Practice
Section: THE LPN/VN’S ROLE AND THE NURSING PROCESS
Stem: An LPN is reviewing the nursing process as it applies to
medication administration. Which action by the LPN best
represents the implementation phase for a patient prescribed a
new antihypertensive medication?
Options:
A) Noting the patient's baseline blood pressure before the first
dose.
B) Creating a plan to teach the patient about potential side
effects.
C) Administering the medication to the patient with a full glass
of water.
D) Asking the patient two hours later if they feel dizzy or
lightheaded.
Correct Answer: C
Rationale: C is correct because implementation involves the
actual execution of the nursing care plan, which includes
administering medications as prescribed. A represents
assessment, B represents planning, and D represents
evaluation. The LPN's role in implementation is crucial and
within their scope of practice for medication administration.
,Teaching Point: Implementation is the "doing" phase of the
nursing process, where planned interventions are carried out.
2.
Chapter 1, Section: THE LPN/VN’S ROLE AND THE NURSING
PROCESS
Stem: During the planning phase of the nursing process for a
patient starting a new diuretic, which nursing action is most
appropriate for the LPN to perform under the direction of an
RN?
Options:
A) Independently set a goal for the patient to have a weight loss
of 2 kg in 24 hours.
B) Formulate a nursing diagnosis of "Deficient Fluid Volume."
C) Reinforce the RN's teaching plan about monitoring daily
weights at home.
D) Evaluate the patient's understanding of the need for
potassium-rich foods.
Correct Answer: C
Rationale: C is correct. LPNs participate in the planning phase
by reinforcing the teaching plan developed by the RN or
provider. A and B are actions that require the advanced
assessment and diagnostic skills of an RN. D is part of the
evaluation phase, not planning.
Teaching Point: LPNs contribute to the planning phase by
assisting with and reinforcing the established plan of care.
, 3.
Chapter 1, Section: THE LPN/VN’S ROLE AND THE NURSING
PROCESS
Stem: An LPN is responsible for collecting data during the
assessment phase for a patient receiving an opioid analgesic.
Which finding is the priority for the LPN to report immediately
to the RN?
Options:
A) The patient reports a pain level of 6 out of 10.
B) The patient's respiratory rate is 8 breaths per minute.
C) The patient states they are feeling mildly nauseated.
D) The patient's blood pressure is 110/70 mm Hg.
Correct Answer: B
Rationale: B is correct. A respiratory rate of 8 breaths/minute is
a sign of significant respiratory depression, a life-threatening
adverse effect of opioids, and requires immediate intervention.
While A and C are important to report, they are not
immediately life-threatening. D is a normal finding.
Teaching Point: Assessing for and reporting respiratory
depression is a critical safety priority when a patient is receiving
opioid analgesics.
4.
Chapter 1, Section: THE LPN/VN’S ROLE AND THE NURSING
PROCESS
Stem: Which task is typically outside the scope of practice for
an LPN regarding medication administration?
Options: