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2024 KAPLAN Fundamentals of Nursing Practice Exam With Answers (890 Solved Questions)

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    KAPLAN FUNDAMENTALS A & B 2024 UPDATED AND EXPERT VERIFIED ANSWERS . The nurse helps a client to cough and deep breathe after surgery. It is desirable for the client to assume which position? Side - lying Prone Supine with one pillow High Fowler's High Fowler's - high Fowler's is the best position to deep breathe and cough. Explanation Side - lying impedes expansion of lungs; ask client to take two slow, deep breaths, inhaling through nose and exhaling through mouth; inhale deeply third time and cough. Prone lying on abdomen; would not be able to expand lungs; lying prone will prevent hip flexion. Supine with one pillow ask client to splint abdominal wound with pillow; administer analgesic prior to asking client to cough and deep breath Overview Cough and Deep Breathe (CDB) - After surgery or immobility for any period of time, client develops pulmonary disorders; coughing and deep breathing (CDB) will alleviate these problems; client might use an incentive spirometer or just take several deep breat hes and cough - deep cough; once mucus is disturbed the client will cough it up; CDB is an independent nursing activity; each cycle of CDB includes at least 3 deep breaths and a deep cough; at least 10 cycles every 1 - 2 hours.

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    The nurse identifi es which diet best meets the needs of a person with multiple wounds? High - protein, low - fat, high - iron diet High - vitamin C, high - protein, high - carbohydrate diet High - vitamin A, high - calcium, high - fat diet High - vitamin B, high - protein, low - carbohydrate diet High - vitamin C, high - protein, high - carbohydrate diet - increased vitamin C is essential to wound healing, and high protein is necessary for tissue growth; carbohydrate is needed or energy so the protein is properly utilized for repair of tissue Explanation High - protein, low - fat, high - iron diet - increased iron appropriate for client with iron deficiency anemia High - vitamin A, high - calcium, high - fat diet - vitamin A contributes to night vision and growth of bones and teeth; vitamin A found in liv er, fish, liver oils, and fortified dairy products High - vitamin B, high - protein, low - carbohydrate diet - high carbohydrates needed for energy Overview Wound Healing Diet Diet to support wound healing should be high in protein, fat, carbohydrates, vitamins (especially A, C, E), and minerals (including zinc). Essential Nursing Care Proper nutrition is one of the most important factors to effect wound healing, and can be assessed by monitoring urinary and bowel elimination patterns. Purpose . Promotes wound healing . Prevents infection

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    . Influences balanced diet Sample Associated Nursing Dx . Imbalanced Nutrition . Risk for Imbalanced Nutrition . Anxiety . Risk for Impaired Fluid Volume . Delay in Wound Healing . Deficient Knowledge . Disturbed Body Image . Impaired Skin Integrity . Impaired Tissue Integrity . Risk for Infection Implementation . Postoperative Assessment and Interventions . Assess wound drainage and maintain prescribed IV fluid infusion rates . Assess skin turgor and mucous membranes for dehydration . Monitor weight and postoperative dietary progression (i.e., from clear to full liquids, and soft to regular foods) . Identify nutritional needs and monitor for nutritional risks. Encourage food and fluid intake according to dietary progression or as prescribed. . Double the patient's recommended dietary allowance of protein (from 0.8/kg/day) before tissue even begins to heal . Supply fruit juices and high - fiber foods . Adjust the patient's general intake of carbohydrates, fats, vitamins (especially A, C, and E), and minerals (including zinc) according to needs . Ensure that patient's environment is clean, neat, and free of odors to promote appetite . Encourage patient to sit up in bed or chair for meals, and encourage family participation in meals . Provide privacy when patient is using the bedpan, urinal, commode, or bathroom . Monitor patterns of intake and output and assess patient's ability to pass flatus and stool . Palpate above the symphis pubis if: . Patient has not voided within 8 hours after surger . Patient has been voiding frequently in amounts of less than 50mL . Notify physician of abnormalities . Auscultate bowel sounds every 4 hours when the patient is awake to assess for

