AHT 2 EXAM 2 2023 EXAM (AUTHENTIC EXAM WITH
ANSWERS) KEY CONCEPTS EXAM GRADED A+]
• A nurse is having difficulty arousing a client following an
esophagogastrostroduodenoscopy (EGD). Which of the following is the
priority action by the nurse?
• Assess the airway
• Allow the client to sleep
• Prepare to administer an antidote to the sedative
• Evaluate procedure lab findings9*
• A patient is scheduled for a liver biopsy. Which laboratory results would be
ofmost concern to the nurse?
• Hemoglobin of 11 g/dL
• Prothrombin time of 32 seconds
• Serum ammonia level of 56 mcg N/dL
• White blood cell count of 14.2 x 103/µL
• The nurse listens to bowel sounds for 60 seconds and does not hear
gurgling. Which action should the nurse take next?
• Document the bowel sounds as hypoactive.
• Continue to listen for at least another 60 seconds.
• Administer the prescribed drug for constipation.
• Review the patient's dietary intake for the past 24 hours
• During the postoperative care of a 76-year-old patient, the nurse monitors
the patient's intake and output carefully, knowing that the patient is at risk
for fluid and electrolyte imbalances primarily because
• older adults have an impaired thirst mechanism and need reminding to
drink fluids.
• water accounts for a greater percentage of body weight in the older adult
than in younger adults.
• older adults are more likely than younger adults to lose extracellular
fluid during surgical procedures.
• small losses of fluid are significant because body fluids account for 45%
to 50% of body weight in older adults.
• In a patient with prolonged vomiting, the nurse monitors for fluid volume
deficit because vomiting results in
• Fluid movement from the cells into the interstitial space and the blood vessels
• Excretion of large amounts of interstitial fluid with depletion of
extracellularfluids
• An overload of extracellular fluid with a significant increase in intracellular
fluidvolume
• Fluid movement from the vascular system into the cells, causing
cellular swelling and rupture
• Which assessment action will help the nurse determine if an obese patient
has metabolic syndrome?
• Take the patient's apical pulse.
, • Check the patient's blood pressure.
• Ask the patient about dietary intake.
• Dipstick the patient's urine for protein
• A patient is admitted to a medical unit with a diagnosis of malnutrition. The
student nurse asks the nurse assigned to this patient about the relationship
between drugs and nutrition. What is the most appropriate response for the
nurse to make?
• "Foods alter the absorption or bioavailability of all drugs."
• "If the patient skips a meal, drugs may not be taken."
• "Some drugs increase the requirements for essential nutrients."
• "Drugs should be taken with food to prevent GI irritation."
• The nurse obtains a drug history from a patient with ascites and elevated
aspartate and alanine aminotransferase levels. The nurse is most concerned
if the patient makes which statement?
• "Occasionally I will use Benadryl for my allergies."
• "Sometimes probiotics can make me feel bloated."
• "I add flaxseed powder to my cereal every morning."
• "I take acetaminophen 4 to 5 times a day for back pain."
• - M.H., a 62-year-old female, was admitted with confusion and lethargy related
to hyponatremia.
- Her husband tells you that M.H. had c/o diarrhea over the past week and was
drinking lots of water to prevent dehydration.
What caused M.H.'s serum sodium level to fall?
• Excessive diarrhea can cause fluid and sodium loss
• Constipation
• Adequate nutrition
• Excessive vomiting and increase drainage from nasogastric tube
• An older woman was admitted to the medical unit with GI bleeding and fluid
volume deficit. Clinical manifestations of this problem are (select all that
apply)
• a. weight loss.
• dry oral mucosa.
• full bounding pulse.
• engorged neck veins.
• decreased central venous pressure.
• The nursing care for a patient with hyponatremia and fluid volume
excess includes
• fluid restriction.
• administration of hypotonic IV fluids.
• administration of a cation-exchange resin.
• placement of an indwelling urinary catheter.
