Applying LPN/LVN Standards in Medical-Surgical Nursing: Chapter 2, Critical Thinking and the Nursing Process: Sherpath

Question 1 of 6

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Which finding would the licensed practical/vocational nurse (LPN/LVN) obtain through inspection of the patient?

• Correct
  • The patient’s hair is dirty.Inspection involves looking during data collection. By looking at the patient, the nurse would see that the patient’s hair is dirty.
• • The patient’s skin is clammy.Clammy skin would be noted during palpation.
• • The patient’s heartbeat is abnormal.The patient’s abnormal heart rhythm would be noted during auscultation.
• • The patient’s breath has an odor of alcohol.The nurse would use the olfactory sense to note the odor of alcohol.

Question 2 of 6

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For medications requiring auscultation of the apical pulse to ensure safe medication administration, in which area would the nurse place the stethoscope’s diaphragm to obtain the patient’s apical pulse?

• • At the sternal borderThe sternal border is not in the mitral area, where the apical pulse is auscultated.
• Correct
  • At the apex of the heartThe nurse would place the stethoscope at the apex of the heart to listen to the apical pulse.
• • At the base of the heartThe base of the heart is in the upper chest, just below the clavicle.
• • At the center of the chestThe center of the chest is not in the mitral area, where the apical pulse is auscultated.

Question 3 of 6

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Which source would the licensed practical/vocational nurse (LPN/LVN) use to determine whether the patient’s prescribed medication is new to the patient?

• • The admission physical assessmentThe admission physical assessment provides subjective and objective information about the patient’s physical condition. It does not provide a list of home or previous medications.
• • The beginning of shift physical assessmentThe beginning of shift physical assessment supports the admission assessment, demonstrating progress toward outcomes or changes since admission. It does not provide historical information for medications.
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  • The history and physicalThe history and physical provide reasons for admission, home medications, past hospitalizations, and lab or radiology results, for example. The nurse could determine if a prescribed medication is new to the patient by reviewing this content.
• • The face sheetThe face sheet provides demographic data, such as home address, date of birth, insurance, and marital status. It does not provide a list of home or historical medications.

Question 4 of 6

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Which statement demonstrates a nursing intervention for the patient whose primary problem is a urinary tract infection?

• • The patient did not report pain with urination between 0700 and 1300.The patient not reporting pain with urination between the hours of 0700 and 1300 is an assessment finding rather than a nursing intervention.
• Correct
  • Encourage the patient to drink additional fluid during each shift.Encouraging the patient to drink additional fluid during each shift is a nursing intervention.
• • The patient will not report urinary frequency after 3 days of treatment.The patient will not report urinary frequency after 3 days of treatment is an outcome. It states a specific expectation rather than an action the nurse will take to achieve a patient outcome.
• • Urinary tract infections are caused by bacterial growth causing irritation.Urinary tract infections are caused by bacterial growth causing irritation is an example of rationale or pathophysiology, which forms the basis for interventions, outcomes, and assessments. It is not a nursing intervention.

Question 5 of 6

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Which statement demonstrates a patient outcome with expected characteristics when developed by the nurse and patient?

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  • The patient will report pain at or below level 2 with pain medication at the end of the shift.This statement includes patient centeredness, is measurable, and includes a time frame.
• • The patient will report nausea to the nurse and request medication.This statement lacks a time frame and is not clearly measurable; it is patient centered.
• • The nurse will tell the patient their blood sugar results within 1 hour.This statement is measurable and includes a time frame; however, it is not patient centered. The outcome is for the nurse, not the patient.
• • The patient will independently walk in the hallway by day 3 postoperatively.This statement is not clearly measurable; it does include a time frame and is patient centered.

Question 6 of 6

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Based on Maslow’s hierarchy of needs, which nursing intervention would the licensed practical/vocational nurse (LPN/LVN) prioritize during patient care?

• • Promote privacy for family and friends to visit.Promoting privacy for family and friends to visit encourages love and belonging. According to Maslow’s hierarchy, this is not the first priority. Safety is the first priority.
• Correct
  • Implement fall precautions according to policy.Implementing fall precautions maintains the patient’s safety, which is a physiologic need. Safety is the first priority according to Maslow’s hierarchy of needs.
• • Encourage the patient to complete their own bath.Encouraging the patient to complete their own bath promotes self-esteem. Self-esteem, according to Maslow’s hierarchy of needs, is not the first priority. Safety is the first priority.
• • Teach the patient to manage their own medications.Teaching the patient to manage their own medications addresses the patient’s self-esteem. Self-esteem, according to Maslow’s hierarchy of needs, is not the first priority. Safety is the first priority.