Free PEBC® MCQ Practice Questions

These 20 original practice questions are written against the PEBC® Qualifying Examination Blueprint Ver. 03-2026, which maps to the 2024 NAPRA professional competencies. They are case-based, like the real Part I, and spread across all six competency areas in roughly the same proportions as the blueprint. Every answer comes with an explanation, a note on why each wrong option is wrong, and the Canadian guideline or reference it rests on.

To get an honest read on where you stand, give yourself about one minute per question and commit to an answer before you reveal the explanation. Treat every miss as a lead: it points to the guideline or concept you should review next.

Last reviewed October 18, 2026 · Based on the Pharmacist Qualifying Examination Blueprint, Ver. 03-2026

How Part I is weighted

The blueprint groups pharmacist competencies into six areas. Clinical care alone makes up half of Part I, so this set leans the same way.

For the full picture of eligibility, format and scheduling, see the full exam guide.

Competency area weights for Part I (MCQ), Blueprint Ver. 03-2026
Competency areaPart I weight
Providing Care: Clinical Care50%
Providing Care: Distribution20%
Professionalism12%
Knowledge and Expertise11%
Communication and Collaboration4%
Leadership and Stewardship3%

How to get the most from these questions

  • Answer first, then read the explanation. Peeking turns a test into reading, and reading feels like learning without building recall.
  • Review every distractor, not just the correct answer. Part I options are written to be plausible, so knowing why each wrong choice fails is where most of the marks are.
  • Note the guideline behind each question. If you missed it, skim the relevant section of that guideline rather than memorizing the single fact.
  • Re-test the questions you got wrong in two or three days, without looking at the explanation first. Spaced retrieval is what makes it stick.
  • Show your working on calculations every time, including units. Most calculation errors on exam day are unit or concentration slips, not arithmetic.

Practice questions

Original questions written for this page. Answer each one before you open the explanation.

Question 1Asthma
Providing Care: Clinical Care

A 27-year-old woman with asthma diagnosed two years ago uses salbutamol 100 mcg/puff, 2 puffs as needed. She reports needing it about 3 times a week for wheeze and chest tightness and has woken once at night in the past month. She has had no exacerbations needing oral corticosteroids. Her inhaler technique is good and she uses no other medications.

According to the Canadian Thoracic Society, which of the following is the most appropriate change?

  1. A.Continue salbutamol as needed, since she has had no exacerbations
  2. B.Add salmeterol 50 mcg inhaled twice daily
  3. C.Replace salbutamol with budesonide/formoterol (Symbicort Turbuhaler) taken as needed
  4. D.Prescribe a 5-day course of oral prednisone
  5. E.Increase salbutamol to 2 puffs four times daily, scheduled
Show answer and explanation

Answer: C

The CTS 2021 update recommends against SABA-only treatment for patients 12 years and older because it does not address airway inflammation and is linked to higher exacerbation risk. For mild asthma, either as-needed budesonide/formoterol or a daily low-dose ICS with a reliever is recommended. As-needed budesonide/formoterol delivers an ICS dose every time she relieves symptoms.

Why the other options are wrong

  • A:SABA monotherapy is no longer recommended for anyone 12 or older, even with no prior exacerbations. Absence of past exacerbations does not mean low future risk.
  • B:LABA monotherapy without an ICS is contraindicated in asthma because of an increased risk of severe exacerbations and asthma-related death.
  • D:Oral corticosteroids are for exacerbations, not for stepping up maintenance therapy in a stable patient.
  • E:Scheduled SABA use adds no anti-inflammatory benefit and can worsen control. Escalating reliever use is a sign to add a controller.

Reference: Canadian Thoracic Society asthma guideline, 2021 focused update

Question 2COPD
Providing Care: Clinical Care

A 66-year-old man with COPD (post-bronchodilator FEV1 55% of predicted) has a CAT score of 18 and an mMRC dyspnea grade of 2. He has had no exacerbations in the past year. He quit smoking 3 years ago. His only medication is salbutamol as needed, which he uses most days.

Which of the following is the most appropriate maintenance therapy to start?