, • The nurse should be alert for which manifestations in a patient receiving a
loop diuretic?
• Restlessness and agitation
• Paresthesias and irritability
• Weak, irregular pulse and poor muscle tone
• Increased blood pressure and muscle spasms
• Priority Decision: A 75-year-old patient who is breathing room air has the
following arterial blood gas (ABG) results: pH 7.40, PaO2 74 mm Hg, SaO2
92%,
PaCO2 40 mm Hg. What is the most appropriate action by the nurse?
• Document the results in the patient's record knowing that this is a
normal finding in older adult
• Repeat the ABGs within an hour to validate the findings.
• Encourage deep breathing and coughing to open the alveoli.
• Initiate pulse oximetry for continuous monitoring of the patient's oxygen status.
• A patient is being admitted for bariatric surgery. Which nursing action can
thenurse delegate to unlicensed assistive personnel (UAP)?
• Demonstrate use of the incentive spirometer.
• Plan methods for turning the patient after surgery.
• Assist with IV insertion by holding adipose tissue out of the way.
• Develop strategies to provide privacy and decrease embarrassment
• Which patient is at greatest risk for developing hypermagnesemia?
• 83-year-old man with lung cancer and hypertension
• 65-year-old woman with hypertension taking β-adrenergic blockers
• 42-year-old woman with systemic lupus erythematosus and renal failure
• 50-year-old man with benign prostatic hyperplasia and a urinary tract infection
• It is important for the nurse to assess for which clinical manifestation(s) in
a patient who has just undergone a total thyroidectomy (select all that
apply)?
• a. Confusion
b. Weight gain
c. Depressed
reflexes
d. Circumoral
numbness
e. Positive Chvostek's sign
• The nurse expects the long-term treatment of a patient with
hyperphosphatemia secondary to renal failure will include
• fluid restriction.
• calcium supplements.
• magnesium supplements.
• increased intake of dairy products.
• Which finding for a young adult who follows a vegan diet may indicate the
need for cobalamin supplementation?
ANSWERS) KEY CONCEPTS EXAM GRADED A+]
• A nurse is having difficulty arousing a client following an
esophagogastrostroduodenoscopy (EGD). Which of the following is the
priority action by the nurse?
• Assess the airway
• Allow the client to sleep
• Prepare to administer an antidote to the sedative
• Evaluate procedure lab findings9*
• A patient is scheduled for a liver biopsy. Which laboratory results would be
ofmost concern to the nurse?
• Hemoglobin of 11 g/dL
• Prothrombin time of 32 seconds
• Serum ammonia level of 56 mcg N/dL
• White blood cell count of 14.2 x 103/µL
• The nurse listens to bowel sounds for 60 seconds and does not hear
gurgling. Which action should the nurse take next?
• Document the bowel sounds as hypoactive.
• Continue to listen for at least another 60 seconds.
• Administer the prescribed drug for constipation.
• Review the patient's dietary intake for the past 24 hours
• During the postoperative care of a 76-year-old patient, the nurse monitors
the patient's intake and output carefully, knowing that the patient is at risk
for fluid and electrolyte imbalances primarily because
• older adults have an impaired thirst mechanism and need reminding to
drink fluids.
• water accounts for a greater percentage of body weight in the older adult
than in younger adults.
• older adults are more likely than younger adults to lose extracellular
fluid during surgical procedures.
• small losses of fluid are significant because body fluids account for 45%
to 50% of body weight in older adults.
• In a patient with prolonged vomiting, the nurse monitors for fluid volume
deficit because vomiting results in
• Fluid movement from the cells into the interstitial space and the blood vessels
• Excretion of large amounts of interstitial fluid with depletion of
extracellularfluids
• An overload of extracellular fluid with a significant increase in intracellular
fluidvolume
• Fluid movement from the vascular system into the cells, causing
cellular swelling and rupture
• Which assessment action will help the nurse determine if an obese patient
has metabolic syndrome?
