ATI Capstone Fundamentals Assessment

1. a nurse is completing a nutritional assessment on a client and measures BMI, which of the following readings correlates with a BMI of an overweight client? - 25 (25-29.9) 2. a nurse is verifying ng tube placement by the pH of aspirated gastric fluid. which of the following pH values provides a good indication of correct tube placement? - 2 (pH between 0-4) 3. a nurse is caring for a client with a closed head injury. when pressure is applied to the client's nail beds, the clients 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 GCS? - 7 eye opening 1-4 verbal 1-5 motor 1-6 4. a nurse should teach which of the following clients requiring crutches about how to use a three point gait? - a client who has a R femur fracture with no weight bearing on the affected leg 5. (bears all weight on one foot, then both shoulders on crutches, and uninvolved leg, the affected leg does not touch the ground) 6. a nurse is providing teaching about the Mediterranean diet to a client newly who has a new diagnosis of hypertension. what statement indicates need for further teaching? - i will limit my intake of red meat to 2x weekly (should be limited to 2x monthly) 7. 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? - roast turkey, rice pilaf, green beans 8. a client with cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvic organ prolapse. What exercise will the client need to perform - Kegals (reduce pelvic prolapse and stress urinary incontinence) 9. a nurse is caring for an older adult client with delirium. which intervention will most likely reduce the client's risk for falls? - hourly rounding by the nurse ATI Capstone Fundamentals Assessment 10. a nurse is caring for a client who has been prescribed furosemide. which of the following foods should the nurse encourage this to include in his diet? - oranges 11. (along with dried fruits, tomatoes, avocados, dried peas, meats, broccoli, bananas are good for a potassium wasting diuretic) 12. 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? - limit alcohol and nicotine prior to bedtime (at least 4 hours) 13. a nurse is caring for several clients prescribed heat/cold therapies. which of the following clients are at risk of injury from these therapies? SATA - use caution with clients who are very young, older adult, fair skinned, impaired cognition, and comorbidities --> higher risk for fragile skin 14. a nurse is caring for a client with HF who has evidence of dyspnea, bibasalar crackles and frothy sputum. what dietary recommendations should be provided to this client in management of their HF? - reduce sodium intake 15. (stop smoking, monitor fluid intake to 2L/d, increase protein, consume small frequent meals that are soft and easy to chew) 16. a nurse is caring for a client receiving opiates for PM, initially after PM plan was started the client was sedated and sleeping most of the time. after three days the client is no longer sedated and sleeping regularly. what action should the nurse take? - no action is needed at this time (opiates initially cause sedation but it subsides with maintenance pain control) 17. a nurse is caring for a client who is admitted for observation and has full range of motion. which is the best manner to encourage the client to void? - client bathroom (promotes independence and ADLs) 18. a nurse is caring for a client with encephalopathy secondary to liver failure, the client has been prescribed a high calorie, low protein diet. which of the following meals are appropriate? - chicken breast, mashed potatoes, spinach 19. a client with hearing loss has been fitted for a hearing aid. which of the following teaching points are important for the nurse to discuss with the client? - use mild soap and water to clean the ear mold 20. what is the name of a legal document that instructs hcp's and family members about what, if any life-sustaining treatment and individual wants if at some time the individual is unable to make decisions? - living will 21. a nurse is caring for a client with celiac disease, which food should be removed? - tortillas (contain gluten) 22. a nurse is assisting a client with his meal that is at risk for aspiration d/t stroke, what interventions should the nurse take to prevent aspiration? - position upright upper back and head are supported tuck chin when swallowing 23. a nurse is assessing four clients for fluid balance, the nurse should identify what as dehydration? - a client that has a temperature of 39C or 102F 24. a nurse is preparing to administer TPN, what indicates a need to obtain a new bag? - the TPN solution has an oily appearance and a layer of fat on top of the solution ("cracking") 25. which can cause a low pulse ox reading? - inadequate peripheral circulation 26. a nurse is admitting a client who has TB and a productive cough. what types of isolation precautions should the nurse initiate for the client? - airborne (measles, chicken pox, herpes zoster, TB) TB requires negative pressure room, and staff need to wear N95 27. a nurse manager is providing staff education on the correct use of restraints. what should be included in this education? - restraints are a last resort NV and NS status should be assessed every 2h use the least restrictive intervention possible and never let it interfere with treatment thorough and timely documentation need to be completed when restraints are applied 28. a nurse is caring for a client receiving chemo that is experiencing neutropenia, what should the nurse include in pt education? - avoid crowded events (can't fight infection) 29. a nurse is caring for a client with a stage 2 pressure ulcer, define the characteristics of this ulcer? - partial-thickness kin loss involving the epidermis and the dermis ulcer is visible and superficial, may appear as abrasion, blister, or shallow crater edema persists, ulcer may become infected with possible pain and scant drainage 30. a nurse is preparing to administer 250mg of an antibiotic IM. available is 3g/5mL. how many mL would the nurse administer per dose? - 0.4