Exam (elaborations)
Fundamentals ATI capstone NCLEX
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Fundamentals ATI capstone NCLEXa 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? - ANS 25
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? - ANS 2
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? - ANS 7
a nurse should teach which of the following clients requiring crutches about how to use a three point
gait? - ANS 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? - ANS 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? - ANS
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 perform - ANS 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? - ANS 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? - ANS 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? - ANS 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?
SATA - ANS 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 recommenda- tions should be provided to this client in management of their HF? - ANS
reduce sodium intake
(stop smoking, monitor fluid intake to 2L/d, increase protein, con- sume small frequent meals that are
soft and easy to chew)
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