  1. A.Fluticasone propionate inhaler, 250 mcg twice daily
  2. B.Umeclidinium/vilanterol (Anoro Ellipta), one inhalation once daily
  3. C.Roflumilast 500 mcg orally once daily
  4. D.Azithromycin 250 mg orally once daily
  5. E.Budesonide/formoterol/glycopyrronium triple therapy, two inhalations twice daily
Show answer and explanation

Answer: B

He has significant symptoms (CAT 10 or more, mMRC 2 or more) and impaired lung function but a low exacerbation risk. The CTS COPD guideline recommends a LAMA/LABA combination for this group, because dual bronchodilation improves dyspnea, lung function and quality of life more than a single long-acting bronchodilator.

Why the other options are wrong

  • A:ICS monotherapy is not recommended in COPD. It does not improve lung function decline and increases pneumonia risk.
  • C:Roflumilast is an add-on for patients with chronic bronchitis and repeated exacerbations despite inhaled therapy, not an initial maintenance agent.
  • D:Long-term azithromycin is reserved for patients who keep having exacerbations despite optimal inhaled therapy, and it carries resistance, QT and hearing risks.
  • E:Triple therapy is for patients with ongoing exacerbations despite dual therapy. Without exacerbation history, adding an ICS adds pneumonia risk without clear benefit.

Reference: Canadian Thoracic Society COPD pharmacotherapy guideline, 2023 update

Question 3Dyslipidemia
Providing Care: Clinical Care

A 61-year-old man had a myocardial infarction 8 months ago. He takes atorvastatin 80 mg daily, ASA 81 mg daily, bisoprolol 5 mg daily and ramipril 10 mg daily. He tolerates all medications and reports full adherence. His most recent fasting lipid panel shows LDL-C 2.1 mmol/L, triglycerides 1.4 mmol/L and HDL-C 1.1 mmol/L.

According to the Canadian Cardiovascular Society, what is the most appropriate next step for his lipid therapy?

  1. A.No change, because he is already on a maximal statin dose
  2. B.Add ezetimibe 10 mg once daily
  3. C.Add fenofibrate 145 mg once daily
  4. D.Add niacin extended-release, titrated to 2 g daily
  5. E.Add an over-the-counter fish oil capsule, 1 g daily
Show answer and explanation

Answer: B

For patients with atherosclerotic cardiovascular disease on maximally tolerated statin therapy, the CCS 2021 guideline recommends intensifying therapy when LDL-C remains at or above 1.8 mmol/L. Ezetimibe is an appropriate first add-on: it is oral, inexpensive and lowers LDL-C by roughly a further 20 to 25%. A PCSK9 inhibitor is the other intensification option.

Why the other options are wrong

  • A:He is above the CCS treatment intensification threshold (LDL-C 1.8 mmol/L) for secondary prevention, so leaving therapy unchanged misses a chance to reduce his risk.
  • C:Fibrates target triglycerides, which are normal here, and have not shown cardiovascular benefit when added to statins.
  • D:Niacin added to statin therapy did not reduce cardiovascular events in outcome trials and increases adverse effects.
  • E:Over-the-counter fish oil has not shown cardiovascular benefit. Prescription icosapent ethyl has a niche in patients with elevated triglycerides, which he does not have.

Reference: Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia, 2021

Question 4Heart failure
Providing Care: Clinical Care

A 64-year-old man has heart failure with reduced ejection fraction (LVEF 30%), NYHA class II. His medications are sacubitril/valsartan 97/103 mg twice daily, bisoprolol 10 mg daily, spironolactone 25 mg daily and furosemide 20 mg daily. He does not have diabetes. Blood pressure is 112/70 mmHg, heart rate 62 beats/min, potassium 4.6 mmol/L and eGFR 55 mL/min/1.73 m².

Which of the following should be added to his regimen?

  1. A.Ramipril 2.5 mg twice daily
  2. B.Diltiazem CD 120 mg once daily
  3. C.Dapagliflozin 10 mg once daily
  4. D.Digoxin 0.125 mg once daily
  5. E.Ivabradine 5 mg twice daily
Show answer and explanation

Answer: C

The CCS/CHFS heart failure guidelines recommend four foundational therapies for HFrEF: an ARNI (or ACE inhibitor/ARB), an evidence-based beta-blocker, an MRA and an SGLT2 inhibitor. He is missing the SGLT2 inhibitor. Dapagliflozin reduces cardiovascular death and heart failure hospitalization in HFrEF whether or not diabetes is present, and his eGFR supports starting it.

