MILESTONE EXAM 1 QUESTIONS AND ANSWERS
Two hours after taking the first dose of penicillin, a client arrives at the emergency
department complaining of feeling ill, exhibiting hives, having difficulty breathing, and
experiencing hypotension. The nurse will develop an immediate plan of care based on
which finding?
A.Severe acute anaphylactic response
B.Side reaction that should resolve
C.Idiosyncratic reaction
D.Cumulative drug response
A - Answers -Rationale: Anaphylaxis related to penicillin can cause a life-threatening
allergic response characterized by bronchospasm, laryngeal edema, and a precipitous
drop in blood pressure. This client's ingestion of penicillin and presenting clinical picture
indicate the client is having an acute reaction with respiratory difficulty. Options B, C,
and D are other physiologic responses to medications, but immediate action is required
for a potential loss of airway, breathing, and circulation.
Which response best supports the observations that the nurse identifies in a client who
is experiencing a placebo effect?
A.Beneficial response or cure for disease
B.Behavioral or psychotropic responses
C.Malingering or drug-seeking behaviors
D.Psychological response to inert medication
D - Answers -Rationale:The placebo effect is a response in the client that is caused by
the psychological impact of taking an inert drug that has no biochemical properties. A
placebo effect can be therapeutic, negative, or ineffective but provides no cure or
benefit to the client's progress. The placebo effect may evoke behavioral changes but
does not affect neurochemical psychotropic changes. Malingering and drug seeking are
behaviors that a client exhibits to obtain treatment for nonexistent disorders or obtain
prescription medications.
A 21-year-old female client is receiving tetracycline for acne. Which client teaching
should the nurse include?
A.Oral contraceptives may not be effective.
B.Drinking cranberry juice will promote healing.
C.Breast tenderness may occur as a side effect.
D.The urine will turn a red-orange color.
A - Answers -Rationale:Certain antibiotics, such as tetracycline, decrease the
effectiveness of oral contraceptives. Options B, C, and D do not convey accurate
information related to client teaching about this medication.
An 80-year-old client who had a colon resection yesterday is receiving a constant dose
of hydromorphone via a patient-controlled analgesia (PCA) pump. Which finding
requires immediate nursing action?
A.The client is drowsy and complains of pruritus.
, B.Pupils are 3 mm; PERRLA.
C.The area around the sutures is reddened and swollen.
D.Respirations decrease to 10 breaths/min.
D - Answers -Rationale:Hydromorphone is an opioid agonist-analgesic of opiate
receptors that inhibits ascending pathways and can cause respiratory depression. Older
adults are more sensitive to opioids so the "start low and go slow" approach should be
taken. Option A lists common side effects of opioids, particularly the opiates, which are
usually harmless and often transient. Option B is within the normal range (2 to 6 cm).
The suture site may be red and swollen as an inflammatory response, but no action is
required if the skin around the incision is a normal color and temperature.
The nurse has completed diabetic teaching for a client who was newly diagnosed with
diabetes mellitus. Which statement by this client would indicate to the nurse that further
teaching is needed?
A."Regular insulin can be stored at room temperature for 30 days."
B."My legs, arms, and abdomen are all good sites to inject my insulin."
C."I will always carry hard candies to treat hypoglycemic reactions."
D."When I exercise, I should plan to increase my insulin dosage."
D - Answers -Exercise helps facilitate the entry of glucose into the cell, so increasing
insulin doses with exercise would place the client at high risk for a hypoglycemic
reaction. Options A, B, and C reflect accurate statements about the use of insulin and
management of hypoglycemic reactions.
To evaluate whether the administration of an antihypertensive medication has caused a
therapeutic effect, what is the best nursing action?
A.Ask the client about the onset of any dizziness since taking the medication.
B.Measure the client's blood pressure while the client is lying, sitting, and then
standing.
C.Compare the client's blood pressure before and after the client takes the medication.
D.Interview the client about any past or recent history of high blood pressure.
C - Answers -Rationale:Therapeutic effects are the expected or predictable physiologic
responses to a medication. An antihypertensive medication is administered to lower
blood pressure, so to determine if the therapeutic effect has been achieved, the nurse
should compare the client's blood pressure before and after the client takes the
medication. Options A and B provide data related to the side effect of hypotension,
which may occur following the administration of an antihypertensive medication. Option
D provides useful data but does not evaluate the medication's effectiveness.
Minocycline, 50 mg PO every 8 hours, is prescribed for an adolescent girl diagnosed
with acne. The nurse discusses self-care with the client while she is taking the
medication. Which teaching points should be included in the discussion? (Select all that
apply.)
A.Report vaginal itching or discharge.
B.Take the medication at 0800, 1500, and 2200 hours.
C.Protect skin from natural and artificial ultraviolet light.
