ATI Capstone- Fundamentals Pre-Assessment

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.

A nurse is preparing to administer total parenteral nutrition (TPN) to a client. Which of the following findings indicates a need to obtain a new bag of TPN before administering? A. The TPN solution has an oily appearance and a layer of fat on top of the solution. B. The TPN solution contains added electrolytes, vitamins and trace elements. C. The bag of TPN was prepared by the pharmacy 12 hours prior. D. The bag of TPN is labeled with the client's name, medical record number and prescription.

A. The TPN solution has an oily appearance and a layer of fat on top of the solution. Rationale: Before administration of TPN, the nurse should look for "cracking" of TPN solution. This occurs if the calcium or phosphorus content is high or if poor-salt albumin is added. A "cracked" TPN solution has an oily appearance or a layer of fat on top of the solution and should not be used. To prevent interruption of therapy the next bag of TPN should be available prior to the previous bags completion.

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

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 nurse is caring for a client with celiac disease. Which food should be removed from the meal tray? A. Corn bread B. Mashed potato C. Lentils D. Tortillas

D. Tortillas Rationale: Tortillas contain gluten. Corn bread, mashed potatoes and lentils do not contain gluten.

A nurse manager is providing staff education on the correct use of restraints. Which of the following should be included in this education? Select all that apply. A. Restraints should not interfere with treatment. B. Restraints should not be used because of short staffing. C. It is not necessary to document the behaviors making restraint necessary. D. Staff must document type and location of the restraint and time applied. E. Assess neurovascular and nerosensory status every 2 hours.

A, B, D, and E. Rationale: Restraints should be applied as a last resort after other measures have been used. Thorough and timely documentation needs to be completed when restraints are applied, following protocol and policy. Neurovascular and neurosensory status should be assessed every 2 hours, along with frequent check ins to ensure the safety and comfort of the client. Restraints should not be used as a way to contain the client when a unit is short staffed. The type or technique of restraint used must be the least restrictive intervention possible and should never interfere with treatment.

A nurse is assisting a client with his meal that is at risk for aspiration due to a stroke. What interventions should the nurse take to prevent aspiration? Select all that apply. A. Position the client in Fowler's position. B. Instruct the client to tuck his chin when swallowing. C. Provide oral hygiene before meals. D. Position the client in Trendelenburg position. E. Support the client's upper back, neck and head during feedings.

A, B, and E. Rationale: To decrease the risk of aspiration for a stroke client, ensure the clients position is upright, that the upper back and head are supported during meals. Remind the client to tuck their chin while swallowing, to guide the food's path. Avoid lowering the head of bed during feedings. Oral care can improve the client's well-being and increase the interest for eating, but does not help prevent the potential for aspiration.

A nurse is caring for several prescribed heat/cold therapies. Which of the following clients are at risk of injury from these therapies? Select all that apply. A. An older adult client prescribed heat therapy for hip pain. B. A middle age adult client prescribed cold therapy for muscle spasms. C. A client with diabetes prescribed cold therapy for a fractured toe. D. A fair-skinned, school age client prescribed heat therapy after a soccer injury. E. A cognitively impaired older adult prescribed alternating heat and cold therapy.

A, C, D, and E. Rationale: The nurse should use extreme caution with clients who are very young, an older adult, fair-skinned, impaired cognition, and have comorbidities because they are at higher risk for fragile skin.

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.

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 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

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 is caring for a client with heart failure who has evidence of dyspnea, bibasilar crackles and frothy sputum. What dietary recommendations should be provided to this client in management of their heart failure? A. Decrease protein intake. B. Reduce sodium intake. C. Increase fluid intake. D. Decrease calcium intake.

B. Reduce sodium intake. Rationale: It is encouraged to stop smoking, reduce sodium intake, monitor fluid intake, restricting intake to 2 L per day. It is also encouraged to increase protein intake to 1.12 g/kg and consume small, frequent meals that are soft, easy-to-chew foods. There are no recommendations on calcium intake associated with heart failure.

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? A. Use the highest setting to promote full auditory comprehension. B. Use mild soap and water to clean the ear mold. C. Turn the hearing aid off to conserve battery life during hours of sleep only. D. Immerse the hearing aid in saline solution to keep it hygienic.

B. Use mild soap and water to clean the ear mold. Rationale: To clean the ear mold, use mild soap and water while keeping the hearing aid dry. Use the lowest setting that allows hearing without feedback. When the hearing aid is not in use, turn it off or remove the batteries to conserve battery power. Keep replacement batteries on hand.

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

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 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.

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 caring for a client receiving chemotherapy that is experiencing neutropenia. Which of the following should the nurse include in this client's education? A. Track oral temperature weekly. B. Gardening is a good form of mild exercise. C. Avoid crowded events. D. Eat plenty of fresh fruits and vegetables.

C. Avoid crowded events. Rationale: Clients with neutropenia do not have enough circulating neutrophils to fight off infections. This client should avoid crowds to prevent exposure to colds/viruses. The client should monitor their temperature daily to track trends that could indicate infection. Gardening would expose the client to microbes in the soil that could cause illness. Fruits and vegetables are covered with microbes that while not normally harmful to non-immunocompromised clients can cause infection in clients with myleosuppression. These foods should be cooked before the client ingests them.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? A. Pruritus B. Hypertension C. Bradykinesia D. Xerostomia

C. Bradykinesia Rationale: The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease. The nurse should expect to find oily skin, which results from autonomic dysfunction, rather than pruritus, which results from dry skin. The nurse should expect to find orthostatic hypotension, which results from autonomic dysfunction. Te nurse should expect to find uncontrolled drooling, especially at night, instead of xerostomia or dry mouth in a client who has Parkinson's disease.