Why the other options are wrong

  • A:An ACE inhibitor must never be combined with sacubitril/valsartan because of the risk of angioedema. A 36-hour washout is required when switching between them.
  • B:Non-dihydropyridine calcium channel blockers have negative inotropic effects and can worsen HFrEF. They should be avoided.
  • D:Digoxin may reduce hospitalizations in patients who remain symptomatic despite optimal therapy, but it does not reduce mortality and is not a foundational therapy.
  • E:Ivabradine is only considered when resting heart rate stays at 70 beats/min or above in sinus rhythm despite a maximally tolerated beta-blocker. His heart rate is 62.

Reference: Canadian Cardiovascular Society/Canadian Heart Failure Society heart failure guidelines update, 2021

Question 5H. pylori
Providing Care: Clinical Care

A 45-year-old woman has a duodenal ulcer and a positive urea breath test for Helicobacter pylori. She has never been treated for H. pylori. She reports a severe penicillin allergy (throat swelling and hives after amoxicillin). She takes no other medications.

According to the Toronto Consensus, which regimen is most appropriate?

  1. A.PPI, amoxicillin and clarithromycin for 14 days
  2. B.PPI, amoxicillin, metronidazole and clarithromycin (concomitant therapy) for 14 days
  3. C.PPI, bismuth subsalicylate, metronidazole and tetracycline (bismuth quadruple therapy) for 14 days
  4. D.PPI, clarithromycin and metronidazole for 7 days
  5. E.PPI, amoxicillin and levofloxacin for 14 days
Show answer and explanation

Answer: C

The Toronto Consensus recommends either concomitant non-bismuth quadruple therapy (PAMC) or bismuth quadruple therapy (PBMT), each for 14 days, as first-line options. Because of her anaphylactic penicillin allergy, the amoxicillin-free bismuth quadruple regimen is the right choice.

Why the other options are wrong

  • A:Contains amoxicillin, which is contraindicated given her allergy. Triple therapy is also restricted in Canada because of high clarithromycin resistance.
  • B:Concomitant therapy is a first-line option for most patients, but it contains amoxicillin.
  • D:PPI-clarithromycin triple therapy is restricted to settings with known low clarithromycin resistance, and 7 days is shorter than the recommended 14-day duration.
  • E:Levofloxacin-containing therapy is reserved for rescue treatment after failure, and this regimen also contains amoxicillin.

Reference: Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults, 2016

Question 6C. difficile infection
Providing Care: Clinical Care

A 58-year-old woman developed 5 watery stools a day after finishing a course of clindamycin for a dental infection. A stool test is positive for toxigenic Clostridioides difficile. This is her first episode. She is afebrile, her white blood cell count is 11 x 10⁹/L and her serum creatinine is at her baseline of 70 µmol/L.

Which of the following is the most appropriate treatment?

  1. A.Vancomycin 125 mg orally four times daily for 10 days
  2. B.Vancomycin 1 g intravenously every 12 hours for 10 days
  3. C.Loperamide 2 mg after each loose stool until diarrhea resolves
  4. D.Restart clindamycin and add a probiotic
  5. E.No treatment, since symptoms usually resolve once the antibiotic is stopped
Show answer and explanation

Answer: A

For a first, non-severe episode of C. difficile infection, oral vancomycin 125 mg four times daily for 10 days (or oral fidaxomicin) is recommended. Metronidazole is no longer preferred because it is less effective. Her normal white cell count and creatinine indicate a non-severe episode.

Why the other options are wrong

  • B:IV vancomycin is not excreted into the colon in meaningful amounts, so it does not treat C. difficile infection. Vancomycin must be given orally (or rectally) for this indication.
  • C:Antimotility agents are generally avoided in active C. difficile infection, especially without concurrent antibiotic treatment, because of concern for toxin retention and complications.
  • D:Clindamycin is one of the highest-risk antibiotics for C. difficile. The inciting antibiotic should be stopped, not restarted.
  • E:Stopping the inciting antibiotic is important, but a confirmed, symptomatic infection with 5 stools a day warrants specific treatment.

Reference: AMMI Canada practice point on treatment of C. difficile infection, 2018; IDSA/SHEA focused update, 2021

Question 7Geriatrics
Providing Care: Clinical Care

An 81-year-old woman with mild cognitive impairment was started on oxybutynin 5 mg three times daily for urge incontinence 6 weeks ago. Her daughter reports she has become more confused, constipated and complains of a dry mouth. Her other medications are atorvastatin 20 mg daily and vitamin D 1000 units daily. Her blood pressure is well controlled without medication.

