ATI Capstone- Fundamentals Pre-Assessment
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
of an overweight client?
A. 18.5
B. 24.9
C. 25
D. 32 <Ans> C. 25
Rationale <Ans> 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 <Ans> A. 2
Rationale <Ans> 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 <Ans> B. 7
(comatose) Rationale
<Ans>
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 extremi-
ties.
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. <Ans> C. A client who has a right femur fracture with no weight bearing
on the affected leg.
Rationale <Ans> A three-point gait requires the client to bear all of his weight on on
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
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
of an overweight client?
A. 18.5
B. 24.9
C. 25
D. 32 <Ans> C. 25
Rationale <Ans> 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 <Ans> A. 2
Rationale <Ans> 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 <Ans> B. 7
(comatose) Rationale
<Ans>
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 extremi-
ties.
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. <Ans> C. A client who has a right femur fracture with no weight bearing
on the affected leg.
Rationale <Ans> A three-point gait requires the client to bear all of his weight on on
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
