amlodipine
 4. D. Verapamil

Answer
Ans: D
Tips:
Drugs Of Choice:
Systolic dysfunction: ACEi alternate ARBs.
Isolated systolic hypertension: ACEi alternate ARBs
Congestive heart failure: avoid using verapamil and diltiazem because they cause negative
inotropic effect.
Among ACEi, fosinopril does NOT require dose adjustment in renal patient because it is
eliminated renal and hepatic (50:50).
53. All of the following drugs causes postural hypotension, EXCEPT:

1. A. Clonidine
2. B. Prazosin
3. C. Methyldopa
4. D. Isoproterenol

Answer
Ans: D
54. A patient is on Captopril to control his hypertension. He has a history of gout,
and his doctor kept him on a maintenance dose of Allopurinol, which he is going to
start from today. Best thing the pharmacist should do:

1. A. Dispense as it is.
2. B. Call the doctor to increase the dose of Captopril.
3. C. Call the doctor to alarm him that the combination may cause Steven Johnson
syndrome.
4. D. Tell the patient about non-pharmacological management of gout and hypertension.

Answer
Ans: C
Tips: RxTx-LexiInteract. Angiotensin-Converting Enzyme Inhibitors may enhance the potential
for allergic or hypersensitivity reactions to Allopurinol. Patients on chronic captopril therapy
have experienced Stevens-Johnson syndrome (fatal), fever, arthralgia, and myalgia within 10 to
35 days after beginning allopurinol therapy. Another case report described anaphylaxis and
myocardial infarction which developed 20 minutes after a single dose of allopurinol in a patient
receiving [Link] can cause these effects in the absence of ACEI [Link] is
particularly true in the presence of diuretics and renal dysfunction, both of which were present
in some of these case report patients. However, in one case the patient improved when the
captopril was discontinued. Therefore, if allopurinol must be used in an ACEi patient, monitor
for evidence of hypersensitivity reactions following the initiation of allopurinol therapy for at
least 5 weeks.
55. The most potent Angiotensin Converting Enzyme Inhibitor (ACEi) is:

1. A. Quinapril
2. B. Fosinopril
 3. C. Trandolapril
4. D. Captopril

Answer
Ans: C
Tips: It is used as 1mg once daily, maximum 4mg once daily.
56. Patient of 50 years of age is suffering from pneumonia. His profile indicates
that he is taking Tetracycline, in addition to other medications. He is now
experiencing moderate hypertension and his doctor wants to prescribe him an
Angiotensin Converting Enzyme Inhibitor (ACEi). All of the following ACEI may be
used, EXCEPT:

1. A. Captopril
2. B. Fosinopril
3. C. Trandolapril
4. D. Quinapril

Answer
Ans: D
Tips: Avoid Quinapril with Tetracycline since Quinapril contains antacid in its formulation.
57. The monitoring parameters for a patient using Lisinopril includes the following,
EXCEPT:

1. A. Creatinine clearance
2. B. Dizziness
3. C. Potassium levels
4. D. Neutropenia

Answer
Ans: D
58. A patient comes at your pharmacy to fill a new prescription for Ramipril 5 mg
once daily following a diagnosis of hypertension. BP: 180/110 from his initial
office visit. Other medical condition is significant for bipolar disorder stabilized by
taking Lithium. If there is a drug therapy problem, what is the appropriate
recommendation you would provide the doctor for this patient?

1. A. Change Lithium to Valproate

2. B. Change Lithium to Lamotrigine
3. C. Change Ramipril to Acebutolol
4. D. Change Ramipril to hydrochlorothiazide

Answer
Ans: C
Tips: Beta-blockers have no effect on electrolyte.
59. A doctor calls regarding a 62-year-old male black patient due to an
uncontrolled blood pressure. He is currently taking perindopril 8 mg daily for
hypertension. He has a history of stroke. Doctor is asking for your
recommendation for a medication to add to patient’s current therapy. Best
recommendation is:

1. A. Add a beta blocker

2. B. Add a diuretic
3. C. Add a calcium channel blocker (CCB)
4. D. Add Angiotensin II Receptor Blocker (ARB)

Answer
Ans: B
60. A patient complains of fainting after starting on a new medication. He was
recently discharged from the hospital following treatment of uncontrolled
hypertension and transient ischemic attack. Current medications include Ramipril
10 mg daily, Amlodipine 5 mg, and Metoprolol 50 mg. Which of the following
agents is responsible for the patient’s complaint?

1. A. Prazosin
2. B. Amlodipine
3. C. Metoprolol
4. D. Combination of Ramipril, Metoprolol and Amlodipine

Answer
Ans: D
61. A patient comes at your pharmacy to fill a new prescription of Salbutamol 1 -2
puffs every 4-6 hours, max 8 puffs/day. Following his recent discharge from the
hospital, he was put on the following medications which he is still currently using:
Ramipril 10 mg daily po, Amlodipine 5 mg daily po, and Propanolol 50 mg daily po.
You take the time to assess the patient’s medications profile. Which of the
following medications concerns you the most?

