ATI Capstone- Fundamentals Pre-Assessment
1. A nurse is completing a nutritional assessment on a client and measures body
mass index (BMI). Which of
... [Show More] the following readings correlates with a BMI of an
overweight client?
A. 18.5
B. 24.9
C. 25
D. 32
C. 25
Rationale: Healthy weight is indicates by a BMI of 18.5-24.9. Overweight is
defined as an increased body weight in relation to height. It is indicated by a BMI
of 25-29.9. Obesity is an excess amount of body fat. It is indicated by a BMI
greater than or equal to 30.
Underweight- less than 18.5
2. A nurse is verifying nasogastric tube placement by the pH of aspirated gastric
fluid. Which of the following pH values provides a good indication of correct tube
placement?
A. 2
B. 5
C. 7
D. 9
A. 2
Rationale: A good indication of appropriate placement is obtaining gastric contents
with a pH between 0 and 4.
3. A nurse is caring for a client with a closed head injury. When pressure is applied
to client's nail beds, the client's eyes open and adduction of the arms with flexion
of the elbows and wrists is noted. The client also moans with stimulation. What is
the client's Glascow Coma Score?
A. 4
B. 7
C. 9
D. 10
B. 7 (comatose)
Rationale:
Eye Opening (ranges from 4-1)
4 = spontaneous
3 = to voice
2 = to pain
1 = none
Verbal (ranges from 5-1)
5 = oriented
4 = confused
3 = inappropriate words
2 = incomprehensible sounds
1= none
Motor (raged from 6-1)
6 = obeys command
5 = localizes pain
4 = withdraws
3 = flexion (decorticate posturing)
2 = extension (decerebrate posturing)
1 = none
4. A nurse should teach which of the following clients requiring crutches about
how to use a three-point gait?
A. A client who is able to bear full weight on both lower extremities.
B. A client who has bilateral leg braces due to paralysis of the lower extremities.
C. A client who has a right femur fracture with no weight bearing on the affected
leg.
D. A client who has bilateral knee-replacements with partial weight bearing on
both legs.
C. A client who has a right femur fracture with no weight bearing on the affected
leg.
Rationale: A three-point gait requires the client to bear all of his weight on one
foot. With a three-point gait, the client bears weight on both crutches and then on
the uninvolved leg, repeating the sequence. The affected leg does not touch the
ground.
5. A nurse is providing teaching about the Mediterranean diet to a client who has a
new diagnosis if hypertension. Which of the following statements by the client
indicates a need for further teaching?
A. "I will limit my intake of red meat to twice weekly."
B. "I can have dairy in moderate portions daily."
C. "I can have fish two times a week."
D. "I can drink wine in moderation."
A. "I will limit my intake of red meat to twice weekly."
Rationale: Following the Mediterranean diet, red meat should be limited to two
times monthly. The client should have dairy in moderate portions daily to weekly.
The intake of fish and seafood is at least two times per week. Drinking wine is
acceptable in moderation.
6. A nurse is providing dietary education to a client with cholecystitis who has
been prescribed a low-fat diet. Which of the following meal selections by the client
indicates understanding of education?
A. Roast beef with gravy, mashed potatoes, ice cream
B. Macaroni and cheese, salad, pudding
C. Creamed chicken on a roll with peas
D. Roast turkey, rice pilaf, green beans
D. Roast turkey, rice pilaf, green beans
Rationale: Roast turkey is a low-fat protein option that would be an excellent
choice for a low-fat diet.
7. A client with a cystocele is encouraged to exercise to strengthen pelvic floor
muscles and prevent pelvis organ prolapse. What exercise will the client need to
perform?
A. Kegel exercises
B. Isometric exercises
C. Circumduction exercises
D. Uterine extension exercises
A. Kegel exercises
Rationale: Kegel exercises strengthen the pelvic floor muscles, which results in
reduction or prevention of pelvic prolapse and stress urinary incontinence. The
other mentioned exercises have no direct effect on prevention or reduction of a
cystocele.
8. A nurse is caring for an older adult client with delirium. Which intervention will
most effectively reduce the client's risk for falls?
A. Use of a night-light.
B. Demonstrate how to use the call light.
C. Place bedside table in close proximity.
D. Hourly rounding by the nurse.
D. Hourly rounding by the nurse.
Rationale: In the health care environment, hourly rounding by the nurse
significantly reduces the occurrence of client falls as well as reducing call light
usage and increasing client satisfaction.
9. A nurse is caring for a client who has been prescribed furosemide. Which of the
following foods should the nurse encourage to include in his diet?
A. Table salt
B. Egg yolks
C. White wine
D. Oranges
D. Oranges
Rationale: Client prescribed potassium-wasting diuretics should be encouraged to
eat foods high in potassium. Oranges, dried fruits, tomatoes, avocados, dried peas,
meats, broccoli, and bananas are all good sources of potassium. Table salt is not a
good source of potassium.
10. A menopausal client is having difficulty getting to sleep and asks what actions
she should incorporate in her daily routine to promote sleep. The nurse would
encourage which of the below measures to promote sleep?
A. Consume a warm drink at bedtime.
B. Take an evening walk before bedtime.
C. Take an afternoon nap.
D. Limit alcohol and nicotine prior to bedtime.
D. Limit alcohol and nicotine prior to bedtime.
Rationale: Limit alcohol, caffeine (stimulant), and nicotine (stimulant) at least 4 hr
before bedtime. Exercise regularly; limit exercise at least 2 hr before bedtime.
Limit fluids 2 to 4 hr before bedtime. [Show Less]