Which of the following is the most appropriate recommendation?

  1. A.Increase oxybutynin to 10 mg three times daily for better bladder control
  2. B.Add donepezil 5 mg daily for the new confusion
  3. C.Stop oxybutynin and consider mirabegron
  4. D.Add diphenhydramine 25 mg at bedtime to improve sleep and reduce nighttime urgency
Show answer and explanation

Answer: C

Oxybutynin is a strongly anticholinergic drug that the AGS Beers Criteria advise avoiding in older adults, particularly those with cognitive impairment. Her confusion, constipation and dry mouth are classic anticholinergic effects. Mirabegron, a beta-3 agonist, treats overactive bladder without anticholinergic burden; blood pressure should be monitored after starting it.

Why the other options are wrong

  • A:Increasing the dose would worsen her anticholinergic adverse effects, including the confusion.
  • B:Treating a drug-induced adverse effect with another drug is a prescribing cascade. Cholinesterase inhibitors also directly oppose the anticholinergic and can worsen urinary incontinence.
  • D:Diphenhydramine is a strongly anticholinergic first-generation antihistamine on the Beers list. It would add to her confusion and constipation.

Reference: American Geriatrics Society Beers Criteria, 2023 update (widely used in Canadian practice)

Question 8Smoking cessation
Providing Care: Clinical Care

A 49-year-old man who smokes 20 cigarettes a day is prescribed varenicline to help him quit. He has normal renal function and no psychiatric history. He asks how to take it.

Which of the following is the correct counselling?

  1. A.Take 1 mg twice daily starting on your quit date
  2. B.Take 0.5 mg once daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily; set your quit date about a week after starting
  3. C.Take 0.5 mg twice daily for 4 weeks only, and stop smoking on the last day
  4. D.Take it only when you have a craving, up to 4 times a day
  5. E.Start varenicline after you have been smoke-free for one week
Show answer and explanation

Answer: B

Varenicline is titrated over the first week (0.5 mg daily on days 1 to 3, 0.5 mg twice daily on days 4 to 7, then 1 mg twice daily) to reduce nausea. Patients usually set a quit date between day 8 and day 35 of treatment, and a standard course is 12 weeks. Taking it after food with a full glass of water also helps with nausea.

Why the other options are wrong

  • A:Starting at the full dose without titration increases nausea, and starting on the quit date means the drug is not yet at steady state when cravings peak.
  • C:1 mg twice daily is the usual maintenance dose, and 12 weeks is the standard course. Four weeks at a reduced dose is too short and too low.
  • D:Varenicline is a scheduled daily medication, not an as-needed craving treatment. Short-acting nicotine replacement products are the ones used for breakthrough cravings.
  • E:Varenicline is started before the quit date so that it is effective by the time the patient stops smoking.

Reference: Health Canada product monograph for varenicline tartrate tablets; CAN-ADAPTT Canadian Smoking Cessation Clinical Practice Guideline, 2011

Question 9Hypothyroidism
Providing Care: Clinical Care

A 57-year-old woman has been stable on levothyroxine 100 mcg daily for years, taken each morning. Two months ago she started calcium carbonate 500 mg (elemental) and ferrous fumarate 300 mg, and she now takes all three together with breakfast. Her TSH has risen from 1.8 mIU/L to 7.2 mIU/L. She has no new symptoms and no other medication changes.

What is the most appropriate first recommendation?

  1. A.Increase levothyroxine to 125 mcg daily and keep taking everything together
  2. B.Take levothyroxine on an empty stomach and separate it from the calcium and iron by at least 4 hours, then recheck TSH in 6 to 8 weeks
  3. C.Switch levothyroxine to liothyronine
  4. D.Stop the calcium and iron permanently
  5. E.Recheck TSH in one week before making any change
Show answer and explanation

Answer: B

Calcium and iron bind levothyroxine in the gut and reduce its absorption, which explains the rising TSH after these were started. Separating levothyroxine from them by at least 4 hours, and taking it consistently on an empty stomach, corrects the problem without changing the dose. TSH takes about 6 to 8 weeks to reach a new steady state, so that is when to recheck.

