ATI CAPSTONE- FUNDAMENTALS PRE-
ASSESSMENT QUESTIONS AND ANSWERS
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 of an overweight
client?
A. 18.5
B. 24.9
C. 25
D. 32 - CORRECT ANSWER- 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
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 - CORRECT ANSWER- A. 2
Rationale: A good indication of appropriate placement is obtaining gastric contents with
a pH between 0 and 4.
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 - CORRECT ANSWER- 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
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.
- CORRECT ANSWER- 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.
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." - CORRECT ANSWER- 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.
ASSESSMENT QUESTIONS AND ANSWERS
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 of an overweight
client?
A. 18.5
B. 24.9
C. 25
D. 32 - CORRECT ANSWER- 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
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 - CORRECT ANSWER- A. 2
Rationale: A good indication of appropriate placement is obtaining gastric contents with
a pH between 0 and 4.
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 - CORRECT ANSWER- 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
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.
- CORRECT ANSWER- 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.
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." - CORRECT ANSWER- 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.