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    return of peristalsis . If bowel sounds not audible, or high - pitches, assess abdominal distention . Administer suppositories, enemas, or medications, and encourage oral fluid intake as prescribed Expected Outcomes . Patent successfully makes transition from fluids to solid foods and maintains normal elimination pattern . Patient's wound(s) heal without complication . Patient adheres to dietary needs following release from the hospital (Adapted from Fundamentals of Nursing Made Incredibly Easy, pp. 410 - 411; Fundamentals of Nursing, Sixth edition, by Taylor et al., pp. 903 - 904) Background for Nursing Care Proper nutrition is one of the most important factors to effect wound healing, and can be assessed by monitoring urinary and bowel elimination patterns Patient Teaching . Encourage patient to actively participate in nutrition intake preoperatively . Manage fluid balance; adjust fluid/food intak . Avoid alcohol and certain medication; can alter body;s use of nutrients . Discuss with patient postoperative complications as direct relation to nutrition . Inform that severity of complications as direct relation to nutrition . Delayed wound healing, wound infection and disruption in integrity of wound . Fluid imbalances (from fluid loss during surgery, wound drainage, or surgical stress response) . Provide patient with pamphlets/other educational resources . Discuss ways that a standard diet needs to be adjusted to influence wound healing Special Considerations . General Considerations . An obese patient has less resistance to infection; poor blood supply; increased risk for respiratory, cardiovascular, and gastrointestinal problems . Pediatric Considerations . Discuss with parents or guardians ways to implement a healthy diet into a pediatric patient's meal plan . Pediatric patient are especially at risk for imbalances in fluid volume (deficits or excess) following surgery . Geriatric Considerations . Older patients are especially at risk for fluid imbalances (deficits or excess) and malnutrition following surgery

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    (Adapted from Fundamentals of Nursing, Sixth edition, by Taylor et al.; pp. 883, 886 - 891, 897 - 905; 1189, 1192 - 1193, 1428 - 1433; Fundamentals of Nursing Made Incredibly Easy, pp. 410 - 411 The nurse identifies which lab finding reflects the signs and symptoms of infection? Serum creatinine level of 2.4 mg/dL AST (SGOT) 15u/L White blood cell count of 16,000/mm3 White blood cell count of 4,000/mm3 White blood cell count of 16,000/mm3 - normal range is 5,000 - 10,000/mm3; elevation indicates infection Serum creatinine level of 2.4 mg/dL - measures renal function; normal is 0.5 - 1.5 mg/dL; elevated in acute kidney injury and chronic kidney disease AST (SGOT) 15u/L - measures damage to liver and heart; normal is 10 - 40 u/L White blood cell count of 4,000/mm3 - indicates patient becoming immunosuppressed Overview Infection Presence and growth of a microorganism that causes tissue damage; chain of infection includes an infectious agent, reservoir where pathogen can live, portal of exit that allows the organism to exit one host, mode of transmission, portal of entry into the new host, and susceptible host. If an infection is localized, indications include pain, tenderness and redness at the wound site. If infection is systemic, indications inc lude fever, fatigue, nausea/vomiting, malaise, enlarged, tender lymph nodes. Treatment: obtain culture and sensitivity of wound, antibiotics/antifungal agents specific to organism(s). While waiting for the culture and sensitivity, broad - based antibiotic/an tifungal might be used until the results are obtained and then switched to the antibiotic/antifungal appropriate for the

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    organism(s). Nursing considerations: obtain culture and sent to laboratory before starting medication. Client education: take medication as ordered and entire course of medication, return for follow - up. The nurse understands which behavior is helpful to facilitate a client to have a bowel elimination? Engage in sedentary activity Increase dietary bulk Decrease fluid intake Use oral laxatives Increase dietary bulk - foods that contain cellulose, suck as whole wheat bread, fruits, and other grains, will increase the bulk in the stool Engage in sedentary activity - should engage in regular exercise Decrease fluid intake - constipation caused by decrease in fluid intake; encourage client to drink adequate amounts of fluid Use oral laxatives - chronic laxative abuse exacerbates constipation Overview Bowel elimination To promote adequate bowel elimination, encourage diet high in fiber (fruits, vegetables, nuts, and whole - grains), daily fluid intake of 2,000 - 3,000mL, engage in regular exercise to improve muscle tone and GI motility, encourage client to establish a regular time for defecating. The nurse knows which statement is a n important fact about warfarin? It has a prolonged action It is never given for prolonged periods of time