1. A. Amlodipine
2. B. Ramipril
3. C. Propranolol
4. D. All of the above

Answer
Ans: C
Tips: Beta blockers antagonize beta2 receptors while Salbutamol potentiates B2 receptors.
Also, Propranolol is a non-selective beta blocker that acts against both beta1 and beta2
receptors.

62. A customer at your pharmacy is looking for something to treat nasal

congestion. Upon questioning, he tells you that he is currently taking
Hydrochlorothiazide 50 mg daily. He has heard of pseudoephedrine that worked
for his friend and is hoping to get it for relief. What is your greatest concern for
this patient relevant to his request?

1. A. Nasal congestion
2. B. Hypertension
3. C. Prescription regulations
4. D. Hydrochlorothiazide

Answer
Ans: B
63. A patient presents to his family physician concerned about several falls he’s
had recently. He describes that before each fall, he would feel a sense of dizziness
and headache. Patient’s medical conditions are significant for hypertension and
osteoporosis. He has been using perindopril 8 mg daily for a long time now. Other
medications include risedronate 35 mg once weekly po and meloxicam 15 mg daily
po. Two weeks ago, he was diagnosed with gastroenteritis for which he was
prescribed esomeprazole 20 mg daily po pc. What might have increased his risk of
falls?

1. A. Lorazepam
2. B. Perindopril
3. C. Meloxicam
4. D. Risedronate

Answer
Ans: A
64. A diabetic patient recently diagnosed with hypertension was put on enalapril
10 mg daily po. However, shortly after starting the therapy, he complains of severe
dry cough. His doctor calls you for an alternative medication. Which would be the
best choice for changing this medication that you will recommend the doctor?

1. A. Ramipril
2. B. Losartan
3. C. Amlodipine
4. D. Indapamide

Answer
Ans: B
Tips: Losartan is an angiotensin II receptor Type 1 (AT-1) inhibitor and would be the best choice
for treatment of hypertension in a diabetic patient with dry cough that is definitely a side effect
of ACE inhibitor like Enalapril.
65. A patient presents to his family physician concerned about his elevated blood
pressure. Using the automated office blood pressure monitor, BP was confirmed to
be high at 170/90. Patient has been in a combination therapy of
Losartan/Hydrochlorothiazide 50/12.5 mg. He has no other medical conditions and
no update to his allergy profile. Due to the uncontrolled hypertension, doctor then
adds Lisinopril 10 mg to his existing antihypertensive therapy. What should be
monitored?

1. A. K, Mg
2. B. K, Creatinine
3. C. Na and water
4. D. Heart rate

Answer
Ans: B
Tips: In cases when a combination of ACEi and ARB is required, monitor serum K+ and SCr.
66. LP, a 50-year-old male patient visits his family physician for his regular check-
up. As part of the routine, his BP is measured using the automated office blood
pressure monitor. BP: 155/90. The doctor asks the patient regarding his readings
at home which the patient confirms to be within the range of 150-160/85-90. When
asked, LP tells his doctor that lately he has been experiencing fatigue with bouts
of headache and blurry vision. Given these, the doctor infers uncontrolled
hypertension. LP has been taking using hydrochlorothiazide 25 mg daily for the
past 4 years. He is not on any other prescription medications and is not taking any
over the counter medications. Doctor now is considering adding an
antihypertensive therapy. Which of the following is appropriate?

1. A. Amlodipine
2. B. Metoprolol
3. C. Ramipril
4. D. Verapamil

Answer
Ans: C
67. Doctor wants to give ACEi and ARBs together for a patient. In which of the
following instances is the combination of these medications can be clinically
appropriate?

1. A. When ACEi is not effective

2. B. When blood pressure >165/95
3. C. In case of post Myocardial infarction
4. D. Only in refractory heart failure

Answer
Ans: D
Tips: other conditions ACEi and ARBs in patient with CHF and not tolerating spironolactone.
68. JD, a 53-year-old white male is suffering from multiple medical conditions that
include hypertension, diabetes and gastroesophageal reflux disease (GERD). His
medication and life style history are as follows :

• HBP : Hydrochlorothiazide 25 mg QAM ( last 3 months)

 • Diabetes: Metformin 500mg 2 tab BID ( last 6 years)
• GERD : Ranitidine 1 tab OD prn ( last 1 month)

- Family history: MI and stroke

- Non-smoker, drinks one glass of wine each day
His blood pressure reading from recent physician visit is 140/90 mm. Which of the
following is appropriate in this setting?

1. A. Start ACEI
2. B. Increase dose of Hydrochlorothiazide
3. C. Advise life style modification that includes regular physical exercise.
4. D. Continue as is

Answer
Ans: C
Tips: Patient’s BP is close to normal and he is not too old.
69. Which of the following would contribute most towards cardiovascular event in
JD’s case?

