ATI LPN Critical Thinking Exam

Extract:

Patient with edema has a problem of fluid overload

Question 1 of 5

The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)

A. Teaching deep breathing and relaxation techniques as neededB. Inserting a nasogastric tube (NG) to relieve gastric distentionC. Placing the nurse call button within reach at all timesD. Giving hand massages dailyE. Repositioning the patient every 2 hours to reduce pressure injury riskF. Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed

Correct Answer: A,C,D,E

Rationale: A: Teaching non-pharmacological techniques is within a nurse's scope without a physician's order. C: Ensuring the call button is accessible promotes safety independently. D: Hand massages are a comfort measure nurses can provide independently. E: Repositioning prevents pressure injuries and is an independent action. B requires a physician's order, and F involves medication administration, which is dependent.

Extract:

Question 2 of 5

Identify the two primary methods used to collect data:

A. interview and physical examinationB. review of the doctor's orders and the KardexC. written report by patient and familyD. review of the chart and the nurse's notes

Correct Answer: A

Rationale: Interview and physical examination (
A) collect subjective and objective data directly. B, C, and D are secondary or supportive methods.

Extract:

Patient with a nursing diagnosis of airway clearance, ineffective

Question 3 of 5

The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:

A. oxygen will be continuedB. the patient's coughing frequency will increaseC. cyanosis may be presentD. within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea

Correct Answer: D

Rationale: The desired outcome for ineffective airway clearance (
D) is measurable improvement, like no dyspnea within 24 hours. A is an intervention, B does not ensure clearance, and C indicates worsening.

Extract:

Patient is confined to bed rest

Question 4 of 5

The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

A. as difficult to maintainB. as a risk factorC. as a nursing responsibilityD. as contributing to the patient's recovery

Correct Answer: B

Rationale: Bed rest (
B) is a risk factor for complications like pressure ulcers or DVT, which should be noted in the care plan. A is subjective, C is an intervention, and D is incomplete as bed rest can hinder recovery if prolonged.

Extract:

Question 5 of 5

The primary source of assessment information is:

A. the patient's friendsB. past medical recordsC. the patient's recordD. the patient

Correct Answer: D

Rationale: The patient (
D) is the primary source for assessment data, providing real-time information on symptoms and concerns. Friends (
A) and records (B,
C) are secondary sources and may not reflect current status.

ATI LPN Critical Thinking Exam | Nurselytic

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