Kaplan Fundamental Exam A with complete solution and rationale(Graded A)

Kaplan Fundamental Exam A 1. 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? a. Privacy b. Back rubs c. Daily baths d. Daytime ...

Kaplan Fundamental Exam A 1. 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? a. Privacy b. Back rubs c. Daily baths d. Daytime activities 2. The nurse identifies which lab finding reflects the signs and symptoms of infection? a. Serum creatinine level of 2.4 mg/dl b. AST (SGOT) 15 u/l c. White blood count of 16,000/mm^3 d. White blood count of 4,000/mm^3 3. A client is admitted to the hospital with a temperature of 101 and a WBC count of 3,000/mm^3. The nurse should institute which precaution? a. Contact precautions b. Airborne precautions c. Droplet precautions d. Neutropenic precautions 4. The nurse teaches a client how to maintain an adequate intake of protein. The nurse determines further teaching is required if the client chooses which foods? a. Peanut butter on whole wheat bread b. Rice and red beans c. Orange juice and white toast d. Spaghetti and meat sauce 5. The nurse knows that aspirin, if given in high, prolonged dosages, may precipitate which physiological change? a. Urinary frequency b. Hypoventilation c. GI bleeding d. Hemoconcentration 6. Which action is essential for the nurse to take AFTER administration of a preoperative medication for a client? a. Ensure the operative permit is signed b. Discuss the client’s feelings about surgery c. Raise the side rails of the bed d. Tell the client what to expect in the operating room 7. The nurse prepares four clients for surgery. The nurse is most concerned about the psychological adjustment of which client? a. A 13-year-old scheduled to have a wart removed from the nose b. A 26-year-old scheduled for the whipple procedure due to cancer of the pancreas c. A 42-year-old scheduled to have a benign cyst removed from the left breast d. A 80-year-old scheduled for a colostomy due to severe diverticular disease i. 8. In which situation should the nurse consider withholding morphine until further assessment is completed? a. Client reports acute pain from deep partial thickness burn affecting the lower extremities. b. Clients blood pressure is 140/90, pulse 90, and respirations 28 c. Client’s level of consciousness fluctuates from alert to lethargic d. Client exhibits restlessness, anxiety, and cold, clammy skin 9. The nurse identifies which diet BEST meets the needs of a person with multiple wounds? a. High protein, low-fat, high-iron diet b. High-vitamin C, high-protein, high-carbohydrate diet c. High-vitamin A, high-calcium, high-fat diet d. High-vitamin B, high-protein, low-carbohydrate diet 10. The nurse performs discharge teaching for a client receiving warfarin. The nurse determines further teaching is required if the client makes which statement? a. “I should look for a yellow-tinged complexion.” b. “I will wear a Medic-alert bracelet.” c. “I should tell the health care provider if I have black stools.” d. “I should consult the health care provider before taking any medication.” 11. Several days postop, a client reports pain, tenderness, and redness of the right calf. Which signs and symptoms are critical for the nurse to assess for NEXT? a. Nausea and abdominal distenstion b. Back pain and hematuria c. Chest pain and shortness of breath d. Similar findings in the right arm 12. The nurse instructs the adult client how to successfully establish a regular exercise program. The nurse determines further teaching is necessary when the client makes which statement? a. “I should choose an exercise that suits my lifestyle.” b. “I should incorporate exercise into my daily routine.” c. “I should make a commitment to exercise regularly.” d. “I should start by running 5 miles every day.” 13. 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? a. Assume the pain is psychological b. Check to see if the client has a history of addiction c. Try several other pain relief measures d. Assess location, character, and intensity of pain 14. The nurse provides for a client with a BMI of 38 kg/m^2. Which is the BEST description of the client’s body weight? a. Underweight b. Normal weight c. Overweight d. Obese 15. The home care nurse visits an elderly client living alone on a limited income. The client’s diet consists primarily of carbohydrates. Based on an understanding of the nutritional needs of elderly, which interpretation of the client’s diet by the nurse is MOST justified? a. The client should increase the intake of protein b. The