1. A. Hypertension
2. B. Diabetes
3. C. Life style
4. D. Family History

Answer
Ans: A
Tips: hypertension, diabetes and smoking are the major cardiovascular risk factors.
70. MK, a 50-year-old woman has been living with high cholesterol and
hypertension for approximately 7 years now. She visits the pharmacy expressing
her interest to know more about blood pressure. She has completely changed her
lifestyle. She is watching her diet and is fairly physically active by walking every
day for at least 30 minutes. Her body weight remains the same at 90 kg for the
past 5 years. She cut down her alcohol intake to 1-2 drinks daily and stopped
smoking. Her cholesterol has improved. In fact, her current lab reports indicate
LDL 2.50 mmol/L, eGFR 70 ml/min, and potassium 4.5 mmol/L. Albumin to creatine
ratio (ACR) 1.8 mg/mmol. Her current medications include Atorvastatin 20 mg
daily, Ramipril 10 mg daily. She is just a little disappointed with her blood pressure
as the recent reading was 150/90. She was hoping that with her new healthy
lifestyle, it would have improved as well. Which of the following dietary
recommendation is appropriate for MK to gain more control over her blood
pressure?

1. A. Balanced diet
2. B. DASH diet or Canada Food Guide
3. C. Low saturated fats
 4. D. Low carbohydrate diet

Answer
Ans: B
Tips: CTMA. Diets for cardiovascular disease. Sodium restricted diet is indicated in essential
hypertension, heart failure and renal disease. CHEP recommend sodium restricted diet (<50 y,
<1500 mg salt, 51-70 y 1300 mg/d, >70 over <1200 mg). (Dietary Approaches to stop
hypertension) and Eating Well with Canada Food Guide and this encourage by Heart and Stroke
Foundation of Canada. The DASH diet is promoted to control hypertension; it limits sodium
intake, encourages consumption of nuts, whole grains, fish, poultry, fruits and vegetables, and
suggests lower consumption of red meats, sweets and sugar. It is also rich in calcium,
magnesium, potassium, protein and fibre. DASH and Canada's Food Guide are similar; Canada's
Food Guide has a greater range in the number of servings, whereas DASH recommends a
higher level of vegetable and fruit intake.
71. What is correct about the effect of Ramipril on cholesterol levels?

1. A. Increase in LDL, decrease in TG

2. B. No effect on serum lipids
3. C. Decrease HDL, increase in LDL
4. D. Lowers total cholesterol

Answer
Ans: B
Tips: ACEi and CCB have no side effect on lipids. Thiazides increase LDL and TG, except
Indapamide. Beta blockers increase LDL, less common with acebutolol.
72. After initiating antihypertensive therapy, when to reassess drug effectiveness?

1. A. 1 week
2. B. 2 weeks
3. C. 8 weeks
4. D. 4 weeks

Answer
Ans: D
Tips: Dose titration to achieve goal blood pressure should be done every 4–8 weeks for all but
those with severe hypertension or target organ damage or high cardiovascular risk, for whom
closer follow-up and more frequent dosage titration is required. Lack of control over blood
pressure is in most cases due to a failure to titrate therapy (adding drugs and/or increasing
doses) in response to high office readings. Generally, high office readings should trigger a
dosage increase, addition of another medication, investigations to identify the cause of the
high readings or a follow-up appointment within 2–8 weeks to reassess blood pressure.
73. SD is a 91kg, 52-year-old female who was recently diagnosed with mild
hypertension. From her recent physical exam, her BP is 150/94, serum creatinine
is 150 umol/L, and K is 4.5 mmol/L. She is taking Metformin and Gliclazide for the
past 4 years for type 2 DM. Hypertension therapy for SD is recommended if her
blood pressure is?

1. A. >130/80
 2. B. <140/90
3. C. <125/75
4. D. <100/80

Answer
Ans: A
74. VR has received a new prescription of Irbesartan150 mg/Hydrochlorothiazide
12.5 mg daily for her hypertension. The most appropriate laboratory monitoring
that should be performed is:

1. A. Baseline serum creatinine and serum potassium levels, then both repeated 2 weeks
after initiation.
2. B. Baseline serum creatinine and potassium, then repeat both 1 month after initiation.
3. C. Baseline serum potassium with repeat level 1 month after initiation.
4. D. Baseline serum creatinine with repeat level 2 weeks after initiation.

Answer
Ans: A
Tips: Within 1 to 2 wks of initiating ARBs and ACEi, serum creatinine and serum potassium levels
should be checked.
All ACEi and ARB renally eliminated thus renal function test (serum creatinine) is monitored. But
NO liver function is necessary for all ACEi and ARBs. These drugs also associated with
hyperkalemia, need to monitored K+ levels.
75. Thiazide diuretics increase?

