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 -Correct Answer C. 25
Rationale: Healthy weight is indicates by a BMI of 18.5-24.9. Overwe...
Capstone Fundamentals Exam Study Guide
Questions and Answers Graded A 2024
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 -Correct 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 -Correct 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 -Correct 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
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.
-Correct 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." -Correct 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 -Correct 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?
Capstone Fundamentals Exam
, Capstone Fundamentals Exam
A. Kegel exercises
B. Isometric exercises
C. Circumduction exercises
D. Uterine extension exercises -Correct 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. -Correct 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 -Correct 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. -Correct 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.
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
Capstone Fundamentals Exam
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