AHT I Exam Notes

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for FURTHER teaching?

"I need to LIMIT my intake of daily fiber"

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicted a need for FURTHER instruction?

"I should increase the fiber in my diet"

The nurse determines the clients needs FURTHER instruction on cimetidine if which statements were true? SATA

"I will take the Cimetidine with my meals" "I'll know the medication is working if my diarrhea stops" "Taking the Cimetidine with antacid will increase its effectiveness"

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event. 2. The client is experiencing early signs of ischemic bowel. 3. The client should not have the nasogastric tube removed. 4. This indicates inadequate preoperative bowel preparation.

1. This is a normal, expected event.

The nurse is reading a primary health care provider's (HCP) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily" The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

Integumentary output

The nurse is assigned to care for a group of clients. On review of the client's medical records, the nurse determines that which client is MOST LIKELY at risk for a fluid volume deficit?

A client with an ileostomy

A client has just had a hemorrhoidectomy. Which nursing intervention is appropriate for this client? SATA.

Administer Stool softeners as prescribed Encourage a high-fiber diet to promote bowel movements without straining. Apply cool packs to the anal-rectal area over the dressing until packing is removed.

A client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication?

An episode of diarrhea

The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet?

Bowel Sounds

The client with the flu has been taking acetylcysteine. Which adverse effect should the nurse assess for?

Bronchospasm

A client has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administer with which condition?

Vomiting following Cancer Chemo

A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the EFFECTIVENESS of the treatment?

Checking the frequency and consistency of bowel movements.

An older client recently has been taking cimetidine. The nurse monitors the client for which MOST frequent central nervous system side effect of this medication?

Confusion

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown discharge since the surgery. Which nursing intervention is MOST appropriate?

Document the findings.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis?

Fever Complaints of indigestion Pain in the RUQ after a fatty meal

A client just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which MOST frequent complication of this type of surgery?

Fluid and Electrolyte imbalance

A client has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?

Heartburn

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

Hyperactive Bowel Sounds

A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication?

Hypokalemia

The nurse observes a student nurse administer ear drops to an 80 year old client. The nurse intervenes when the student performs which action?

Instills ear drops with dropper by occluding the upper ear

The client with hiatal hernia chronically experiences heartburn following meals. The nurses plans to teach the client to avoid which action because it is contraindicated with a hiatal hernia?

Lying recumbent following meals

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 1.8 mg/Dl (0.58 mmol/L). Which condition MOST LIKELY caused this serum phosphorus level?

Malnutrition

A client has an as needed prescription for ondansetron. For which condition(s) should the nurse administer the medication?

Nausea and Vomiting

A client with a gastric ulcer has a prescription for sucralfate 1 gram by mouth 4 times daily. The nurse should schedule the medication for which times?

One hour before meals and at bedtime

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

Prominent U Waves Tall peaked T waves Prolonged ST segment

The nurse is providing care for a client with recent transverse colostomy. Which observation require immediate notification of primacy HCP?

Purple discoloration of the Stoma

A client who uses nonsteroidal anti-inflammatory drugs has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted?

Relief of epigastric pain

The nurse reviews the electrolyte results of an assigned client with CKD and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

Tall peaked T waves Widened QRS complexes

Which client is at risk for the development of a sodium level at 130 mEq/L?

The client who is taking diuretics

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?

The client with kidney disease and a 12-year history of diabetes mellitus.

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the chart?

Twitching

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

Weight loss and poor skin turgor.

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL. which patterns would the nurse watch for the electrocardiogram

prolonged QT interval and Prolonged ST segment