1. A. LDL and HDL

2. B. TG and HDL and total cholesterol
3. C. HDL, LDL, and TG
4. D. LDL and TG

Answer
Ans: D
76. Concomitant use of diuretics and ARBs or ACEi, especially in whom diuretic
therapy was recently instituted, may experience hypotension effects after the first
dose of ARB. This can be minimized by:

1. A. Discontinuing ACEI
2. B. Loop diuretics
3. C. Discontinuing diuretics
4. D. Discontinuing diuretic for few days

Answer
Ans: D
77. Which of the following antihypertensives is appropriate for a 69-year-old
patient, smoker, hypertensive with bilateral renal stenosis and high cholesterol
with LDL>4 mmol?
 1. A. Ramipril
2. B. Atenolol
3. C. Hydrochlorothiazide
4. D. Indapamide

Answer
Ans: D
Tips: In patients with bilateral stenosis ACE and ARBs are not used. Hydrochlorothiazide and
indapamide increase LDL thus, not good choices. Atenolol has less lipid solubility and less
effect on cholesterol so can prefer. Calcium ion channel blockers have no affect on lipids.
78. If patient was put on Ramipril 10 mg daily dose, but blood pressure still
remains uncontrolled after 6 months with reading of 155/90, what is the next
appropriate step?

1. A. Increase dose to Ramipril 10 mg

2. B. Check the compliance of medication
3. C. Change Ramipril 2.5 mg to Losartan
4. D. Change Ramipril 2.5 mg to Hydrochlorothiazide 25 mg

Answer
Ans: B
Tips: If it SBP is 20 units higher than 160 and DBP >10, may require combo.
79. A pharmacy student measures blood pressure for an obese patient with BMI
33.5. What is true?

1. A. Take at least two readings from one hand and take average.
2. B. Use adult cuff size 33-43 cm.
3. C. Measure on standing position.
4. D. Take at least two reading in each hand and take average.

Answer
Ans: B
Tips: Ensure the right cuff size is chosen. Cuff size is based on the measurement of the upper
arm. For people with thin arms less than 23 cm, there are small cuffs. An adult cuff ranges from
23–33 cm; a large from 33–43 cm. There are also cuff sizes for children.
It is recommended that 2 or 3 readings be taken at one time, resting for about 5 minutes
between each reading. The readings can be compared and averaged. Keeping a log of blood
pressure readings will reflect what is normal for an individual and the effect of various
activities or medications on blood pressure readings.
80. JD, a 49-year-old customer of your pharmacy comes on a busy morning as he
is alarmed by blood pressure reading of 180/95. He checks his blood pressure in
your pharmacy. JD’s social habits include occasional drinking of alcohol, smoking
and regular drinking of a cup of coffee. He is currently not taking medication for
hypertension. Three months ago, his physician diagnosed him with borderline
blood pressure. However, he did not initiate medications and instead,
recommended lifestyle modifications. All of the following may be causes of high
blood pressure, EXCEPT:
 1. A. He might have smoked 5 min before taking his blood pressure.
2. B. He might have had coffee 10 min before taking his blood pressure.
3. C. He might have measured blood pressure from both arms with a 5 min interval and
calculated the average.
4. D. He might have measured the blood pressure twice only from the right arm with 5
min interval and calculated the average.

Answer
Ans: C
81. A patient consults a physician due to a possible CVD. He is under a
tremendous stress because he was laid off from his job recently. His mother died
due to stroke at the age of 62 and father died at 59 due to heart attack. He is o bese
and smokes and drinks 4 bottles daily. From this patient’s profile, what is not a risk
factor for CVD?

1. A. Family history
2. B. Smoking
3. C. Alcohol
4. D. Stress

Answer
Ans: A
Tips: CVD family history risk factor parents died like mother age <65 y and father <55 y.
82. Which of the following is least likely monitored for chronic use of Irbesartan?

1. A. Serum creatinine clearance

2. B. Transaminases (AST/ALT)
3. C. Blood pressure
4. D. Serum potassium levels

Answer
Ans: B
Tips: ACEi are mainly eliminated renal elimination, and do not increase live enzyme. Only dose
adjustment may be requiring in renal impairment.
83. To monitor effectiveness of Furosemide through fluid loss with cardiac edema
or ascites, which of the following is obtained?

1. A. Fluid input, fluid output

2. B. Glomerular Filtration Rate (GFR)
3. C. Patient weight
4. D. ECG

Answer
Ans: C
84. SD, a 45-year-old male presents to his family physician due to a severe
headache accompanied by fatigue and blurring of vision. Upon assessment, doctor
diagnosed SD with acute hypertension. Which of the following drugs is the best
choice to initiate?

1. A. Lisinopril
2. B. Enalapril
3. C. Fosinopril
4. D. Captopril
5. E. Perindopril

Answer
Ans: D
Tips: Captopril peak effect is in 1-1.5 hours. Whereas all other ACEi are >2 hours peak affect.
85. Which has more indications among calcium channel blockers (dihydropyridines
and non-dihydropyridines) in cardiovascular system disorders?

