ATI LPN
ATI Fundamentals LPN Questions
Question 1 of 5
The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?
Correct Answer: A
Rationale: A Glasgow Coma Scale (GCS) score of 6 (A) indicates coma, defined as ≤8, reflecting minimal responsiveness (eye, verbal, motor). Scores of 9 (B) and 12 (C) suggest moderate injury. 15 (D) is normal. A is correct. Rationale: GCS ≤8 signifies severe brain dysfunction, often requiring intubation, a standard threshold in neurocritical care for coma classification and management.
Question 2 of 5
A client who experienced a traumatic brain injury has a Glasgow Coma Scale score of 6 and is at risk for increased intracranial pressure (ICP). Which position should the nurse maintain for this client?
Correct Answer: C
Rationale: For a GCS of 6 with ICP risk, semi-Fowler's at 30 degrees (C) optimizes venous drainage, reducing ICP. Supine (A) or prone (B) increases pressure. High Fowler's (D) may destabilize. C is correct. Rationale: 30-degree elevation balances ICP reduction and perfusion, per neurocare standards, critical in severe brain injury.
Question 3 of 5
When working as a licensed vocational nurse, you determine that your client scheduled for surgery does not understand the physician's earlier explanation of the surgery. The client is asking many questions about the risks and seems worried. Which of the following actions would be best on your part?
Correct Answer: D
Rationale: When a client scheduled for surgery shows a lack of understanding and expresses concern, notifying the physician is the best action for a licensed vocational nurse. The physician, as the primary decision-maker and the one obtaining informed consent, has the responsibility to ensure the client fully comprehends the procedure, risks, and benefits. The nurse's role is to facilitate communication and advocate for the client's needs, not to independently explain complex medical details outside their scope or cancel the surgery, which exceeds their authority. Asking the supervising RN might help, but it delays direct resolution by the physician, who is legally accountable for ensuring consent is informed. This approach upholds the nurse's duty to prioritize client understanding and safety while respecting professional boundaries and legal standards.
Question 4 of 5
The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
Correct Answer: A
Rationale: Among four diagnoses, chest pain related to pneumonia takes highest priority because it addresses a physiologic need breathing and circulation per Maslow's hierarchy. Pain and potential respiratory compromise threaten survival, requiring immediate intervention like medication or oxygen. Self-care deficits, family process risks, and self-esteem issues, while important, are less urgent, impacting higher-level needs like independence or esteem. Prioritizing chest pain ensures the client's airway and oxygenation are stabilized, preventing deterioration, a fundamental principle in acute care nursing.
Question 5 of 5
When charting in the client's record or chart, the nurse most needs to do which one of the following things?
Correct Answer: A
Rationale: Dating and signing each chart entry is most essential, establishing a legal timeline and accountability for actions. Fixed intervals aren't mandatory, pens ensure permanence but aren't the priority, and crossing out errors risks misinterpretation. This practice validates care, crucial for nursing documentation integrity.