ATI Capstone Fundamentals
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? - ANSWER
25
below 18.5 - underweight range.
between 18.5 and 24.9 - healthy weight range.
between 25 and 29.9 - overweight range.
between 30 and 39.9 - obese range.
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? -
ANSWER 2
(pH between 0-4)
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? - ANSWER 7
eye opening 1-4
verbal 1-5
motor 1-6
a nurse should teach which of the following clients requiring crutches about how to
use a three point gait? - ANSWER a client who has a R femur fracture with no
weight bearing on the affected leg
(bears all weight on one foot, then both shoulders on crutches, and uninvolved leg,
the affected leg does not touch the ground)
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?
- ANSWER i will limit my intake of red meat to 2x weekly
(should be limited to 2x monthly)
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? - ANSWER roast turkey, rice pilaf, green
beans
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 -
ANSWER Kegals
(reduce pelvic prolapse and stress urinary incontinence)
, a nurse is caring for an older adult client with delirium. which intervention will most
likely reduce the client's risk for falls? - ANSWER hourly rounding by the nurse
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? - ANSWER
oranges
(along with dried fruits, tomatoes, avocados, dried peas, meats, broccoli, bananas
are good for a potassium wasting diuretic)
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? - ANSWER limit alcohol and
nicotine prior to bedtime
(at least 4 hours)
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 - ANSWER use
caution with clients who are very young, older adult, fair skinned, impaired cognition,
and comorbidities --> higher risk for fragile skin
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? - ANSWER reduce sodium intake
(stop smoking, monitor fluid intake to 2L/d, increase protein, consume small frequent
meals that are soft and easy to chew)
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? - ANSWER no action is needed at this time
(opiates initially cause sedation but it subsides with maintenance pain control)
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? - ANSWER client
bathroom
(promotes independence and ADLs)
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? - ANSWER chicken breast, mashed potatoes, spinach
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? - ANSWER
use mild soap and water to clean the ear mold
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? - ANSWER
25
below 18.5 - underweight range.
between 18.5 and 24.9 - healthy weight range.
between 25 and 29.9 - overweight range.
between 30 and 39.9 - obese range.
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? -
ANSWER 2
(pH between 0-4)
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? - ANSWER 7
eye opening 1-4
verbal 1-5
motor 1-6
a nurse should teach which of the following clients requiring crutches about how to
use a three point gait? - ANSWER a client who has a R femur fracture with no
weight bearing on the affected leg
(bears all weight on one foot, then both shoulders on crutches, and uninvolved leg,
the affected leg does not touch the ground)
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?
- ANSWER i will limit my intake of red meat to 2x weekly
(should be limited to 2x monthly)
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? - ANSWER roast turkey, rice pilaf, green
beans
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 -
ANSWER Kegals
(reduce pelvic prolapse and stress urinary incontinence)
, a nurse is caring for an older adult client with delirium. which intervention will most
likely reduce the client's risk for falls? - ANSWER hourly rounding by the nurse
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? - ANSWER
oranges
(along with dried fruits, tomatoes, avocados, dried peas, meats, broccoli, bananas
are good for a potassium wasting diuretic)
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? - ANSWER limit alcohol and
nicotine prior to bedtime
(at least 4 hours)
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 - ANSWER use
caution with clients who are very young, older adult, fair skinned, impaired cognition,
and comorbidities --> higher risk for fragile skin
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? - ANSWER reduce sodium intake
(stop smoking, monitor fluid intake to 2L/d, increase protein, consume small frequent
meals that are soft and easy to chew)
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? - ANSWER no action is needed at this time
(opiates initially cause sedation but it subsides with maintenance pain control)
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? - ANSWER client
bathroom
(promotes independence and ADLs)
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? - ANSWER chicken breast, mashed potatoes, spinach
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? - ANSWER
use mild soap and water to clean the ear mold