• Take the patient's apical pulse.
, • Check the patient's blood pressure.
• Ask the patient about dietary intake.
• Dipstick the patient's urine for protein
• A patient is admitted to a medical unit with a diagnosis of malnutrition. The
student nurse asks the nurse assigned to this patient about the relationship
between drugs and nutrition. What is the most appropriate response for the
nurse to make?
• "Foods alter the absorption or bioavailability of all drugs."
• "If the patient skips a meal, drugs may not be taken."
• "Some drugs increase the requirements for essential nutrients."
• "Drugs should be taken with food to prevent GI irritation."
• The nurse obtains a drug history from a patient with ascites and elevated
aspartate and alanine aminotransferase levels. The nurse is most concerned
if the patient makes which statement?
• "Occasionally I will use Benadryl for my allergies."
• "Sometimes probiotics can make me feel bloated."
• "I add flaxseed powder to my cereal every morning."
• "I take acetaminophen 4 to 5 times a day for back pain."
• - M.H., a 62-year-old female, was admitted with confusion and lethargy related
to hyponatremia.
- Her husband tells you that M.H. had c/o diarrhea over the past week and was
drinking lots of water to prevent dehydration.
What caused M.H.'s serum sodium level to fall?
• Excessive diarrhea can cause fluid and sodium loss
• Constipation
• Adequate nutrition
• Excessive vomiting and increase drainage from nasogastric tube
• An older woman was admitted to the medical unit with GI bleeding and fluid
volume deficit. Clinical manifestations of this problem are (select all that
apply)
• a. weight loss.
• dry oral mucosa.
• full bounding pulse.
• engorged neck veins.
• decreased central venous pressure.
• The nursing care for a patient with hyponatremia and fluid volume
excess includes
• fluid restriction.
• administration of hypotonic IV fluids.
• administration of a cation-exchange resin.
• placement of an indwelling urinary catheter.
, • The nurse should be alert for which manifestations in a patient receiving a
loop diuretic?
• Restlessness and agitation
• Paresthesias and irritability
• Weak, irregular pulse and poor muscle tone
• Increased blood pressure and muscle spasms
• Priority Decision: A 75-year-old patient who is breathing room air has the
following arterial blood gas (ABG) results: pH 7.40, PaO2 74 mm Hg, SaO2
92%,
PaCO2 40 mm Hg. What is the most appropriate action by the nurse?
• Document the results in the patient's record knowing that this is a
normal finding in older adult
• Repeat the ABGs within an hour to validate the findings.
• Encourage deep breathing and coughing to open the alveoli.
• Initiate pulse oximetry for continuous monitoring of the patient's oxygen status.
• A patient is being admitted for bariatric surgery. Which nursing action can
thenurse delegate to unlicensed assistive personnel (UAP)?
• Demonstrate use of the incentive spirometer.
• Plan methods for turning the patient after surgery.
• Assist with IV insertion by holding adipose tissue out of the way.
• Develop strategies to provide privacy and decrease embarrassment
• Which patient is at greatest risk for developing hypermagnesemia?
• 83-year-old man with lung cancer and hypertension
• 65-year-old woman with hypertension taking β-adrenergic blockers
• 42-year-old woman with systemic lupus erythematosus and renal failure
• 50-year-old man with benign prostatic hyperplasia and a urinary tract infection
• It is important for the nurse to assess for which clinical manifestation(s) in
a patient who has just undergone a total thyroidectomy (select all that
apply)?
• a. Confusion
b. Weight gain
c. Depressed
reflexes
d. Circumoral
numbness
e. Positive Chvostek's sign
• The nurse expects the long-term treatment of a patient with
hyperphosphatemia secondary to renal failure will include
• fluid restriction.
• calcium supplements.
• magnesium supplements.
• increased intake of dairy products.
• Which finding for a young adult who follows a vegan diet may indicate the
need for cobalamin supplementation?
