ATI LPN Critical Thinking Exam

Extract:

Question 1 of 5

Who should document care in the patient record?

A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.C. All staff members should document all of the care that they have provided.D. All staff should document all care they provided but the RN (as the only independent practitioner) must sign their notes.

Correct Answer: C

Rationale: All staff (
C) must document their own care for accuracy and accountability. A, B, and D incorrectly assign documentation responsibilities.

Question 2 of 5

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

A. ethically can look at a friend's chart to see the diagnosisB. shares information from a chart to protect a friendC. knows that only the Patient's Bill of Rights advocates confidentialityD. reads charts only for professional reasons

Correct Answer: D

Rationale: Nurses must access records only for professional reasons (
D) to comply with HIPAA. A and B violate confidentiality, and C is incorrect as multiple laws protect privacy.

Extract:

Patient with edema has a problem of fluid overload

Question 3 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:

Patient reporting moderate to severe pain

Question 4 of 5

A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (select all that apply)

A. Repeat the details of the prescription back to the providerB. Record the reason for the call made to the provider and the results of the call in the Nurses NotesC. Tell the charge nurse that the provider has prescribed morphine by telephoneD. Refuse to accept the verbal prescription because this is not an emergency

Correct Answer: A,B

Rationale: A: Repeating the prescription ensures accuracy via read-back verification. B: Documenting the call's reason and outcome is essential for legal records. C is good practice but not required, and D is incorrect as verbal orders can be accepted with proper protocol.

Extract:

Patient with a nursing diagnosis of airway clearance, ineffective

Question 5 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.

ATI LPN Critical Thinking Exam | Nurselytic

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