1. A nurse is completing a nutritional assessment on a client and measures
body mass index (BMI). Which of the following readings correlates with a
BMI
... [Show More] 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? [Show Less]