Medication order review MCQs With Answer

Introduction:

This collection of Medication Order Review MCQs with answers is designed specifically for M.Pharm students specializing in Clinical Pharmacy Practice. The quiz emphasizes critical aspects of medication order review including identification of prescribing errors, dosing adjustments (renal/hepatic/pediatric), drug–drug and drug–disease interactions, high-alert medications, IV compatibility, therapeutic duplication, and documentation principles. Each question targets practical decision-making skills required in hospital and clinical settings, encouraging deeper understanding of guidelines, calculations, and risk mitigation strategies. Use these questions to assess competency, reinforce rational prescribing principles, and prepare for clinical rotations and postgraduate examinations.

Q1. Which of the following is the most appropriate immediate action when a medication order contains a dose written as “10 IU” insulin for a patient with altered mental status and no recent blood glucose documented?

• Administer 10 IU as ordered and monitor glucose hourly
• Hold the dose and obtain a point-of-care blood glucose before giving insulin
• Administer 1 IU and reassess patient response
• Substitute with insulin sliding scale dose without verification

Correct Answer: Hold the dose and obtain a point-of-care blood glucose before giving insulin

Q2. While reviewing a medication order, you note the prescription “cefepime 2 g IV q8h in a 75 kg patient with creatinine clearance 25 mL/min.” Which action is most appropriate?

• Accept the order; cefepime dose requires no adjustment for CrCl 25 mL/min
• Recommend dose reduction to 1 g IV q12h due to renal impairment
• Change to oral cefalexin since IV not necessary
• Advise increasing dose frequency to q6h to maintain levels

Correct Answer: Recommend dose reduction to 1 g IV q12h due to renal impairment

Q3. Which entry represents a prescribing error related to look-alike/sound-alike medications?

• Ordered “metoprolol 25 mg” for hypertension and patient receives metformin 25 mg
• Ordered “vancomycin 1 g IV q12h” and pharmacy verifies weight-based dosing
• Ordered “lisinopril 10 mg” but pharmacy clarifies allergy to ACE inhibitors first
• Ordered “warfarin 5 mg nightly” with documented INR monitoring plan

Correct Answer: Ordered “metoprolol 25 mg” for hypertension and patient receives metformin 25 mg

Q4. When reviewing an order for aminoglycoside therapy, which monitoring parameter is most critical to recommend prior to each subsequent dose?

• Serum transaminases (AST/ALT)
• Serum creatinine and estimated creatinine clearance
• Fasting blood glucose
• Serum potassium

Correct Answer: Serum creatinine and estimated creatinine clearance

Q5. For a pediatric patient (5-year-old, 18 kg) prescribed amoxicillin 500 mg PO TID, why might this order require revision?

• Amoxicillin is contraindicated in children under 10 years
• Dose likely exceeds recommended mg/kg dosing for common infections
• Oral administration route is inappropriate in pediatrics
• Frequency TID is unacceptable; should be once daily

Correct Answer: Dose likely exceeds recommended mg/kg dosing for common infections

Q6. A patient on warfarin has a new order for trimethoprim-sulfamethoxazole. What is the best recommendation while reviewing the medication order?

• No action required; no known interaction
• Recommend holding warfarin while patient receives TMP-SMX
• Recommend closer INR monitoring and possible warfarin dose reduction
• Substitute TMP-SMX with ciprofloxacin without consulting prescriber

Correct Answer: Recommend closer INR monitoring and possible warfarin dose reduction

Q7. During review you find the abbreviation “U” (for units) on an insulin order. What is the safest recommendation?

• Leave as is; “U” is commonly accepted
• Clarify prescriber intention and request “units” spelled out to avoid misinterpretation
• Convert “U” to “IU” and proceed
• Change to an oral hypoglycemic without prescriber approval

Correct Answer: Clarify prescriber intention and request “units” spelled out to avoid misinterpretation

Q8. Which of the following orders indicates therapeutic duplication that should be queried?

• Metformin 500 mg BID and insulin for hyperglycemia in type 2 diabetes
• Lisinopril 10 mg daily and losartan 50 mg daily for hypertension
• Acetaminophen PRN for fever and scheduled ibuprofen for pain
• Omeprazole 20 mg daily and sucralfate for peptic ulcer

Correct Answer: Lisinopril 10 mg daily and losartan 50 mg daily for hypertension

Q9. An order reads “heparin 5,000 units SQ q8h for DVT prophylaxis” but the patient has platelet count 40,000/µL. What is the best course of action?

• Administer heparin as ordered; thrombocytopenia is unrelated
• Recommend holding heparin and notify prescriber due to high bleeding risk
• Reduce heparin dose to 2,500 units SQ q8h
• Switch to warfarin for prophylaxis immediately

Correct Answer: Recommend holding heparin and notify prescriber due to high bleeding risk

Q10. Which item is the most appropriate intervention when encountering an ambiguous continuous IV infusion order that lacks rate units (e.g., “midazolam 2 mg/hr” but pump requires mcg/kg/min)?