1. A. Nifedipine
2. B. Verapamil IR
3. C. Verapamil SR
4. D. Diltiazem CD

Answer
Ans: B
Tips: Verapamil official indications: Hypertension, Stable Angina (not used as monotherapy),
Atrial fibrillation, SVT, Coronary spasm and Obstructive Hypertrophic Cardiomyopathy.
86. A patient has hypertension, diabetes, solitary kidney and Raynaud’s
phenomenon. What should be the treatment of hypertension?

1. A. ACEi
2. B. Hydrochlorothiazide
3. C. Amlodipine
4. D. Metoprolol

Answer
Ans: C
87. Which of the following drug should not be given to a pregnant hypertensive
patient?

1. A. Hydrochlorothiazide
2. B. Propranolol
3. C. Verapamil
4. D. Atenolol

Answer
Ans: D
Tips: Avoid atenolol, as its use for the treatment of hypertension in pregnancy has been
associated with fetal intrauterine growth restriction (IUGR).[32] The other beta -blockers, in
contrast, are only weakly associated with IUGR and have been used widely in pregnancy for
various indications.
88. Which of the following antihypertensive drugs has the greatest effect on
reducing blood sugar?

1. A. Hydralazine
2. B. Acebutolol
3. C. Propranolol
4. D. Captopril

Answer
Ans: C
Tips: CPS-Beta Adrenergic Blocking Agents
In patients at risk of hypoglycemia, cardio-selective agents are preferred. Nonselective agents
may delay recovery from hypoglycemia in diabetic patients by blocking beta-2-receptor mediated
glycogenolysis. Nonselective agents are also more likely to increase blood pressure during
hypoglycemia, by blocking the beta-2-mediated vasodilation from epinephrine leaving unopposed
alpha-receptor-mediated vasoconstriction. Risk factors for hypoglycemia include nutritional
deficits, strenuous exercise, liver disease, and the use of hypoglycemic drugs.
Both selective and nonselective beta-blockers may mask some symptoms of hypoglycemia
(tachycardia, tremor, anxiety). Warn patients to watch for symptoms that are not masked
(sweating).
Propranolol (Inderal) Monograph
Adverse effects: hypoglycaemia in elderly patients, patients on haemodialysis, patients on
concomitant antidiabetic therapy, patients with prolonged fasting and patients with chronic liver
disease
89. Who of the following patients is most suited for primary therapy with
hydrochlorothiazide?

1. A. Patient with impaired renal function

2. B. Patient with gout
3. C. Elderly patient
4. D. Young hypertensive patient with rapid resting heart rate
5. E. tensive evidence supports low-dose thiazide or related diuretics as first-line therapy
for uncomplicated hypertension. They should generally be selected unless there are
specific indications for other drugs. They have proven antihypertensive effectiveness
in patients with isolated systolic hypertens

Answer
Ans: C
Tips: RxTx/CTC. Hypertension.
90. Thiazide diuretics increase?

1. A. Low Density Lipoprotein (LDL)only

2. B. Low Density Lipoprotein (LDL) and Triglyceride (TG)
3. C. Low Density Lipoprotein (LDL), Triglyceride (TG) and High Density Lipoprotein (HDL)
4. D. Triglyceride (TG) only

Answer
Ans: B
91. Which of the following conditions is asymptomatic?

1. A. Hypoglycemia
2. B. Hypertension
3. C. Hyperglycemia
4. D. Hypothyroidism

Answer
Ans: B
92. An obese diabetic woman with albuminuria has been newly diagnosed with
hypertension. Her blood pressure was 160/95. Her physician wanted her to try
changing her lifestyle for 3 months before starting therapy and he advised her to
follow salt substitution in her diet. Which statement is true?

1. A. DASH diet can be of same benefit as pharmacotherapy.

2. B. Salt substitution has no benefit for her case.
3. C. Reducing trans-fatty acids help in salt restriction.
4. D. Most of the patients cannot accomplish salt substitution.

Answer
Ans: D
93. Three months later, this woman lost 6 kg and her blood pressure was 154/90.
She presented to you at the pharmacy with a prescription for Ramipril 5mg daily.
What is the drug therapy problem?

1. A. The dose of Ramipril is too low in her case.

2. B. Monotherapy is not a good option for her.
3. C. Inappropriate therapy.
4. D. Dispense as it is.

Answer
Ans: A
94. Jack is a 64-year-old white male patient with hypertension and hyperlipidemia.
He has a family history of acute coronary syndrome (ACS). His recent blood
pressure reading is 154/95 and the LDL-C level is 5.0 mmol/L. Which medicine is
appropriate for hypertension?

1. A. Acebutolol
2. B. Lisinopril
3. C. Hydrochlorothiazide
4. D. Verapamil

Answer
Ans: A
95. A patient has hypertension, Raynaud’s disease, diabetes with solitary kidney
(have one kidney). What is the treatment for hypertension?

