EXAM 2 LVN FUNDAMENTALS
QUESTIONS AND ANSWERS GRADED
A+
Following the gathering of subjective and objective data, performing a health history and a
physical assessment, the nurse sets up a plan of care. What is the first step to identify the
problem? - ANS ✔✔Patient problem
The patient problem is the title or label given to an identified problem and is the first step in a
patient's plan of care. A medical diagnosis is the problem identified by the health care provider
upon admission. Nursing intervention is the action used to meet the goal of the plan of care.
Evaluation is the last step in the plan of care to see if the interventions are working or need to
be changed.
A patient is admitted to the hospital with a sacral wound that has a foul odor, purulent drainage,
and necrotic tissue in the center. It measures 4 cm in circumference by 2 cm deep. What is the
most appropriate patient problem? - ANS ✔✔Impaired skin integrity.
The collected data all show that there is impaired skin integrity. The data show that an infection
is already present and so the diagnosis needs to be actual and not at risk for infection. More
data would need to be collected to know if the patient has pain. More assessment data would
need to be collected, so impaired peripheral circulation is not the most appropriate diagnosis at
this time.
The nurse reads the order: "Ambulate the patient three times a day at 0900, 1400, 1900 as
tolerated" and identifies this as what part of the nursing process? - ANS ✔✔Nurse-prescribed
intervention
This statement is an example of an intervention that has been made more specific to the
patient, which is a nurse-prescribed intervention. Nurse-prescribed interventions are any
, actions that a nurse is legally able to order or begin independently. A patient problem is a
NANDA-approved statement that identifies a specific problem. A patient goal is a statement that
includes what the patient needs to do to make changes in the problem. Evaluation is the review
of the plan of care to see what revisions are necessary to the plan of care.
Considering Maslow's hierarchy of needs, what would be the highest priority patient problem? -
ANS ✔✔Imbalanced nutrition
The lack of nutrition falls in the base of Maslow's hierarchy, therefore being of the highest
importance. Knowledge deficit is generally a result of another problem and falls in Maslow's
level of safety and security. Pain is a result of another problem and falls in Maslow's level of
safety and security. Whenever there is risk, it is not the main priority in the plan of care, but the
result of another problem.
A patient has returned from surgery and has a history of smoking. The nurse health care
provider has orders for the use of incentive spirometry (IS) every 2 hours. The patient asks why
he has to do IS so often. The nurse teaches the patient about the importance of breathing
deeply to clear any secretions and prevent pneumonia. What is this teaching an example of? -
ANS ✔✔Implementation of a nursing intervention
Teaching is the implementation of a nursing intervention or provider order. A patient problem is
an identified problem. An outcome statement is what you want to see your patient do or how
they improve. The nursing process is a 6-step process in which teaching is only one step.
What is the role of the licensed practical nurse in writing a patient problem? - ANS ✔✔To assist
with the determination of an accurate patient problem
The LPN/LVN is to work with the supervising RN to determine if the correct problem(s) have
been identified and are accurate.
QUESTIONS AND ANSWERS GRADED
A+
Following the gathering of subjective and objective data, performing a health history and a
physical assessment, the nurse sets up a plan of care. What is the first step to identify the
problem? - ANS ✔✔Patient problem
The patient problem is the title or label given to an identified problem and is the first step in a
patient's plan of care. A medical diagnosis is the problem identified by the health care provider
upon admission. Nursing intervention is the action used to meet the goal of the plan of care.
Evaluation is the last step in the plan of care to see if the interventions are working or need to
be changed.
A patient is admitted to the hospital with a sacral wound that has a foul odor, purulent drainage,
and necrotic tissue in the center. It measures 4 cm in circumference by 2 cm deep. What is the
most appropriate patient problem? - ANS ✔✔Impaired skin integrity.
The collected data all show that there is impaired skin integrity. The data show that an infection
is already present and so the diagnosis needs to be actual and not at risk for infection. More
data would need to be collected to know if the patient has pain. More assessment data would
need to be collected, so impaired peripheral circulation is not the most appropriate diagnosis at
this time.
The nurse reads the order: "Ambulate the patient three times a day at 0900, 1400, 1900 as
tolerated" and identifies this as what part of the nursing process? - ANS ✔✔Nurse-prescribed
intervention
This statement is an example of an intervention that has been made more specific to the
patient, which is a nurse-prescribed intervention. Nurse-prescribed interventions are any
, actions that a nurse is legally able to order or begin independently. A patient problem is a
NANDA-approved statement that identifies a specific problem. A patient goal is a statement that
includes what the patient needs to do to make changes in the problem. Evaluation is the review
of the plan of care to see what revisions are necessary to the plan of care.
Considering Maslow's hierarchy of needs, what would be the highest priority patient problem? -
ANS ✔✔Imbalanced nutrition
The lack of nutrition falls in the base of Maslow's hierarchy, therefore being of the highest
importance. Knowledge deficit is generally a result of another problem and falls in Maslow's
level of safety and security. Pain is a result of another problem and falls in Maslow's level of
safety and security. Whenever there is risk, it is not the main priority in the plan of care, but the
result of another problem.
A patient has returned from surgery and has a history of smoking. The nurse health care
provider has orders for the use of incentive spirometry (IS) every 2 hours. The patient asks why
he has to do IS so often. The nurse teaches the patient about the importance of breathing
deeply to clear any secretions and prevent pneumonia. What is this teaching an example of? -
ANS ✔✔Implementation of a nursing intervention
Teaching is the implementation of a nursing intervention or provider order. A patient problem is
an identified problem. An outcome statement is what you want to see your patient do or how
they improve. The nursing process is a 6-step process in which teaching is only one step.
What is the role of the licensed practical nurse in writing a patient problem? - ANS ✔✔To assist
with the determination of an accurate patient problem
The LPN/LVN is to work with the supervising RN to determine if the correct problem(s) have
been identified and are accurate.