client should reduce the intake of fat c. The client should increase the caloric intake d. The client should decrease the fluid intake 16. The nurse observes a staff member prepare to leave the room of a client on droplet precuations. The nurse should intervene if which action is observed? a. The staff member removes the gloves by pulling of inside out b. The staff member holds onto the outer surface of the facemask while pulling mask away from nose c. The staff member unties the gown and removes it without touching the outside of the gown d. The nurse performs hand hygiene for 15 seconds 17. The nurse cares for the client diagnosed with a fractured humorous due to a fall in the home. Which nursing observation requires an immediate intervention? a. The bathroom is equipped with grab bars b. Small area rugs have been removed c. The client ambulates wearing socks d. The stairs are well lighted 18. A client returns from abdominal surgery with an order for morphine sulfate IV q 3 hours prn for pain. During the first 24 after surgery, which action by the nurse is BEST? a. Offer pain medication every 4 hours b. Administer pain medication every 3 hours c. Offer pain mediation every 3 hours d. Administer pain medication every 4 hours 19. Which behavior does the nurse encourage for the adult client to facilitate bowel elimination? a. Engaging in sedentary activity b. Increasing dietary bulk c. Decreasing fluid intake d. Using oral laxatives 20. The nurse identifies which findings are characteristics of chronic pain? a. Weight loss or gain and fatigue b. Obesity, restlessness, and thirst c. Anxiety, insomnia, and memory loss d. Quick response to analgesics 21. A client requires a dressing change. The LPN/LVN assigned care for the client reports to the RN that the LPN/LVN once observed a similar dressing change while in nursing school but has never performed the procedure. The RN will take which action? a. Ask the LPN/LVN to review the hospital’s procedure manual regarding dressing changes b. Review the steps of the dressing change with the LPN/LVN c. Complete the dressing change while the LPN/LVN observes d. Assign a more experienced LPN/LVN to the client 22. A client comes to the ER 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? a. Administer tetanus toxoid b. Determine how many td immunizations the client has received c. Administer tetanus immune globin d. Monitor for lockjaw 23. The nurse notes an elderly client has a reddened area on the coccyx. Which action does the nurse take FIRST? a. Continues assessment of the area b. Repositions the client every 1-2 hours c. Massages the reddened area four times a day d. Places the client in a semi reclining position 24. The nurse knows which statement is an important fact about warfarin? a. It has a prolonged action b. It is never given for prolonged periods of time c. It must be given several times a day to be effective d. It can only be given parenterally 25. The nurse understands the purpose of a drain in a wound is to a. Keep the tissue close together so that healing can occur b. Prevent infection by providing a means for bacteria to escape c. Evaluate the effectiveness of hemostasis d. Create a space that will facilitate reconstructive surgery at a later date 26. The nurse cares for a postop client with a NG tube. Which observation by the nurse is the MOST reliable indication the NG tube is correctly positioned? a. Absence of respiratory distress b. pH of aspirate is 3 c. the marking on the tube designating the correct length remains visible just outside the nares d. the tube is securely taped 27. the nurse explains to the client the MOST vitamin C can be found in which juice? a. Canned apple juice b. Canned tomato juice c. Frozen grapefruit juice d. Fresh orange juice 28. The nurse helps a client to cough and deep breathe after surgery. It is desirable for the client to assume which position? a. Side-lying b. Prone c. Supine with one pillow d. High fowler’s 29. The nurse observes a staff member enter the client’s room wearing a fit-tested respiratory device. The nurse determines care is appropriate when the staff member is caring for which client? a. A client diagnosed with varicella b. A client diagnosed with mumps c. A client diagnosed with VRE d. A client diagnosed with pneumonia 30. On the first postop day, a client develops a fever. The nurse auscultates crackles bilaterally in the lower lobes. The nurse understands this complication of surgery is probably developing? a. Heart failure b. Thrombophlebitis c. Pulmonary embolism d. Atelectasis