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

Name: 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 breathes 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.

The nurse identifies 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 liver, 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

. 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

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

(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 include 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/antifungal 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 an 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
Overview
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, observe 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 and 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 experiences. 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 relief. 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 preoperative
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 choice, 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 after 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 localized 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, cough, 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 cylinder
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), monitor 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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Canned 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 renal 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 than 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) prohibiting 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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