CURRENTLY TESTING SOLUTIONS OF ATI Capstone
Fundamentals EXAM WITH ACTUAL CORRECT DETAILED
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 - 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 - 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 - 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. - 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." - 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.
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?
A. Roast beef with gravy, mashed potatoes, ice cream
B. Macaroni and cheese, salad, pudding
C. Creamed chicken on a roll with peas
D. Roast turkey, rice pilaf, green beans - ANSWER-D. Roast turkey, rice pilaf, green beans
Rationale: Roast turkey is a low-fat protein option that would be an excellent choice for a low-fat diet.
A client with a cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvis
organ prolapse. What exercise will the client need to perform?
A. Kegel exercises
B. Isometric exercises
C. Circumduction exercises
D. Uterine extension exercises - ANSWER-A. Kegel exercises
, Rationale: Kegel exercises strengthen the pelvic floor muscles, which results in reduction or prevention
of pelvic prolapse and stress urinary incontinence. The other mentioned exercises have no direct effect
on prevention or reduction of a cystocele.
A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce
the client's risk for falls?
A. Use of a night-light.
B. Demonstrate how to use the call light.
C. Place bedside table in close proximity.
D. Hourly rounding by the nurse. - ANSWER-D. Hourly rounding by the nurse.
Rationale: In the health care environment, hourly rounding by the nurse significantly reduces the
occurrence of client falls as well as reducing call light usage and increasing client satisfaction.
A nurse is caring for a client who has been prescribed furosemide. Which of the following foods should
the nurse encourage to include in his diet?
A. Table salt
B. Egg yolks
C. White wine
D. Oranges - ANSWER-D. Oranges
Rationale: Client prescribed potassium-wasting diuretics should be encouraged to eat foods high in
potassium. Oranges, dried fruits, tomatoes, avocados, dried peas, meats, broccoli, and bananas are all
good sources of potassium. Table salt is not a good source of potassium.
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?
A. Consume a warm drink at bedtime.
B. Take an evening walk before bedtime.
C. Take an afternoon nap.
D. Limit alcohol and nicotine prior to bedtime. - ANSWER-D. Limit alcohol and nicotine prior to bedtime.
Rationale: Limit alcohol, caffeine (stimulant), and nicotine (stimulant) at least 4 hr before bedtime.
Exercise regularly; limit exercise at least 2 hr before bedtime. Limit fluids 2 to 4 hr before bedtime.
Fundamentals EXAM WITH ACTUAL CORRECT DETAILED
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 - 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 - 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 - 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. - 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." - 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.
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?
A. Roast beef with gravy, mashed potatoes, ice cream
B. Macaroni and cheese, salad, pudding
C. Creamed chicken on a roll with peas
D. Roast turkey, rice pilaf, green beans - ANSWER-D. Roast turkey, rice pilaf, green beans
Rationale: Roast turkey is a low-fat protein option that would be an excellent choice for a low-fat diet.
A client with a cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvis
organ prolapse. What exercise will the client need to perform?
A. Kegel exercises
B. Isometric exercises
C. Circumduction exercises
D. Uterine extension exercises - ANSWER-A. Kegel exercises
, Rationale: Kegel exercises strengthen the pelvic floor muscles, which results in reduction or prevention
of pelvic prolapse and stress urinary incontinence. The other mentioned exercises have no direct effect
on prevention or reduction of a cystocele.
A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce
the client's risk for falls?
A. Use of a night-light.
B. Demonstrate how to use the call light.
C. Place bedside table in close proximity.
D. Hourly rounding by the nurse. - ANSWER-D. Hourly rounding by the nurse.
Rationale: In the health care environment, hourly rounding by the nurse significantly reduces the
occurrence of client falls as well as reducing call light usage and increasing client satisfaction.
A nurse is caring for a client who has been prescribed furosemide. Which of the following foods should
the nurse encourage to include in his diet?
A. Table salt
B. Egg yolks
C. White wine
D. Oranges - ANSWER-D. Oranges
Rationale: Client prescribed potassium-wasting diuretics should be encouraged to eat foods high in
potassium. Oranges, dried fruits, tomatoes, avocados, dried peas, meats, broccoli, and bananas are all
good sources of potassium. Table salt is not a good source of potassium.
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?
A. Consume a warm drink at bedtime.
B. Take an evening walk before bedtime.
C. Take an afternoon nap.
D. Limit alcohol and nicotine prior to bedtime. - ANSWER-D. Limit alcohol and nicotine prior to bedtime.
Rationale: Limit alcohol, caffeine (stimulant), and nicotine (stimulant) at least 4 hr before bedtime.
Exercise regularly; limit exercise at least 2 hr before bedtime. Limit fluids 2 to 4 hr before bedtime.