D.Avoid driving until response to medication is known.
Two hours after taking the first dose of penicillin, a client arrives at the emergency
department complaining of feeling ill, exhibiting hives, having difficulty breathing, and
experiencing hypotension. The nurse will develop an immediate plan of care based on
which finding?
A.Severe acute anaphylactic response
B.Side reaction that should resolve
C.Idiosyncratic reaction
D.Cumulative drug response
A - Answers -Rationale: Anaphylaxis related to penicillin can cause a life-threatening
allergic response characterized by bronchospasm, laryngeal edema, and a precipitous
drop in blood pressure. This client's ingestion of penicillin and presenting clinical picture
indicate the client is having an acute reaction with respiratory difficulty. Options B, C,
and D are other physiologic responses to medications, but immediate action is required
for a potential loss of airway, breathing, and circulation.
Which response best supports the observations that the nurse identifies in a client who
is experiencing a placebo effect?
A.Beneficial response or cure for disease
B.Behavioral or psychotropic responses
C.Malingering or drug-seeking behaviors
D.Psychological response to inert medication
D - Answers -Rationale:The placebo effect is a response in the client that is caused by
the psychological impact of taking an inert drug that has no biochemical properties. A
placebo effect can be therapeutic, negative, or ineffective but provides no cure or
benefit to the client's progress. The placebo effect may evoke behavioral changes but
does not affect neurochemical psychotropic changes. Malingering and drug seeking are
behaviors that a client exhibits to obtain treatment for nonexistent disorders or obtain
prescription medications.
A 21-year-old female client is receiving tetracycline for acne. Which client teaching
should the nurse include?
A.Oral contraceptives may not be effective.
B.Drinking cranberry juice will promote healing.
C.Breast tenderness may occur as a side effect.
D.The urine will turn a red-orange color.
A - Answers -Rationale:Certain antibiotics, such as tetracycline, decrease the
effectiveness of oral contraceptives. Options B, C, and D do not convey accurate
information related to client teaching about this medication.
An 80-year-old client who had a colon resection yesterday is receiving a constant dose
of hydromorphone via a patient-controlled analgesia (PCA) pump. Which finding
requires immediate nursing action?
A.The client is drowsy and complains of pruritus.
, B.Pupils are 3 mm; PERRLA.
C.The area around the sutures is reddened and swollen.
D.Respirations decrease to 10 breaths/min.
D - Answers -Rationale:Hydromorphone is an opioid agonist-analgesic of opiate
receptors that inhibits ascending pathways and can cause respiratory depression. Older
adults are more sensitive to opioids so the "start low and go slow" approach should be
taken. Option A lists common side effects of opioids, particularly the opiates, which are
usually harmless and often transient. Option B is within the normal range (2 to 6 cm).
The suture site may be red and swollen as an inflammatory response, but no action is
required if the skin around the incision is a normal color and temperature.
The nurse has completed diabetic teaching for a client who was newly diagnosed with
diabetes mellitus. Which statement by this client would indicate to the nurse that further
teaching is needed?
A."Regular insulin can be stored at room temperature for 30 days."
B."My legs, arms, and abdomen are all good sites to inject my insulin."
C."I will always carry hard candies to treat hypoglycemic reactions."
D."When I exercise, I should plan to increase my insulin dosage."
D - Answers -Exercise helps facilitate the entry of glucose into the cell, so increasing
insulin doses with exercise would place the client at high risk for a hypoglycemic
reaction. Options A, B, and C reflect accurate statements about the use of insulin and
management of hypoglycemic reactions.
To evaluate whether the administration of an antihypertensive medication has caused a
therapeutic effect, what is the best nursing action?
A.Ask the client about the onset of any dizziness since taking the medication.
B.Measure the client's blood pressure while the client is lying, sitting, and then
standing.
C.Compare the client's blood pressure before and after the client takes the medication.
D.Interview the client about any past or recent history of high blood pressure.
C - Answers -Rationale:Therapeutic effects are the expected or predictable physiologic
responses to a medication. An antihypertensive medication is administered to lower
blood pressure, so to determine if the therapeutic effect has been achieved, the nurse
should compare the client's blood pressure before and after the client takes the
medication. Options A and B provide data related to the side effect of hypotension,
which may occur following the administration of an antihypertensive medication. Option
D provides useful data but does not evaluate the medication's effectiveness.
Minocycline, 50 mg PO every 8 hours, is prescribed for an adolescent girl diagnosed
with acne. The nurse discusses self-care with the client while she is taking the
medication. Which teaching points should be included in the discussion? (Select all that
apply.)
A.Report vaginal itching or discharge.
B.Take the medication at 0800, 1500, and 2200 hours.
C.Protect skin from natural and artificial ultraviolet light.
D.Avoid driving until response to medication is known.