Why the other options are wrong

  • A:Raising the dose treats the number but not the cause. If she later separates the doses, she could become over-replaced.
  • C:Liothyronine is not a recommended routine treatment for hypothyroidism and would still be affected by poor absorption timing.
  • D:She may have valid reasons for calcium and iron. Separating the doses resolves the interaction without stopping needed supplements.
  • E:TSH changes slowly. A recheck after one week would not reflect a new steady state and delays correcting a clear cause.

Reference: Health Canada product monograph for levothyroxine sodium (Synthroid); American Thyroid Association hypothyroidism guideline, 2014

Question 10Self-care in pregnancy
Providing Care: Clinical Care

A 29-year-old woman who is 24 weeks pregnant asks for something for constipation. She has 2 hard bowel movements a week. She has already increased her dietary fibre and fluid intake for 2 weeks with little improvement. She takes a prenatal vitamin containing iron. She has no abdominal pain, bleeding or other symptoms.

Which product is the most appropriate recommendation?

  1. A.Castor oil 15 mL as needed
  2. B.Mineral oil 15 mL at bedtime daily
  3. C.Polyethylene glycol 3350 (RestoraLAX, Lax-A-Day) 17 g in a glass of fluid once daily
  4. D.Sodium phosphate enema (Fleet) daily until regular
Show answer and explanation

Answer: C

When fibre and fluids are not enough, an osmotic laxative such as polyethylene glycol 3350 is a preferred option in pregnancy. It is minimally absorbed, effective and well tolerated. It can be adjusted to effect, and she should be told to seek care if she develops abdominal pain or bleeding.

Why the other options are wrong

  • A:Castor oil can stimulate uterine contractions and should be avoided in pregnancy.
  • B:Regular mineral oil use can reduce absorption of fat-soluble vitamins (including vitamin K) and carries aspiration risk.
  • D:Repeated sodium phosphate enemas can cause electrolyte disturbances and are not appropriate for ongoing management.

Reference: Canadian Pharmacists Association, Compendium of Therapeutics for Minor Ailments, constipation chapter (current edition)

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Question 11Calculations: paediatric dosing
Providing Care: Distribution

A 4-year-old boy weighing 18 kg has a fever. His physician recommends acetaminophen 15 mg/kg/dose every 6 hours as needed. The family has children's acetaminophen suspension 160 mg/5 mL.

What volume should be given per dose?

  1. A.3.4 mL
  2. B.5.6 mL
  3. C.8.4 mL
  4. D.16.9 mL
Show answer and explanation

Answer: C

Dose: 15 mg/kg x 18 kg = 270 mg. Concentration: 160 mg/5 mL = 32 mg/mL. Volume: 270 mg ÷ 32 mg/mL = 8.4 mL (8.44 mL). In practice this would usually be rounded to a measurable volume with an oral syringe, and the daily total (4 doses, 1080 mg) stays well under the 75 mg/kg/day maximum.

Why the other options are wrong

  • A:This uses the 80 mg/mL infant drop concentration (270 ÷ 80), not the 160 mg/5 mL suspension the family has. Mixing up concentrations is a classic paediatric dosing error.
  • B:This is 10 mg/kg (180 mg ÷ 32 mg/mL), the low end of the dose range, not the 15 mg/kg ordered.
  • D:This treats the suspension as 80 mg/5 mL (16 mg/mL), which doubles the volume and the dose.

Reference: Canadian Paediatric Society, fever in children guidance (caring for kids); Health Canada labelling standard for paediatric acetaminophen

Question 12Calculations: IV infusion
Providing Care: Distribution

A 70 kg adult in hospital is ordered dopamine at 5 mcg/kg/min. The pharmacy supplies a premixed bag of dopamine 400 mg in 250 mL of D5W.

At what rate should the infusion pump be set?

  1. A.0.22 mL/h
  2. B.1.3 mL/h
  3. C.13.1 mL/h
  4. D.21 mL/h
  5. E.131 mL/h
Show answer and explanation

Answer: C

Dose per minute: 5 mcg/kg/min x 70 kg = 350 mcg/min. Per hour: 350 x 60 = 21,000 mcg/h. Concentration: 400 mg ÷ 250 mL = 1.6 mg/mL = 1600 mcg/mL. Rate: 21,000 ÷ 1600 = 13.1 mL/h.