1. A. Angiotensin Converting Enzyme inhibitor

2. B. Hydrochlorothiazide
3. C. Amlodipine
4. D. Metoprolol

Answer
Ans: C
Tips: The recommended treatment for hypertensive patients with Raynaud’s phenomenon are
the dihydropyridine CCBs like Nifedipine, Amlodipine and Felodipine before cold exposure PRN.
If not tolerated, can use diltiazem or prazosin.
96. All of the following are appropriate counselling points regarding Captopril,
EXCEPT:

1. A. If there is cough, stop the medication.

2. B. If there is nausea, take medication with a snack.
3. C. If there is dark urine, go to emergency.
4. D. If there is dizziness, walk and drive carefully.

Answer
Ans: A
97. An 85-year-old obese patient has dyslipidemia and hypertension. He was just
recently diagnosed with Alzheimer’s disease. What could have caused his
Alzheimer?

1. A. Dyslipidemia
2. B. Age
3. C. Weight
4. D. Hypertension

Answer
Ans: A
98. A 48-year-old patient was recently diagnosed with hypertension following a
high blood pressure 180/85 read from automated office blood pressure monitor.
He recently had nosebleeds following a bad headache that prompted him to see his
family physician. He works 2 jobs, eats junk food, and consumes salt substitute
supplement. He is also a smoker. What is recommended for his hypertension?

1. A. Nadolol
2. B. Clonidine
3. C. Hydrochlorothiazide/Lisinopril
4. D. Ramipril

Answer
Ans: C
99. A hypertensive patient was admitted to the hospital. She is taking valsartan
160 mg daily. The physician increased the dose to 160 mg BID. A day later, her
potassium level was found to be 5.9 (normal 3.4-4.5) but had no ECG changes.
What is the most appropriate action?

1. A. Stop Valsartan temporarily.

2. B. Change Valsartan to Lisinopril.
3. C. Decrease the dose of Valsartan
4. D. Change to other ARBs.

Answer
Ans: A
Stop K + supplements and/or drugs inducing hyperkalemia. If necessary, resume K +supplements at
a reduced dose once the hyperkalemia is resolved.
In mild hyperkalemia (plasma K + 5–6 mmol/L) these measures are usually sufficient. Increasing
K+ level, ongoing K + absorption, release of intracellular K + or renal failure require further measures,
e.g., hemodialysis.
100. MP is a 56-year-old male patient who was transported to the emergency
department by EMS due to chest tightness and pressure. Upon arrival to ER, blood
pressure registered 159/99 mmHg. Patient information was gathered from MP’s
wife. MP is a chronic smoker, drinks a cup of coffee or tea in the morning and a
bottle of beer nightly. MP is a fan of savory and spicy foods. What other non -drug
therapies (self-care) might be used to manage MP’s hypertension risks after
discharge from the hospital?

1. A. Smoking cessation program

2. B. DASH diet
3. C. Weight loss program
4. D. Salt intake reduction

Answer
Ans: A
Tips: If the average SBP/DBP is 140–159/90–99 mm Hg, pharmacologic treatment is
recommended in the presence of either:

• Hypertensive target organ damage or

• Other independent risk factors for cardiovascular disease, e.g., cigarette smoking,
dyslipidemia, strong family history of premature cardiovascular disease, truncal obesity,
sedentary lifestyle, males older than 55 years of age, females older than 60 years of age.

101. HH, a 45-year-old woman was newly diagnosed with hypertension. She has no
other medical conditions and is not taking prescription medications besides her
multivitamins. She has fairly active lifestyle and a well-balanced diet. She does not
smoke and no documented allergies. Doctor initiated an appropriate
antihypertensive medication. When can the doctor review HH's blood pressure?

1. A. After 1 week
 2. B. After 4 to 8 weeks
3. C. After 2 weeks
4. D. After 3 weeks

Answer
Ans: B
102. BN is a 91kg, 52-year old female who was recently diagnosed with type 2
diabetes. Her physical exam has the following results: BP: 190/94, SrCr: 150
umol/L, K: 4.5 mmol/L. The recommended BP target for BN is:

1. A. <130/80
2. B. >130/80
3. C. 140/90
4. D. <140/90

Answer
Ans: A
103. Following, BN’s case, what is likely the initial therapy that the doctor would
initiate?

1. A. Ramipril 5 mg
2. B. Verapamil + Losartan
3. C. Atenolol
4. D. Metoprolol

Answer
Ans: B
Tips: If it SBP is 20 units higher than 160 and DBP >10, may require combination preferably an
ACEi or ARB and a long-acting CCB.
104. Continuing BN’s case, after 6 months, from her last visit, her blood pressure
is 155/90 which is high from the target. What would you recommend the doctor to
do?

1. A. Increase dose to Ramipril 10 mg.

2. B. Check the compliance of medication and optimize the dose
3. C. Change Ramipril 2.5 mg to Losartan.
4. D. Change Ramipril 2.5 mg to Hydrochlorothiazide 25 mg.