• Program the pump with 2 mg/hr assuming device converts units automatically
• Clarify with prescriber to specify concentration and units required by the infusion pump
• Estimate infusion rate based on patient weight and proceed
• Change to intermittent bolus dosing without consulting prescriber

Correct Answer: Clarify with prescriber to specify concentration and units required by the infusion pump

Q11. A chemotherapy order lists vincristine 2 mg IV push on the wrong route (intrathecal is contraindicated). Which statement is true regarding order verification?

• Intrathecal vincristine is acceptable in selected cases
• Pharmacist must ensure route is explicitly intravenous and communicate with prescriber before dispensing
• Administer as written; route errors are nursing responsibility
• Substitute with oral vincristine alternative

Correct Answer: Pharmacist must ensure route is explicitly intravenous and communicate with prescriber before dispensing

Q12. When reviewing a medication list during admission reconciliation, which discrepancy warrants highest priority intervention?

• Patient reports taking vitamin D but not documented on admission list
• Home use of insulin omitted from admission list for a patient with type 1 diabetes
• OTC antihistamine listed but not continued
• Patient prefers different brand of multivitamin

Correct Answer: Home use of insulin omitted from admission list for a patient with type 1 diabetes

Q13. A prescription for “furosemide 40 mg IV stat” is written for an outpatient clinic with no documented blood pressure or potassium level. What should the pharmacist request before dispensing?

• No additional information; dispense stat dose immediately
• Obtain current blood pressure and serum potassium to assess risk of hypotension and hypokalemia
• Refer patient for echocardiogram first
• Recommend oral furosemide instead

Correct Answer: Obtain current blood pressure and serum potassium to assess risk of hypotension and hypokalemia

Q14. How should a medication order for a high-alert drug like potassium chloride concentrate 20 mEq/100 mL be documented to minimize error?

• Write “KCl concentrate” without dilution instructions
• Specify final concentration, total dose, infusion rate, and require pharmacist double-check
• Order as “potassium 20 mEq IV push” for quick correction
• Leave dilution to nursing discretion at bedside

Correct Answer: Specify final concentration, total dose, infusion rate, and require pharmacist double-check

Q15. While reviewing an antimicrobial order, you find vancomycin 1 g IV q12h for a patient with severe MRSA and a trough target of 15–20 µg/mL. The patient is obese (BMI 38). What is the best recommendation?

• Keep 1 g q12h regardless of weight
• Recommend dosing based on actual body weight and consider loading dose and more frequent dosing with therapeutic drug monitoring
• Switch to oral vancomycin since systemic absorption is low
• Decrease dose due to obesity-related toxicity risk

Correct Answer: Recommend dosing based on actual body weight and consider loading dose and more frequent dosing with therapeutic drug monitoring

Q16. An order for levothyroxine is written as “levothyroxine 100 mg PO daily.” What is the correct pharmacist action?

• Dispense 100 mg; levothyroxine dosing in mg is routine
• Clarify with prescriber since typical levothyroxine doses are in micrograms (µg) and 100 mg is likely a ten-thousand-fold error
• Convert to 0.1 mg and dispense without consulting
• Substitute liothyronine instead

Correct Answer: Clarify with prescriber since typical levothyroxine doses are in micrograms (µg) and 100 mg is likely a ten-thousand-fold error

Q17. Which of the following is the best method for detecting potential IV incompatibilities when reviewing a complex infusion order?

• Rely on nursing anecdote about previous mixing
• Consult an evidence-based compatibility reference and pharmacy compounding resources before co-administering
• Assume all antibiotics are compatible with normal saline
• Mix drugs at bedside to visually check for precipitation

Correct Answer: Consult an evidence-based compatibility reference and pharmacy compounding resources before co-administering

Q18. A patient with chronic kidney disease is prescribed metformin 500 mg BID; eGFR is 28 mL/min/1.73 m2. What is the most appropriate recommendation during order review?

• Continue metformin without change
• Hold metformin or reduce dose and discuss alternative glycemic agents due to risk of lactic acidosis
• Increase dose to improve glycemic control
• Convert to sulfonylurea empirically

Correct Answer: Hold metformin or reduce dose and discuss alternative glycemic agents due to risk of lactic acidosis

Q19. When an order includes “gentamicin peak and trough levels to be drawn,” which instruction should be present to ensure correct timing?

• Draw trough 30 minutes after dose and peak immediately before dose
• Draw trough immediately before the next dose and peak 30 minutes after the end of a 30-minute infusion (or 30–60 minutes after IM dose)
• No timing required; any random sample is acceptable
• Draw both levels simultaneously anytime during therapy

Correct Answer: Draw trough immediately before the next dose and peak 30 minutes after the end of a 30-minute infusion (or 30–60 minutes after IM dose)

Q20. Which documentation practice is essential after you identify and resolve a medication order discrepancy during chart review?

• Make the change silently without documenting to avoid alarming prescribers
• Document the discrepancy, action taken, communication with prescriber, and rationale in the medical record
• Only inform nursing staff verbally and omit record entry
• Log the event in a personal note for future reference without charting

Correct Answer: Document the discrepancy, action taken, communication with prescriber, and rationale in the medical record

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