ATI Capstone Fundamentals

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?

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?

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?

a nurse should teach which of the following clients requiring crutches about how to use a three point gait?

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?

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 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

a nurse is caring for an older adult client with delirium. which intervention will most likely reduce the client's risk for falls?

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?

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 nurse is caring for several clients prescribed heat/cold therapies. which of the following clients are at risk of injury from these therapies? SATA

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?

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?

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?

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?

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?

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?

a nurse is caring for a client with celiac disease, which food should be removed?

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?

a nurse is assessing four clients for fluid balance, the nurse should identify what as dehydration?

a nurse is preparing to administer TPN, what indicates a need to obtain a new bag?

which can cause a low pulse ox reading?

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?

a nurse manager is providing staff education on the correct use of restraints. what should be included in this education?

a nurse is caring for a client receiving chemo that is experiencing neutropenia, what should the nurse include in pt education?

a nurse is caring for a client with a stage 2 pressure ulcer, define the characteristics of this ulcer?

a nurse is preparing to administer 250mg of an antibiotic IM. available is 3g/5mL. how many mL would the nurse administer per dose?

a nurse is reviewing psychosocial stages of development for a school-age child, what would be an expected behavioral finding for this child?

a nurse is assessing a client who has Parkinsons disease, what manifestations should be expected?

a nurse is caring for a client receiving radiation treatments for cancer. the client states he is experiencing dryness, redness, and scaling at the treatment area. which of the following should the nurse instruct the client to do?

a nurse is assessing the pain level of a client who has dementia and difficulty communicating, which pain assessment technique should the nurse use?

a nurse receives a report from an assistive personnel that a client's BP is 160/95, what should the nurse do first?

a nurse is caring for a client who has an indwelling urinary cath, what should the nurse identify as a cath occlusion?

a nurse is discussing immunity with a client who has received an immunization, the nurse should identify that an immunization functions as part of which of the following types of immunity?

a nurse is reviewing the health history of an OA who has a hip fracture the nurse should identify what is a risk of developing pressure injuries?

a nurse is assessing the IV infusion site of a client who reports pain at the site. the site is red and there is warmth along the coarse of the vein, what should the nurse do?

a nurse is caring for an OA who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. which of the following terms should the nurse use to document this finding?

a community health nurse is teaching a group of clients about first aid for different types of wounds. which of the following client statements indicates an understanding of the teaching?

a nurse is sitting with the partner of a client who recently died. which of the following actions should the nurse take to facilitate mourning?

a nurse is in an acute care facility is caring for a client who is postop following abdominal surgery. which of the following behaviors should the nurse identify as increasing the client's risk for constipation?

a nurse is caring for a client who expresses anxiety about an upcoming surgery, what should the nurse do?

a nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. which of the following actions should the nurse take to prevent contamination during the dressing change?

a nurse is caring for a pt who is scheduled for a cataract surgery, the client states "is see just fine and have decided to cancel my surgery". which of the following responses should the nurse make?

a nurse is teaching a client about the use of a MDI, which instruction should the nurse include in the teaching?

a nurse is teaching a group of AP about the expected integumentary changes in OA, which should the nurse include

a nurse is monitoring a client who has been receiving intermittent enteral feedings, what should the nurse identify as an intolerance to the feeding?

a nurse enters a clients room and sees smoke coming from the trash can. which of the following actions should the nurse take first

a nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery, which of the following statements should the nurse make?

a nurse is reviewing info about advance directives with a newly admitted client. which of the following statements by the client indicates an understanding of the teaching?

a nurse is admitting a client who has meningococal meningitis, what should the nurse do first?

a nurse finds a client on the floor of their room experiencing a seizure, which of the following actions is the nurse's priority

a nurse is providing discharge teaching to a client who has a prescription for home O2, which info should the nurse teach?

a nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. which of the following client information should the nurse identify as a contributing factor to the decrease in the medication's effectiveness?

a nurse is teaching a client about the correct use of a cane, what should the nurse include?

a nurse is teaching about safety risks for adolescents, what should be included?

a nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. the nurse should instruct the client to avoid which of the following foods?

a nurse is reviewing the medical records of a group of OA clients. the nurse should identify that which of the following is a risk factor that places OA at an increased risk for developing infections?

a nurse is caring for a client who has a prescription for a narcotic med, after admin the nurse is left with an unused portion, what should the nurse do?

a nurse is performing a focused assessment for a client who has dysrhythmias, what indicates ineffective cardiac contractions?

a nurse is preparing to transfer a client from a chair to the bed. the client can bear partial weight and has upper body strength. which of the following devices should the nurse use to transfer the pt?

a nurse is planning to administer several meds to a client through a ng tube, which actions should the nurse take?

a nurse is teaching about measures to promote sleep with insomnia, what statement indicates understanding?

a nurse is teaching about foot care to a client who has DM, what statement indicates understanding?

a nurse is preparing to perform a routine abdominal assessment for a client, which action should the nurse take?

a nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3d, what lab results indicates the client is experiencing FVD?

a nurse is updating a plan of care after an evaluation of a client who has dysphagia, which interventions should the nurse include in the plan?

a nurse is caring for a client who reports burning around the peripheral IV site, which finding should the nurse identify as a manifestation of infiltration?

a charge nurse is making assignments for the upcoming shift, what assignments should the charge nurse assign to a LPN?

a nurse is in an ED monitoring the hydration status of a client receiving oral rehydration, what should the intervene for?

a nurse is documenting client care, which of the following entries should the nurse identify as an example of implementation of client care?

a charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. the charge nurse should identify that the nurse is accountable for which of the following torts?

a nurse is completing an admission assessment for a client who has hearing lsos, what action should the nurse take?

a nurse is caring for a client who has dementia and frequently tries to get out of bed, which of the following actions should the nurse take? (SATA)

a nurse is preparing a client for transfer to another unit? which finding does the nurse include in the transfer report?

a nurse in a providers office is assessing the motor skill development of a 15 month old toddler during a well-child visit, what gross motor skills should the nurse expect?

a nurse is admitting a client who has recently developed fever, confusion, and a decreased level of consciousness. which of the following actions should the nurse take first after obtaining the client's history and assessment?

a nurse is planning a community education program about colorectal cancer. which of the following risk factors should the nurse identify as modifiable?

a nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea, which of the findings should the nurse expect?

a nurse is performing a cultural assessment of a group of clients to maintain respect for their value sytems and beliefs. which of the following should the nurse identify as examples of cultural variables?