ATI LPN Critical Thinking Exam

Extract:

Patient's vital signs are B/P 120/80, P 88, and R 18; Non-responsive patient; Disoriented patient; Critically ill patient

Question 1 of 5

A focused assessment should be done by the nurse in all of the following situations EXCEPT:

A. patient's vital signs are B/P 120/80, P 88 and R 18B. non-responsive patientC. disoriented patientD. critically patient ill

Correct Answer: A

Rationale: Stable vital signs (
A) do not require a focused assessment unless indicated. B, C, and D signal urgent conditions needing targeted evaluation.

Extract:

Patient was administered a stat insulin dose

Question 2 of 5

The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

A. the insulin was administered based per the nurse's testimonyB. none of the answers are correctC. the insulin was administered based on the witness testimonyD. the insulin was not administered because it was not charted

Correct Answer: D

Rationale: Legally, 'if it wasn't documented, it wasn't done' (
D). Without MAR documentation, the insulin administration cannot be verified, despite testimony (A,
C). B is incorrect as D is accurate.

Extract:

Question 3 of 5

How is Maslow's Hierarchy of Human Needs used by nurses in a clinical setting?

A. It serves as a reminder of human growth and development across the life spanB. It helps in prioritizing nursing diagnoses and careC. It outlines the basic psychological needs that people have when they are hospitalized and feel anxietyD. It is a framework for thinking critically

Correct Answer: B

Rationale: Maslow's hierarchy (
B) prioritizes care by addressing physiological needs first, then safety, love, esteem, and self-actualization. A, C, and D are less accurate uses.

Question 4 of 5

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

A. Incident reports must be recorded in the nurse's notesB. Institutions are only reimbursed for patient care that is documentedC. Document only when not successfulD. The patient record is a complete picture of individualized problems, treatments and responses to treatments

Correct Answer: B,D

Rationale: B: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as it proves care was provided. D: The patient record provides a comprehensive view of the patient's problems, treatments, and responses, ensuring continuity of care. A is incorrect because incident reports are separate from the medical record to maintain patient safety internally. C is incorrect because documentation should include both successful and unsuccessful interventions for completeness.

Extract:

Patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation

Question 5 of 5

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:

A. signs of fluid overloadB. symptomsC. data clusteringD. urinary retention

Correct Answer: C

Rationale: Grouping signs like flushed skin and fever (
C) is data clustering, suggesting dehydration or infection. Fluid overload (
A) shows edema, symptoms (
B) are subjective, and urinary retention (
D) involves bladder issues.

ATI LPN Critical Thinking Exam | Nurselytic

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