A nurse is reviewing psychosocial stages of development for a school-age child. What would be an expected behavioral finding for this child? A. Personalize values and beliefs and base reasoning on ethical fairness principles. Establish close relationships. Have influences that help with formation of healthy self-concept, such as family and friends. (Young adults 20-35 years) B. Develop sense of personal identity that family expectations influence. Peer relationships develop as a support system. Concerned with body images that media portray. (Adolescents 12-20 years) C. Develop a sense of industry through advances in learning. Strive to develop healthy self-respect by finding out in what areas they excel. Peer groups play important role in social development. D. Take on new experiences and when unable to accomplish task may feel guilty or misbehave. Generally do not exhibit stranger anxiety. Understand behavior in

C. Develop a sense of industry through advances in learning. Strive to develop healthy self-respect by finding out in what areas they excel. Peer groups play important role in social development. Rationale: This behavior is an expected finding of School-age children 6-12 years.

Which of the following can cause a low pulse oximetry reading? A. Hyperthermia B. Increased hemoglobin level C. Inadequate peripheral circulation D. Low altitudes

C. Inadequate peripheral circulation Rationale: Hypothermia rather than hyperthermia can result in a low reading. A decreased hemoglobin level rather than an increased hemoglobin level can result in a low reading. Low altitudes do not impact pulse oximetry readings.

***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. Sit in the sun for 15 minutes per day. B. Apply moist heat to the area twice daily. C. Liberally apply prescribed lotion to the area. D. Wash the affected area daily with antimicrobial soap.

C. Liberally apply prescribed lotion to the area. Rationale: Hydrating lotions are commonly prescribed to treat irradiated areas. Antimicrobial soaps can be harsh and further traumatize new epidermal cells. The client should avoid applying other lotions not prescribed by the radiologist to affected areas. Clients receiving radiation therapy should avoid exposing irradiated areas to sun. Moist heat should be avoided over irradiated areas.

What is the name of a legal document that instructs the health care providers 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. Do Not Resuscitate B. Informed consent C. Living will D. Durable power of attorney for health care

C. Living will Rationale: A living will is a legal document that specifically outlines a clients wishes regarding life-sustaining treatment. A DNR order is written by the provider when the client requests not the be resuscitated in the event of cardiac arrest. Informed consent is a consent to surgery or a procedure and is obtained after a client received complete disclosure of all pertinent information regarding the surgery or procedure to be performed. A durable power of attorney for health care is a legal document that designates another person to make health care decisions for the client when the client becomes unable to make decisions independently.

***A nurse is caring for a client receiving opiates for pain management. Initially after the pain management plan was started, the client was sedated and sleeping most of the time. After three days on the plan the client is no longer sedated and sleeping regularly. What action should the nurse take? A. Initiate additional non-pharmacological pain management techniques. B. Notify the provider that a dosage adjustment is needed. C. No action is needed at this time. D. Contact the provider to request an alternate method of pain management.

C. No action is needed at this time. Rationale: Opiates initially cause sedation but this effect subsides with maintenance pain control. The pain management plan is working. There is no need to change or add additional methods at this time.

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) 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

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. Rationale: This is a stage 2 pressure ulcer (partial-thickness, involving the epidermis and dermis).

A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? A. A client who has a urine specific gravity of 1.010. B. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr. C. A client who has a hematocrit of 45%. D. A client who has a temperature of 39 degrees Celsius (102 degrees Fahrenheit).

D. A client who has a temperature of 39 degrees Celsius (102 degrees Fahrenheit). Rationale: An elevated temperature is a manifestation of dehydration. The urine specific gravity is within the expected reference range of 1.010 to 1.025. Concentrated urine and a specific gravity of grater than 1.030 are manifestations of dehydration. Weight gain is a manifestation of fluid volume excess. The hematocrit is within expected reference range of 37% to 64%. An elevated hematocrit is a manifestation of hemoconcentration and dehydration.

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? A. Contact B. Droplet C. Protective D. Airborne

D. Airborne Rationale: The nurse should initiate airborne precautions when a client has an infection that spreads through small droplets that remain airborne for longer periods, such as tuberculosis and measles. The client requires a negative-pressure airflow room, and staff should wear an N95 respirator when in contact with the client. The nurse should initiate contact precautions when a client has an infection that spreads through indirect contact, such as major wound infections or infection with multi-drug resistant organisms such as MRSA. The nurse should initiate droplet precautions when a client has an infection that spreads through droplets larger than 5 microns, such as pneumonia or streptococcal pharyngitis. The nurse should initiate a protective environment when clients require a room with positive-pressure airflow, such as those who have undergone stem-cell transplants.

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 meal selections is appropriate for this client? A. Scrambled eggs, bacon and pancakes. B. Grilled cheese sandwich, potato chips, chocolate pudding. C. Steak, french fried, corn. D. Chicken breast, mashed potatoes, spinach.

D. Chicken breast, mashed potatoes, spinach. Rationale: This option meets the prescribed diet. It is high in calories and while chicken does provide protein it is a low-fat source and can be eaten in moderation on a low-protein diet. Spinach will provide additional vitamin K for this client at risk for bleeding due to liver failure.

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. Urinal B. Bedpan C. Bedside Commode D. Client Bathroom

D. Client Bathroom Rationale: The goal is to encourage clients to maintain independence and privacy if the client has full function and is able to safely complete ADLs.

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.

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 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.

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 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.