What do you report?
A patient’s blood pressure is 88/54. What do you do?
Report immediately. Do not proceed with routine care or give BP medication.
A patient’s pain is 5/10 and their Tylenol order says give if pain ≥4/10. Do you give it?
Yes — 5/10 meets the ≥4/10 threshold.
Name the 6 rights of medication administration.
Right patient, right drug, right dose, right route, right time, right documentation.
You gave Tylenol at 1800 for pain rated 5/10. At 1830 the patient rates pain at 2/10. How do you document this?
“Patient reported pain 5/10 at 1800. Acetaminophen 650 mg PO administered as ordered. Patient reports pain decreased to 2/10 at 1830.”
Name 3 environmental safety hazards you would correct before providing patient care.
Any 3: bed too high, call bell out of reach, clutter on floor, no non-skid socks, walker out of reach, spill on floor, curtain open.
You notice redness on your patient’s coccyx that does not turn white when you press it. What is this called and what do you do?
Stage 1 pressure injury. Report, reposition, apply barrier cream, document objectively.
Robert’s Amlodipine says hold if SBP <100. His BP is 88/54. Do you give it?
No — HOLD. SBP 88 is below the hold parameter of <100.
What are the components of an LPN head-to-toe assessment?
VS, pain, neuro/orientation, pupils, lung sounds, bowel sounds, skin, mobility, fall risk.
Is “Patient was uncooperative and difficult” acceptable nursing documentation?
No. Judgmental language. Use: “Patient verbalized refusal of care at 1800.”
What do you do if a patient tells you they are going to get up and you know they are a fall risk?
Stay close. Ask patient to wait. Call for help. Never leave them alone. Use fall precautions. Document
A patient’s blood glucose is 58 mg/dL. What is this and what do you do?
Hypoglycemia. Report immediately to the charge nurse before any other routine care.
A patient’s allergy is Penicillin. You are about to give Tylenol (acetaminophen). Is it safe?
Yes — Penicillin allergy does not contraindicate acetaminophen.
What does SBAR stand for and what is each component?
Situation, Background, Assessment, Recommendation.
You held a medication because the patient’s BP was below the hold parameter. What must your documentation include?
Medication name, dose, time due, VS obtained, hold parameter, reason for hold, who was notified, and their response.
What does restraint-free fall prevention look like in practice?
Non-skid socks, bed in lowest position, call bell within reach, patient coached to call before standing, clutter removed, assistive devices accessible.
Your patient has a heart rate of 112 and says they feel dizzy when standing. What do you report and what do you do first?
Report HR and dizziness. Keep patient seated or in bed. Do not attempt ambulation. Fall precautions.
A patient’s Metoprolol order says hold if HR <60. Their HR is 58. What do you do?
Hold the Metoprolol. Report to charge nurse. Document hold with reason and VS.
What is the correct sequence for repositioning a patient to prevent pressure injury?
Reposition to 30° lateral, place pillow between knees and behind back, apply barrier cream to at-risk areas, document and reassess.
A patient fell and was not injured. What must be in the nursing note?
Time, what patient was doing, how found, VS after, any injuries (state “no injuries noted”), who was notified, and patient’s response.
You are about to give a medication and you realize the patient’s ID band is missing. What do you do?
Stop. Do not give the medication. Find a second identifier (ask name and DOB). Replace the ID band. Document. Then proceed if identity confirmed.
Your patient ate less than 25% of their meal, has a blood glucose of 58, and says they feel shaky. Put these findings together and tell me your priority report
Hypoglycemia with poor oral intake. Report immediately. Follow protocol — do not leave patient alone.
You are about to give a daily antihypertensive. The patient says “I already took that pill this morning.” The MAR shows it was not signed off. What do you do?
Pause. Do not give. Check with the charge nurse or pharmacy. Never give a medication if there is uncertainty about whether it was already administered.
You are performing a head-to-toe and the patient’s lung sounds are diminished in the bases bilaterally. What does this potentially indicate and what do you do?
Could indicate atelectasis, fluid, or pneumonia. Report immediately. Note respiratory rate and SpO2. Position patient upright if safe.
A patient refuses a dressing change and signs a refusal form. What goes in the nursing note?
What care was offered, patient’s exact words (quoted), that refusal was explained and understood, any education provided, who was notified, and follow-up plan.
A patient on fall precautions is found standing at the bedside holding the side rail. No staff are present. Walk me through your response.
Approach calmly. Stay close. Guide patient back to bed if safe. Assess for injury. Lower bed. Place call bell within reach. Reinforce call-before-standing. Notify charge nurse. Document event and all interventions