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    It must be given several times a day to be effective It can only be given parenterally It has a prolonged action - duration is 2 - 5 days It is never given for prolonged periods of time - it is given for up to 6 months after a DVT It must be given several times a day to be effective - is given once daily It can only be given parenterally - is given orally; heparin is given parenterally Over view Warfarin Anticoagulant; action: interferes with synthesis of vitamin K - depending on clotting factors; side effects: hemorrhage, alopecia (hair loss); nursing considerations: monitor prothrombin test, therapeutic level is 1.5 - 2 times the control, obser ve for petechiae, bleeding gums, bruises, and dark stools; antidote - vitamin K To promote evening rest and sleep for clients who are immobilized and in bed, it is most important for the nurse to provide which care? Privacy Back rubs Daily baths Daytime activities Daytime activities - particularly important for the immobilized and bedridden client. It causes them to nap less during the day, and provides relief from tension. It enables the client to relax and sleep at night Privacy - more important that clients maintain daytime activity

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    Back rubs - will help the client relax, but daytime activity is more important Daily baths - bathing and skin care are part of hygiene of the client Overview Rest and Sleep Rest is a basic physiological need that allows the body to repair damaged cells, enhances removal of waste products from the body, restores tissue to maximum functional ability before another activity is begun. Sleep restores balance among different parts of the CNS, mediates stress, anxiety an d tension, and helps a person cope with daily activities. Disturbances in rest and sleep are caused by stress, medication (hypnotics, antidepressants, stimulants, caffeine, beta - adrenergic blockers, barbiturates, diuretics, and alcohol), unfamiliar and/or noisy and/or bright environments, daytime sleeping, working shifts, and overeating. Nursing care includes establishing a database about the client's pattern or rest and sleep, give care in blocks to allow for uninterrupted periods of rest and sleep, avoid unnecessary lights and noises, comfortable room temperature, non - stimulating beverages, promote bedtime routine, encourage daytime activity, limit daytime naps, reposition client, straighten and replace wrinkled or soiled linens, administer pain mediation, provide diversionary and occupational activities during the day to relieve boredom and utilize nighttime for sleep. A client with acute pain has a health care provider's order for morphine 8 mg IV every 3 - 4 hrs prn for pain. The client asks the nurse for medication at bedtime. Prior to administering the pain medication, the nurse should take which action? Assume the pain is psychological Check to see if the client has a history of addiction Try several other pain relief measures Assess location, character, and intensity of pain Assess location, character, and intensity of pain - Determine onset, duration, and sequence of pain as well as location and intensity Assume the pain is psychological - pain is "whatever the person says it is, and it

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    exists whenever the person says it does". Assume the client's pain is real. Check to see if the client has a history of addiction - assessment answer, the nurse should assess the characteristic of the client's pain Try several other pain relief measures - appropriate to use a variety of relief measures, such as relaxation, guided imagery, listening to music, biofeedback. Prior to implementing any measures for pain relief the nurse must assess the client. Overview Pain Management Pain is often referred to as the fifth vital sign and is defines as, "Whatever the person says it is, and it exists whenever the person says it does." Pain can be acute or chronic. Culture and past experiences with pain are major factors influencing pain experienc es. Indications include increased blood pressure and pulse, rapid irregular respiration, pupil dilation, increased perspiration, increased muscle tension, apprehension and irritability, grimacing, guarding, and verbalization of pain. Nursing interventions include establishing a therapeutic relationship, establishing a 24 - h pain profile, teach the patient about pain and it's relief, reduce anxiety an fears, provide comfort measures, administer pain medications, and refer for alternative methods of pain relie f. With regard to pain medication, use the preventive approach (if pain is expected to occur throughout most of a 24 - h period a regular schedule is better than prn because it usually takes smaller doses to alleviate mild pain or to prevent occurrence of pain. Which action is essential for the nurse to take after administration of preoperative medication to a client? Raise the side rails of the bed - this will prevent injury to the client Ensure the operative permit is signed - cannot be signed once preop erative medication is administered Discuss the client's feelings about surgery - safety takes priority over psychosocial needs Tell the client what to expect in the operating room - this is part of the preoperative teaching and occurs prior to administering preoperative medication

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    Overview Preoperative Checklist Preoperative checklist includes ensuring that informed consent is signed and attached to the chart, all lab tests, chest x - ray, and EKG have all been completed, performing skin and bowel prep, NPO, administering preoperative medications (sedation, antibiotics), removing dentures, jewelry, and nail polish. A nurse explains to a client how to eat enough protein. The client indicates the choice of food. Based on the client's ch oice, the nurse determines that the client needs more teaching. What kind of food does the client choose to eat? Spaghetti and meat sauce Orange juice and white toast Rice and red beans Peanut butter on whole wheat bread Orange juice and white toast - juice contains little protein, most of it is in the pulp. Bread is made from white flour and is also limited in protein content Peanut butter on whole wheat bread - both peanut butter and whole wheat bread contain protein Rice and red beans - red beans contain some protein Spaghetti and meat sauce - meat sauce contains some protein Overview Increased Protein Diet Diet in which protein is increased from the normal expected amounts. Protein is used during tissue repair and rebuilding. This diet is used afte r surgery, fractures, stress to the body, cancers, and other times when increase repair is required. Foods which are high in protein include: meat, fish, nuts, cheese, protein powder, and peanut butter.

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    On the first postoperative day, a client develops a fever. The nurse auscultates crackles bilaterally in the lower lobes. The nurse understands which complication of surgery is probably developing? Heart failure Thrombophlebitis Pulmonary embolism Atelectasis Atelectasis - the most probable cause for crackles because secretions block the bronchioles and the alveoli collapse, causing hypoventilation Heart failure - failure of the cardiac muscle to pump sufficient blood to meet the body's metabolic needs. Manifestations include dyspnea, orthopnea (the sensation of breathlessness when in the recumbent position), pleural effusion, dependent edema, and bounding pulses. Thrombophlebitis - manifestations include unilateral edema, warmth and tenderness of lower extremity, swelling tenderness, and localiz ed redness over a vein with an intravenous catheter. Thrombophlebitis (throm - boe - fluh - BY - tis) occurs when a blood clot blocks one or more of your veins, typically in your legs. Rarely, thrombophlebitis (sometimes called phlebitis) can affect veins in your arms or neck. The affected vein may be near the surface of your skin, causing superficial thrombophlebitis, or deep within a muscle, causing deep vein thrombosis (DVT). Thrombophlebitis can be caused by trauma, surgery or prolonged inactivity. Superficial thrombophlebitis may occur in people with varicose veins. A clot in a deep vein increases your risk of serious health problems, including the possibility of a dislodged clot (embolus) traveling to your lungs and blocking an artery there (pulmonary embolism ). Deep vein thrombosis is usually treated with blood - thinning medications. Superficial thrombophlebitis is sometimes treated with blood - thinning medications, too. Pulmonary embolism - Manifestations include: dyspnea, tachypnea, and pleuritic chest pain

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    Overview Postoperative (Post Op) Care Full system assessment required because anesthesia, immobility, and surgery can affect any system in the body. Neuropsychosicial (stimulates client post anesthesia) monitor level of consciousness. Cardiovascular (monitor vital signs every 15 minutes x4 (1 hour), every 30 minutes x2 (1 hour), every hour x2 (2 hours), then every hour or prn) check potassium level, monitor central venous pressure. Respiratory (check airway and breath sounds) turn, cou gh, and deep breathe (unless containdicated i.e. brain, spinal, or eye injury), splint wound, offer pain mediction, teach how to use incentive spirometer (hhold mouthpiece in mough, exhale normally, seal lips and inhale slowly and deeply, keep balls or cyl inder elevated, exhale and repeat). Gastrointestinal (check bowel sounds in all four quadrants for 5 minutes each if nothing is heard and keep NPO until bowel sounds are present) provide good mouth care while NPO, provide antiemetics for nausea nd vomiting, check abdomen for distention, check for passage of flatus and stool. Genitourinary (monitor intake and output, encourage to void, check for bladder distention, notify healtcare provider if unable to void within 8 hours, catherize if needed), moni tor for complicaitons (hemorrhage, paralytic ileus, atelectasis, pneumonia, embolism, infection of wound, dehiscence, evisceration, venous thromboembolism (VTE), psychosis). Musculoskeltal get out of bed as soon as possible and ambulate as much as possible . A nurse explains to a client about vitamin C. Which juice contains the most vitamin C? Frozen grapefruit juice Canned tomato juice Fresh orange juice Canned apple juice Fresh orange juice - canned juice is processed in such a way that the vitamin is partially destroyed. This also happens in freezing, but not as much as with canned juice. Fresh foods contain more vitamins. Citrus fruits are a good source of vitamin C and orange juice contains more vitamin C than any other citrus fruit.

