ATI CAPSTONE FUNDAMENTAL EXAM (VERSION A
AND B) COMPLETE QUESTIONS WITH DETAILED
VERIFIED ANSWERS AND RATIONALES /ALREADY
GRADED A+
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
(25-29.9)
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
performanswer..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? SATAanswer..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
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?answer..living will
a nurse is caring for a client with celiac disease, which food should be
removed?answer..tortillas
(contain gluten)
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?answer..position upright
upper back and head are supported
tuck chin when swallowing
a nurse is assessing four clients for fluid balance, the nurse should identify what as
dehydration?answer..a client that has a temperature of 39C or 102F
a nurse is preparing to administer TPN, what indicates a need to obtain a new
bag?answer..the TPN solution has an oily appearance and a layer of fat on top of the
solution
("cracking")
which can cause a low pulse ox reading?answer..inadequate peripheral circulation
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?answer..airborne
(measles, chicken pox, herpes zoster, TB)
TB requires negative pressure room, and staff need to wear N95
a nurse manager is providing staff education on the correct use of restraints. what
should be included in this education?answer..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
AND B) COMPLETE QUESTIONS WITH DETAILED
VERIFIED ANSWERS AND RATIONALES /ALREADY
GRADED A+
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
(25-29.9)
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
performanswer..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? SATAanswer..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
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?answer..living will
a nurse is caring for a client with celiac disease, which food should be
removed?answer..tortillas
(contain gluten)
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?answer..position upright
upper back and head are supported
tuck chin when swallowing
a nurse is assessing four clients for fluid balance, the nurse should identify what as
dehydration?answer..a client that has a temperature of 39C or 102F
a nurse is preparing to administer TPN, what indicates a need to obtain a new
bag?answer..the TPN solution has an oily appearance and a layer of fat on top of the
solution
("cracking")
which can cause a low pulse ox reading?answer..inadequate peripheral circulation
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?answer..airborne
(measles, chicken pox, herpes zoster, TB)
TB requires negative pressure room, and staff need to wear N95
a nurse manager is providing staff education on the correct use of restraints. what
should be included in this education?answer..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
