Nursing Process in LPN Practice
Stem: A 72-year-old resident is scheduled to receive his
morning antihypertensive. During assessment the LPN notes
the resident’s blood pressure is 88/54 mm Hg and heart rate is
48 bpm. Which action best reflects use of the clinical judgment
model before giving the drug?
Options:
A. Administer the medication because it’s scheduled and
document afterwards.
B. Hold the medication and notify the supervising nurse or
prescriber.
C. Give half the dose and monitor vital signs every 15 minutes.
D. Withhold medication only if the patient complains of
dizziness.
Correct Answer: B
Rationales:
Correct: Holding the medication and notifying the supervising
nurse/prescriber follows cue recognition and seeking help when
patient data indicate potential harm from drug administration;
it prioritizes safety.
A: Incorrect — Following schedule without reassessment
ignores current cues and risks adverse effects from
hypotension/bradycardia.
C: Incorrect — Arbitrary dose reduction is not within typical LPN
,scope and may still cause harm; prescriber guidance is required.
D: Incorrect — Absence of subjective dizziness does not make
administration safe when objective hypotension/bradycardia
exists.
Teaching Point: Always integrate assessment cues and consult
when drug administration may harm the patient.
2.
Chapter Reference: Chapter 1 — Pharmacology and the Nursing
Process in LPN Practice
Section: THE LPN/VN’S ROLE AND THE NURSING PROCESS —
USING THE CLINICAL JUDGMENT MODEL
Stem: The LPN prepares to administer a new antibiotic. Which
assessment question best addresses safe drug administration?
Options:
A. “Do you prefer pills or liquids?”
B. “Do you have any allergies to medications or foods?”
C. “How tall are you?”
D. “Did you eat breakfast today?”
Correct Answer: B
Rationales:
Correct: Asking about allergies identifies a major
contraindication or risk for allergic reaction to many antibiotics
and is essential before administration.
, A: Incorrect — Formulation preference is secondary to safety
and may not be clinically necessary.
C: Incorrect — Height alone rarely impacts routine antibiotic
dosing for adults.
D: Incorrect — While food may affect absorption for some
drugs, allergies are a priority safety assessment.
Teaching Point: Always assess for allergies before administering
medications.
3.
Chapter Reference: Chapter 1 — Pharmacology and the Nursing
Process in LPN Practice
Section: THE LPN/VN’S ROLE AND THE NURSING PROCESS —
USING THE CLINICAL JUDGMENT MODEL
Stem: An LPN is using the nursing process to teach a patient
about a newly prescribed warfarin regimen. Which nursing
statement best reflects appropriate teaching under the nursing
process?
Options:
A. “Take this twice daily and don’t worry about diet.”
B. “Avoid green leafy vegetables and report any unusual
bleeding.”
C. “You’ll be fine; warfarin rarely causes problems.”
D. “Double the dose if you miss a dose the next day.”
Correct Answer: B