Why the other options are wrong

  • A:This is the rate in mL per minute (350 ÷ 1600), not per hour. Pumps are programmed in mL/h.
  • B:This is off by a factor of 10, usually from a decimal error when converting mg to mcg.
  • D:This is the dose in mg/h (21 mg/h) mistaken for a volume. Units matter.
  • E:This is off by a factor of 10 in the other direction, usually from using 160 mcg/mL as the concentration.

Reference: Standard pharmaceutical calculation (dose x weight x time ÷ concentration)

Question 13Storage and dispensing
Providing Care: Distribution

A pharmacy technician is putting away a wholesaler order. The order includes several unopened products.

Which of the following should be stored in the refrigerator (2 to 8 °C) until it is dispensed?

  1. A.Nitroglycerin 0.4 mg sublingual tablets in the original glass bottle
  2. B.Latanoprost 0.005% ophthalmic solution (Xalatan)
  3. C.Amoxicillin powder for oral suspension, not yet reconstituted
  4. D.Salbutamol 100 mcg metered-dose inhaler
  5. E.Levothyroxine 50 mcg tablets
Show answer and explanation

Answer: B

Unopened latanoprost (Xalatan) is stored in the refrigerator and protected from light. Once opened, the patient may keep it at room temperature (up to 25 °C) for up to 6 weeks. Patients should be told this when it is dispensed.

Why the other options are wrong

  • A:Sublingual nitroglycerin tablets are stored at room temperature in the original tightly closed glass container to protect potency.
  • C:Dry amoxicillin powder is stored at room temperature. Refrigeration is recommended only after reconstitution, and it improves taste.
  • D:Metered-dose inhalers are stored at room temperature and should be kept away from heat because the canister is pressurized.
  • E:Levothyroxine tablets are stored at room temperature, protected from light and moisture.

Reference: Health Canada product monograph for Xalatan (latanoprost ophthalmic solution)

Question 14Prescription assessment
Providing Care: Distribution

A pharmacist receives a new prescription for a 62-year-old woman recently diagnosed with rheumatoid arthritis: methotrexate 2.5 mg tablets, take 3 tablets (7.5 mg) by mouth once daily, quantity 84. Folic acid 1 mg daily is also prescribed.

What is the most appropriate action?

  1. A.Dispense as written, because 7.5 mg is a low dose
  2. B.Change the directions to once weekly and dispense, since that is clearly what was meant
  3. C.Contact the prescriber to clarify, because oral methotrexate for rheumatoid arthritis is dosed once weekly
  4. D.Dispense as written but counsel the patient to take it once weekly
  5. E.Dispense folic acid only and ask the patient to return when the prescriber is available
Show answer and explanation

Answer: C

Oral methotrexate for rheumatoid arthritis is taken once weekly. Daily dosing errors have caused serious toxicity and deaths, which is why ISMP Canada lists it as a high-alert medication. The pharmacist must contact the prescriber to clarify before dispensing, document the outcome, and counsel the patient on the weekly schedule and the specific day of the week.

Why the other options are wrong

  • A:7.5 mg daily is 52.5 mg per week, a toxic dose for this indication. Daily dosing is the classic, potentially fatal methotrexate error.
  • B:The intended regimen is very likely weekly, but the pharmacist should not change the directions on their own initiative. Clarifying with the prescriber confirms the dose and corrects the record.
  • D:Dispensing a label that contradicts the counselling creates exactly the confusion that leads to daily dosing errors.
  • E:This delays care unnecessarily. The prescriber can usually be reached, and the methotrexate issue is what needs to be resolved.

Reference: ISMP Canada Safety Bulletins on oral methotrexate dosing errors; Canadian Rheumatology Association methotrexate guidance

Question 15Privacy and confidentiality
Professionalism

The adult daughter of a 74-year-old patient phones the pharmacy. She says she is worried about her mother and asks which medications her mother is taking and how often she refills them. The patient is competent, has not named her daughter as an authorized contact, and there is no emergency.

What is the most appropriate response?

