FUNDAMENTALS KAPLAN 2023-2024 TEST BANK
ACTUAL EXAM 250 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
The nurse observes a staff member prepare to leave the room of a client on droplet precautions. The nurse should intervene if which action is observed? - ANSWER- The staff member hold onto the outer surface of the facemaskl while pulling mask away from face.
A client returns from abdominal surgery with an order for morphine sulfate IV q 3 hours prn for pain. During the first 24 hours after surgery, which action by the nurse is best? - ANSWER- administer pain medication every 3 hours
The nurse notes an elderly client has a reddened area on the coccyx.Which action should the nurse take first? - ANSWER- reposition the client every 1-2 hours
The nurse knows that aspirin, if given in high, prolonged dosages, may precipitate which physiological change? - ANSWER- GI bleeding
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? - ANSWER- determine how many Td immunizations the client has received 1 / 4
The nurse cares for a postoperative client with a nasogastric tube. Which observation by the nurse is the most reliable indication the nasogastric tube is correctly placed? - ANSWER- pH of aspirate is 3
The nurse teaches a client how to maintain an adequate intake of protein.The nurse determines further teaching is required is the client chooses which foods? - ANSWER- Orange juice and white toast-- juice contains little protein, most of it is in the pulp; bread made from white cloud is also limited in its protein content
The nurse prepares four clients for surgery. The nurse is most concerned about the psychological adjustment of which client? - ANSWER- A 26- year-old scheduled for the Whippie procedure due to cancer of the pancreas
The nurse understand which behavior is helpful to facilitate a client to have a bowel elimination? - ANSWER- Increased dietary bulk-- foods that contain cellulose, such as whole bread, fruits, and other grains, will increase the bulk in the stool
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? - ANSWER- Atelectasis
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The nurse cares for a client with a body mass index of 38. What is the best description of the client's body weight? - ANSWER- Obese-- BMI 30-39.9 = obese
Several days postoperatively, a client reports pain, tenderness, and redness of the right calf. Which signs and symptoms are critical for the nurse to assess next? - ANSWER- Chest pain and shortness of breath
The nurse identifies which finding are characteristic of chronic pain? - ANSWER- Weight loss or gain and fatigue-- chronic pain is an episode that lasts for 3 months or more; serves no useful function and becomes a problem of its own; chronic pain often becomes a disability; presenting reports often include change in appetite and moderate to severe fatigue
A client with acute pain has a health care provider's order for morphine
- mg IV every 3-4 hours prn for pain. The client asks the nurse for the
medication at bedtime. Prior to administering the pain medication, the nurse should take which action? - ANSWER- Assess location, character, and intensity of pain
A client requires a dressing change. The LPN/LVN assigned to care for the client reports to the registered nurse that the LPN/LVN once observed a similar dressing change while in nursing school, but has never performed the procedure. The registered nurse will take which action? - ANSWER- Complete the dressing change while the LPN/LVN observes
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The nurse cares for a client with an abdominal wound. The nurse notes there is purulent drainage from the wound. Which action should the nurse take first? - ANSWER- Place the client on contact precautions
A client has a left modified radical mastectomy. Upon transfer from the recovery room to the surgical unit, the nurse notices the Hemovac drain is half filled with blood. Which action the the nurse take first? - ANSWER- Look at the recovery room record
While a client is being treated for a wound infection, it is most important for the nurse to routinely perform which action? - ANSWER- check and record the client's temperature-- a client with a wound infection is at risk for bacteremia or other complications, such as glomerulonephritis; nurse should evaluate for temperature elevation
On the morning before surgery, the client signs an operative consent form. Soon afterward, the client tell the nurse that the client does not want the surgery. Which action does the nurse take first? - ANSWER- Encourage the client to discuss reasons for cancelling the surgery
Which fear is most important for the nurse to consider when planning care for a 4-year-old about to have surgery? - ANSWER- Fear of mutilation-- preschool children are frightened of invasive procedures because they fear mutilation; allow child to play with models of equipment; encourage expressions of feelings
The nurse identifies which as a risk factor for a client to develop a pressure ulcer? - ANSWER- Anemia-- decreased oxygen-carrying
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