ATI CAPSTONE FUNDAMENTALS 2020 PRE-ASSESSMENT QUESTIONS AND AND ANSWERS, WITH RATIONALES

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 1. 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 A. 2 lOMoARcPSD| 2. 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 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 with a pH between 0 and 4. contents Rationale: A good indication of appropriate placement is obtaining gastric lOMoARcPSD| 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 3. 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. lOMoARcPSD| 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. 4. 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." 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. 5. 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? affected C. A client who has a right femur fracture with no weight bearing on the lOMoARcPSD| 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. 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 6. 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 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. 7. 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. lOMoARcPSD| C. Place bedside table in close proximity. D. Hourly rounding by the nurse. 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. 8. 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 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. 9. 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. lOMoARcPSD| B. Take an evening walk before bedtime. C. Take an afternoon nap. D. Limit alcohol and nicotine prior to bedtime. 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. A nurse is caring for a client with a stage 2 pressure ulcer. Define the characteristics of the ulcer. A. Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. (Stage 1 pressure ulcer) B. Full-thickness tissue loss with damage to or necrosis of subQ tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. (Stage 3 pressure ulcer) lOMoARcPSD| C. Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. D. Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets or infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material). (Stage 4 pressure ulcer) C. Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. lOMoARcPSD| Rationale: This is a stage 2 pressure ulcer (partial-thickness, involving the epidermis and dermis).