Answer
Ans: B
105. Chris, a 57-year-old male nurse who works for the local pulmonologist,
arrives at work one day complaining of weakness and fatigue. He explains that
these symptoms have worsened over several days. He reports feeling out of breath
when walking around the office but denies having had these difficulties in the past.
Chris’s medical history is significant for hypertension and benign prostatic
hypertrophy. Three months ago, he was hospitalized with a ventricular arrhythmia.
His current medication regimen includes:
Felodipine 5 mg daily
Tamsulosin 0.4 mg daily
Amiodarone 400 mg daily
Chris denies use of herbal products or OTC medications. He denies tobacco use
but admits to social drinking. His family history is significant for hypertension.
The pulmonologist for whom Chris works is concerned about his symptoms and
performs a physical examination, along with laboratory works. Chris’s vital signs
are reported as follows: blood pressure, 150/95 mm Hg; heart rate, 90 beats/min,
temp 98.6°F, and respiratory rate, 20 breaths/min. The exam is unremarkable, with
no signs of pulmonary congestion, lower extremity edema, or signs of infection.
The basic metabolic panel and complete blood count are within normal limits. The
only lab result found to be outside normal limits is an elevated erythrocyte
sedimentation rate (ESR).
The pulmonologist is concerned that Chris’s medications may be causing
pulmonary problems. He performs a bronchoscope to obtain a lung biopsy, which
demonstrates diffused alveolar damage and fibrosis.
What could be the pulmonologist’s concern?

1. A. Felodipine 5 mg daily
2. B. Tamsulosin 0.4 mg daily
3. C. Amiodarone 400 mg daily
4. D. Blood pressure

Answer
Ans: C
Tips: Amiodarone can cause pulmonary fibrosis (cough and SOB). Reduce doses of beta
blockers, Digoxin, procainamide, quinidine and Warfarin by 50%. Monitor transaminases
(AST/ALT), serum TSH Q6 months and CXR annually.
106. A doctor prescribed metoprolol for a hypertensive patient at risk of having
stroke. What is the goal of giving a beta blocker?

1. A. Decreased risk of ischemic stroke

2. B. To prevent Recurrent infarction
3. C. Reduced risk of acute coronary syndrome
4. D. Decrease risk of angina

Answer
Ans: A
107. Which of the following modifiable risk factors contribute to the greatest
reduction in systolic blood pressure?

1. A. Reduction in sodium intake

2. B. Weight loss
3. C. Dietary modification
 4. D. Exercise

Answer
Ans: C
Tips: DASH diet contributes to greatest reduction in SBP by 11.4 mm Hg average.
108. Which of the following modifiable risk factors contribute to the greatest
reduction in diastolic blood pressure?

1. A. Reduction in sodium intake

2. B. Weight loss
3. C. Dietary modification
4. D. Exercise

Answer
Ans: D
Tips: Exercise of 30-45 mins, 3 x week contributes to greatest reduction in DBP by 7.5 mm Hg
average.
109. A patient is at your pharmacy and you are measuring his blood pressure.
Recent BP 150/100. He is a smoker, alcoholic, with poor diet eating mostly
processed and fast food that is high in sodium and fat. He has a sedentary lifestyle
watching TV most of the time with positive family history of cardiovascular
diseases. His father died of MI at 60 and mother has diabetes. He is obese with
BMI 35.5. What is true?

1. A. Take at least two readings on one hand and take average.

2. B. Use adult cuff size 23-33 cm.
3. C. Measure on standing position.
4. D. Take at least two readings on each hand and take average.

Answer
Ans: A
Tips: Electronic device
Choose a cuff with appropriate bladder size matched to size of the arm. Bladder width should be
close to 40% of arm circumference and bladder length should cover 80%-100% arm
circumference. Select the cuff size recommended by its manufacturer.
Cuff should be applied to the non-dominant arm unless SBP difference between arms >10 mm Hg,
in which the arm with highest value obtained should be used.
The patient should be resting comfortably for 5 min in the seated position with back support.
The arm should be bare and supported with BP cuff at heart level.
Measurement should be performed before breakfast and 2 hours after dinner, before taking
medications.
No caffeine, tobacco in the hour and no exercise 30 min preceding the measurement

Procedures. To begin blood pressure measurement, use a properly sized blood pressure cuff. The
length of the cuff's bladder should be at least equal to 80% of the circumference of the upper arm.
Wrap the cuff around the upper arm with the cuff's lower edge one inch above the antecubital
fossa. Lightly press the stethoscope's bell over the brachial artery just below the cuff's edge.
Some health care workers have difficulty using the bell in the antecubital fossa, so we suggest
using the bell or the diaphragm to measure the blood pressure. Rapidly inflate the cuff to
180mmHg. Release air from the cuff at a moderate rate (3mm/sec). Listen with the stethoscope
and simultaneously observe the sphygmomanometer. The first knocking sound (Korotkoff) is the
subject's systolic pressure. When the knocking sound disappears, that is the diastolic pressure
(such as 120/80). Record the pressure in both arms and note the difference; also record the
subject's position (supine), which arm was used, and the cuff size (small, standard or large adult
cuff). If the subject's pressure is elevated, measure blood pressure two additional times, waiting a
few minutes between measurements. A BLOOD PRESSURE OF 180/120mmHg OR MORE
REQUIRES IMMEDIATE ATTENTION!
[Link]

