,Chapter 01 — Pharmacology and the
Nursing Process in LPN Practice
Stem: A 72-year-old patient receiving a new antihypertensive
complains of dizziness when standing. The LPN/VN notes a
blood pressure of 100/60 mm Hg and heart rate 62. Which
action best reflects the LPN/VN applying the interpret phase of
the Clinical Judgment Model?
A. Administer a PRN dose of IV fluids.
B. Instruct the patient to change positions slowly and reassess
blood pressure.
C. Call the prescriber to hold the antihypertensive and request a
new order.
D. Document the blood pressure and leave the patient to rest.
Correct Answer: B
Rationales:
• Correct: B — In the interpret phase, the nurse links
assessment data (dizziness, low BP on antihypertensive) to
probable orthostatic effects and implements immediate,
evidence-based safety measures (slow position changes)
while continuing assessment. This intervention addresses
risk without unilateral medication changes.
• A incorrect: Administering IV fluids is an invasive
intervention that requires assessment of volume status
, and typically a prescriber's order; it bypasses less invasive
nursing actions.
• C incorrect: Calling the prescriber to hold medication may
be appropriate later, but doing so immediately without
first implementing safety measures and rechecking vitals
skips nursing clinical judgment steps.
• D incorrect: Simply documenting and leaving the patient
neglects immediate safety interventions and ongoing
interpretation of the data.
Teaching Point: Always implement immediate safety measures
while interpreting assessment data.
2.
Chapter 1 — The LPN/VN’s Role and the Nursing Process —
Using the Clinical Judgment Model
Stem: An LPN/VN is about to administer a new oral antibiotic.
Which of the following best demonstrates the notice (first) step
of the Clinical Judgment Model?
A. Confirming allergy status in the chart before medication
administration.
B. Pouroff the medication into a cup and provide to the patient.
C. Assessing the patient’s ability to swallow after giving the
medication.
D. Calling the pharmacist to verify the dose before
administration.
, Correct Answer: A
Rationales:
• Correct: A — Notice requires recognizing relevant cues
from the patient’s history; confirming allergy status is a
primary cue that must be identified before giving any
antibiotic.
• B incorrect: Pouring medication is an action of
administration, not the initial noticing of cues.
• C incorrect: Assessing swallowing after administration is
too late — swallowing ability should be assessed before
giving the medication.
• D incorrect: Verifying dose with pharmacy can be
appropriate but comes after noticing potential issues and
is not the primary notice cue (allergies).
Teaching Point: Always identify critical patient cues (e.g.,
allergies) before medication administration.
3.
Chapter 1 — The LPN/VN’s Role and the Nursing Process —
Using the Clinical Judgment Model
Stem: A patient on warfarin reports new bruising and dark
stools. The LPN/VN’s best next action that aligns with
responding in the Clinical Judgment Model is to:
A. Double the patient’s vitamin K intake.
Nursing Process in LPN Practice
Stem: A 72-year-old patient receiving a new antihypertensive
complains of dizziness when standing. The LPN/VN notes a
blood pressure of 100/60 mm Hg and heart rate 62. Which
action best reflects the LPN/VN applying the interpret phase of
the Clinical Judgment Model?
A. Administer a PRN dose of IV fluids.
B. Instruct the patient to change positions slowly and reassess
blood pressure.
C. Call the prescriber to hold the antihypertensive and request a
new order.
D. Document the blood pressure and leave the patient to rest.
Correct Answer: B
Rationales:
• Correct: B — In the interpret phase, the nurse links
assessment data (dizziness, low BP on antihypertensive) to
probable orthostatic effects and implements immediate,
evidence-based safety measures (slow position changes)
while continuing assessment. This intervention addresses
risk without unilateral medication changes.
• A incorrect: Administering IV fluids is an invasive
intervention that requires assessment of volume status
, and typically a prescriber's order; it bypasses less invasive
nursing actions.
• C incorrect: Calling the prescriber to hold medication may
be appropriate later, but doing so immediately without
first implementing safety measures and rechecking vitals
skips nursing clinical judgment steps.
• D incorrect: Simply documenting and leaving the patient
neglects immediate safety interventions and ongoing
interpretation of the data.
Teaching Point: Always implement immediate safety measures
while interpreting assessment data.
2.
Chapter 1 — The LPN/VN’s Role and the Nursing Process —
Using the Clinical Judgment Model
Stem: An LPN/VN is about to administer a new oral antibiotic.
Which of the following best demonstrates the notice (first) step
of the Clinical Judgment Model?
A. Confirming allergy status in the chart before medication
administration.
B. Pouroff the medication into a cup and provide to the patient.
C. Assessing the patient’s ability to swallow after giving the
medication.
D. Calling the pharmacist to verify the dose before
administration.
, Correct Answer: A
Rationales:
• Correct: A — Notice requires recognizing relevant cues
from the patient’s history; confirming allergy status is a
primary cue that must be identified before giving any
antibiotic.
• B incorrect: Pouring medication is an action of
administration, not the initial noticing of cues.
• C incorrect: Assessing swallowing after administration is
too late — swallowing ability should be assessed before
giving the medication.
• D incorrect: Verifying dose with pharmacy can be
appropriate but comes after noticing potential issues and
is not the primary notice cue (allergies).
Teaching Point: Always identify critical patient cues (e.g.,
allergies) before medication administration.
3.
Chapter 1 — The LPN/VN’s Role and the Nursing Process —
Using the Clinical Judgment Model
Stem: A patient on warfarin reports new bruising and dark
stools. The LPN/VN’s best next action that aligns with
responding in the Clinical Judgment Model is to:
A. Double the patient’s vitamin K intake.