  1. A.Share the medication list, since family members are part of the circle of care
  2. B.Share the refill dates only, since those are not clinical information
  3. C.Explain that the information cannot be shared without the patient's consent, and offer to speak with the patient or have the patient authorize the daughter
  4. D.Tell the daughter to come to the pharmacy in person with photo ID, then share the information
  5. E.Hang up without explanation to avoid any risk of disclosure
Show answer and explanation

Answer: C

Personal health information belongs to the patient, and a competent adult's information can only be disclosed with their consent or where the law allows it, such as an emergency. Canadian privacy legislation and the NAPRA Model Standards of Practice require pharmacists to protect confidentiality. The pharmacist can still help the daughter by offering a route to proper consent.

Why the other options are wrong

  • A:Family members are not automatically part of the circle of care. The circle of care refers to health care providers treating the patient, not relatives.
  • B:Refill history is personal health information. Disclosing it without consent is still a breach.
  • D:Proving identity shows who the daughter is, not that the patient has consented. ID does not replace consent.
  • E:Pharmacists should respond respectfully and explain why they cannot share information. Hanging up is unprofessional and does not help the family.

Reference: NAPRA Model Standards of Practice for Canadian Pharmacists, 2022; PIPEDA and provincial health privacy legislation

Question 16Ethics: conscientious objection
Professionalism

A 22-year-old woman asks the pharmacist for levonorgestrel emergency contraception after unprotected intercourse 20 hours ago. The pharmacist on duty has a sincere moral objection to providing emergency contraception. Another pharmacy two blocks away is open, and a second pharmacist will start a shift in this pharmacy in 6 hours.

In most provinces, what is the pharmacist's professional obligation?

  1. A.Decline and say nothing further, since conscientious objection is protected
  2. B.Decline, but ensure she can obtain it promptly, for example by an effective referral to the nearby pharmacy, without judgment
  3. C.Ask her to come back in 6 hours when the other pharmacist is working
  4. D.Provide it but explain the pharmacist's moral objections during counselling
  5. E.Advise her to book an appointment with her family physician
Show answer and explanation

Answer: B

Pharmacists may, in most provinces, decline to provide a service on grounds of conscience, but they may not abandon the patient or obstruct timely access. Emergency contraception is time-sensitive, so the pharmacist must make sure she can get it promptly, respectfully and without having her choices questioned. An effective, timely referral to the nearby open pharmacy meets that obligation.

Why the other options are wrong

  • A:Conscientious objection does not relieve the pharmacist of the duty to ensure continuity of care. Leaving her without a path to the medication is patient abandonment.
  • C:Levonorgestrel is more effective the sooner it is taken. A 6-hour delay when another pharmacy is open nearby does not ensure timely access.
  • D:Sharing personal moral views while counselling is judgmental and inappropriate. The interaction should be about her care, not the pharmacist's beliefs.
  • E:Waiting for a physician appointment delays a time-sensitive, non-prescription medication that she can get from a pharmacy today.

Reference: NAPRA Model Code of Ethics for Canadian Pharmacists, 2023 (and provincial regulatory college standards on conscientious objection)

Question 17Evidence appraisal: NNT
Knowledge and Expertise

In a randomized controlled trial lasting 3 years, a major cardiovascular event occurred in 10% of patients in the placebo group and 7.5% of patients in the treatment group.

How many patients need to be treated for 3 years to prevent one event?

  1. A.4
  2. B.10
  3. C.13
  4. D.25
  5. E.40
Show answer and explanation

Answer: E

Absolute risk reduction (ARR) = control event rate minus treatment event rate = 10% minus 7.5% = 2.5% (0.025). NNT = 1 ÷ ARR = 1 ÷ 0.025 = 40. The NNT always applies to the trial duration, so the answer is 40 patients treated for 3 years.

Why the other options are wrong

  • A:This is 1 ÷ the relative risk reduction (25%). NNT is calculated from the absolute, not the relative, risk reduction.
  • B:This is 1 ÷ the control event rate (10%). It ignores the treatment group entirely.
  • C:This is 1 ÷ the treatment event rate (7.5%), which is not a meaningful measure of benefit.
  • D:This is the relative risk reduction expressed as a number (25%), not the NNT.

Reference: Standard evidence-based medicine calculation (absolute risk reduction and number needed to treat)

Question 18Pharmacokinetics
Knowledge and Expertise

A 35-year-old man with epilepsy takes phenytoin 300 mg daily. His albumin is normal and his total phenytoin level is 40 µmol/L (reference range approximately 40 to 80 µmol/L). Because he has had breakthrough seizures, his neurologist increases the dose to 400 mg daily.

Which of the following best describes the expected effect on his steady-state phenytoin concentration?

  1. A.It will rise by about one third, in proportion to the dose increase
  2. B.It may rise by much more than one third, because phenytoin metabolism is saturable
  3. C.It will stay about the same, because phenytoin induces its own metabolism
  4. D.It will fall, because a higher dose speeds elimination
Show answer and explanation

Answer: B

Phenytoin follows Michaelis-Menten (saturable, non-linear) kinetics within the therapeutic range. As the metabolizing enzymes approach saturation, small dose increases can cause disproportionately large increases in concentration and toxicity. This is why phenytoin dose changes are made in small steps with level monitoring.

Why the other options are wrong

  • A:A proportional rise is what happens with first-order (linear) kinetics. Phenytoin does not behave this way in the therapeutic range.
  • C:Autoinduction (a drug inducing its own metabolism) is characteristic of carbamazepine, not phenytoin.
  • D:With saturable metabolism, a higher dose slows effective clearance relative to dose, so concentrations rise, not fall.

Reference: Standard clinical pharmacokinetics; Health Canada product monograph for phenytoin (Dilantin)

Question 19Patient counselling
Communication and Collaboration

A 68-year-old man is picking up a new prescription for a 10-day prednisone taper that changes dose every few days. He mentions that he often finds written instructions hard to follow. The pharmacist has just explained the schedule and given him a calendar showing each day's dose.

Which of the following is the best way for the pharmacist to confirm he has understood?

  1. A.Ask: "Do you understand how to take this?"
  2. B.Ask: "Do you have any questions?"
  3. C.Ask: "To make sure I explained it clearly, can you tell me how many tablets you will take on day 1 and on day 5?"
  4. D.Repeat the full explanation a second time, more slowly
  5. E.Give him the manufacturer's patient information leaflet to read at home
Show answer and explanation

Answer: C

This is the teach-back method: the patient explains the key instructions in his own words, framed as a check on the pharmacist's explanation rather than a test of the patient. It reveals misunderstandings immediately and is especially useful for complex regimens and patients with lower health literacy.

Why the other options are wrong

  • A:A closed yes/no question invites a polite "yes" and does not show whether he actually understood.
  • B:Patients who misunderstand often do not know what to ask. This question does not verify understanding.
  • D:Repeating the explanation may help, but it still does not confirm what he understood.
  • E:He has already said written instructions are hard for him. A dense leaflet is the least effective option here and does not confirm understanding.

Reference: NAPRA Professional Competencies for Canadian Pharmacists at Entry to Practice, 2024 (communication); health literacy teach-back guidance

Question 20Medication safety
Leadership and Stewardship

During the final check of a prescription for metoprolol 25 mg tablets, the pharmacist notices that the vial was filled with metoprolol 50 mg tablets. The error is corrected before the prescription reaches the patient. The two strengths are stored side by side on the shelf with similar packaging.

What is the most appropriate next step?

  1. A.No further action, because the error did not reach the patient
  2. B.Document and report the near miss through the pharmacy's incident reporting or continuous quality improvement program, and review contributing factors such as shelf placement
  3. C.Formally discipline the technician who filled it, since the root cause was carelessness
  4. D.Call the patient to disclose that an error almost occurred
  5. E.Add a second final check by the same pharmacist on all metoprolol prescriptions
Show answer and explanation

Answer: B

Near misses are valuable safety signals: they reveal system weaknesses before harm occurs. A just culture approach documents and reports them (anonymously where the program allows) and looks for system fixes, such as separating look-alike strengths or adding shelf alerts. Most provinces now require community pharmacies to take part in a structured medication incident reporting program.

Why the other options are wrong

  • A:Near misses should still be documented and analyzed. Ignoring them leaves the same system flaw in place for the next prescription.
  • C:Blaming individuals discourages reporting and does not fix the underlying system cause (look-alike strengths stored together).
  • D:Disclosure is required for incidents that reach the patient. A near miss that was intercepted does not typically require patient disclosure, although reporting is still important.
  • E:A repeated check by the same person adds little, because the same person tends to miss the same error. System changes are more effective.

Reference: ISMP Canada and NAPRA guidance on medication incident reporting and continuous quality improvement in community pharmacy (for example, the NAPRA Model Standards of Practice, 2022)

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