Ensure the right cuff size is chosen. Cuff size is based on the measurement of the upper arm and
adult range from 23-33 cm, a large from 33-43 cm. For people with thin arm less than 23 cm, there
are small cuffs. There is also a cuff for children.
It is recommended that 2 or 3 readings be taken at one time, resting for 5 min between each
reading. The reading can be compared and average. Electronic bp models for wrist or finger are
average however they are not accurate and should be discouraged.
Reference. CTMA Chapter Home Testing
110. OL, a 65 year old man was prescribed an additional BP lowering agent to his
existing antihypertensive medication. OL, realizing the importance of health to live
longer asks for a self-monitoring apparatus he can use at home. The pharmacist is
more than happy to hear this from OL and educates him accordingly. Which is not a
goal of self-measurement of blood pressure?

1. A. To evaluate the patient’s response to the blood pressure therapy.

2. B. To improve patient’s adherence to therapy.
3. C. To evaluate the white coat effect.
4. D. To minimize clinic visits/appointments

Answer
Ans: D
111. A regular customer approaches you at the pharmacy counter for advice. He
rarely gets constipation ad he would pass at least once daily. However, from t he
last two weeks, he noticed a change in his bowel movement going only every
couple of days resulting to lumpy hard stools in which he has to strain. His medical
history indicates DM2, HTN, and was previously on metformin but discontinued
due to low kidney function. Current medications include glargine 15u hs, lispro 8u
TID a.c, ramipril 5mg, and 2 weeks ago, he started verapamil SR 150mg daily due
to uncontrolled blood pressure. How would you solve patient concern?

1. A. Refer to doctor because constipation is associated with diabetes and hypertension.

2. B. No drug therapy problem, address patient’s concern of constipation by
recommending senna to treat it.
3. C. As constipation is likely caused by verapamil, contact doctor for change of
medication to another CCB, and recommend senna to address constipation for the
meantime.
4. D. As constipation is likely caused by insulin, contact doctor to discuss insulin therapy
modification, to minimize constipation associated with uncontrolled diabetes.
Answer
Ans: C
Tips: verapamil associated with constipation 2 to 7% side effect.
112. A distraught patient comes in to your pharmacy with some concerns. He is a
50-year-old male, has hypertension and anxiety, on HCTZ 25mg, ramipril 10mg
and, sertraline 100mg. Usually, he takes HCTZ qam; ramipril and sertraline qpm.
This morning he felt his BP was a little high so he decided to take his ramipril in
the morning as well, but then he forgot about it and took his ramipril again at night
along with the sertraline. He just realized couple hours later and now he’s at the
pharmacy. BP usually 135/85, this morning was 145/95, now at 140/90,
HR100bpm. What is the most appropriate action?

1. A. Refer to doctor for psychiatric assessment.

2. B. Report incidence to Community Pharmacy Incident Reporting System
3. C. Counsel to monitor dizziness, or lightheadedness for next 12-24 hours because
ramipril dose is within allowable limit and contacting poison control center is not
necessary.
4. D. Refer him to emergency because this is a serious medication incident.

Answer
Ans: C
113. KG is 67-year-old women with uncontrolled hypertension. Her current blood
pressure is 170/100. Her medications include Lisinopril/hydrochlorothiazide 20/25
mg daily(Zestrotec), amlodipine 10 mg daily (Norvasc). She has normal renal and
liver function. She has been diabetic for the past 10 years and taking insulin
glargine daily and Aspart insulin twice daily. Her labs potassium levels were
normal. What is suitable antihypertensive would you recommend to control her
blood pressure?

1. A. Doxazosin
2. B. Losartan
3. C. Spironolactone
4. D. Atenolol

Answer
Ans: C
Tips:
Resistant hypertension is defined as BP that is above target despite treatment with 3 drugs,
optimally dosed, 1 of which is a diuretic (typical “optimal” regimen is a long-acting ACE inhibitor
or ARB, thiazide-like diuretic, and dihydropyridine CCB). Resistant hypertension has been
estimated to affect about 10% of hypertensive patients, but the true prevalence is likely much
lower because many patients have either white coat effect or are not adherent.? [20] Hence, all
patients with suspected resistant hypertension should undergo 24-hour ambulatory blood
pressure measurement (ABPM) and have adherence assessed. Other potential causes that
should be looked for are secondary hypertension and renal dysfunction; in those with a poor
response to an adequate combination of medications, consider the possibility of an “interfering
lifestyle,” e.g., high dietary sodium intake. Therapeutic options as add-on therapy to the optimal
3-class regimen described above include spironolactone, amiloride, bisoprolol, doxazosin and
clonidine.? [21] Refer (to a hypertension specialist, nephrologist or internist) those who do not
achieve BP targets with medication regimens you feel comfortable prescribing.