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    Canne d apple juice - contain negligible amounts of vitamin C Canned tomato juice - contains more vitamin C than apple juice, but much less than orange juice Frozen grapefruit juice - contains vitamin C, but less than orange juice Overview Vitamin C (Ascorbic Acid) Necessary for formation of cartilage in connective tissue and essential to maintenance of integrity of intercellular cement in many tissues, especially capillary walls. Deficiency: scurvy, imperfect formation of fetal skeleton, defective teeth, pyorrhea (Periodontitis), anorexia, anemia, injury potential to bones, cells, and blood vessels. RDA for adults is 60mg/day. Excessive high doses can interfere with B12 absorption, cause uricosuria (uric acid in the urine), promote formation of oxalate ren al calculi. Food sources include: raw cabbage, young carrots, lettuce, celery, onions, tomatoes, radishes, green peppers, citrus fruits, rutabagas, strawberries, apples, pears, plums, peaches, pineapples, and apricots. A client comes to the emergency room after puncturing a foot with a dirty, rusty nail. The client states the last Td immunization was 6 years ago. Which of the following actions should the nurse take FIRST? Administer tetanus toxoid Determine how many Td immunizations the client has received Administer tetanus immune globulin (TIG) Monitor for lockjaw Determine how many Td immunizations that client has received - if the client received at least 3 doses of Td, administer tetanus toxoid booster to prevent development of tetanus. If less than 3 doses has been received administer Td AND tetanus immune globulin (TIG) Administer tetanus toxioid - should first determine immunization history because

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    tetanus is a fatal disease caused by a bacterium that can live for a long time in soil and dirt. It can enter the blood via wounds and can affect the CNS. After a dirty wound, a tetanus toxoid booster (TIG) is given to ensure protection against tetanus Administer tetanus immune globulin (TIG) - appropriate action if client received less tha n 3 doses of Td or has developed tetanus Monitor for lockjaw - Lockjaw is the first sign of generalized tetanus. Other manifestations include opisthotonus, muscle rigidity, cramps, and muscle spasms. Give tetanus toxoid to prevent the development of tetanus. Overview Tetanus Acute infectious disease of the CNS caused by exotoxin of Clostridium tetani. Causes painful muscle rigidity. Primary prevention occurs through immunization and boosters. Administer tetanus immune globulin (TIG) to child not immunized or inadequately immunized suffering a puncture wound contaminated with dirt, feces, soil, or saliva. Essential Nursing Care Tetanus is an acute toxic syndrome caused by a protein toxin produced during an infection with Clostridium tetani, a spore - forming anaerobic bacterium. While tetanus can be prevented by a vaccine, it can be fatal (1in 10 cases) if it goes untreated. Signs and symptoms of Tetanus include . Painful muscular rigidity and spasms . Tightening of the jaw muscles (lockjaw) pro hibiting breathing and swallowing . Painful paraoxysmal seizures . Irregular heartbeat and tachycardia . High sensitivity to external stimuli . Profuse sweating . Low grade fever Treatment of tetanus include . Active immunization at age 2 months with Dtap vaccine . Immunizations continue at ages 4, 6, and 15 - 18 months and 4 - 6 years (5 doses

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    total) . Vaccine should be given every 10 years thereafter or when a person presents with a potentially contaminated wound Treatment . Tetanus immune globulin (to neutralize tetanus toxin) and tetanus toxoid . Penicillin G (IV) . Metronidazole, erythromycin, or tetracycline for penicillin allergic patients . Debridement of open wound through which contamination occurred . Muscle relaxants and sedative, to treat and monitor cardiopulmonary status . Antiseizure medications as needed Nursing Care . Maintain a patient airway in the child with tetanus and assure adequate ventilation . Keep emergency airway equipment handy in case of respiratory failure . Monitor vital signs frequently . Maintain a quiet environment by reducing external stimuli from light, sound or touch . While the child is very ill, mentation (mental activity) is unaffected so be sure to explain the disease, its treatment, or any procedures to allay any anxiety the child may be experiencing. . Carefully monitor children with tetanus because they often must take potent muscle relaxants, and the resulting paralysis can make it impossible for the child to communicate clearly Expected Outcomes . Patient is treated successfully without untoward complications and recovery is complete Background for Nursing Care Background . Tetanus is contracted by contamination with C. tetani, which is found in the soil and animal feces. . C. tetani infects the body through a wound. The anaerobic tetanus bacilli reproduce when the oxygen supply is cut off because the wound is deep or forms a crust (e.g. as with burns)

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