Prioritization & Assessment
When a patient has both wheezes and an elevated respiratory rate, which finding is more concerning and should be prioritized?
What is an elevated respiratory rate? (The respiratory rate indicates the severity of respiratory distress more than wheezes)
These three nursing tasks can be delegated to a CNA.
What is hygiene, I&O (intake and output), vital signs, bathroom assistance, and/or daily weights? (Accept any 3)
When a patient has EKG changes and reports shortness of breath, state the priority action using the ABC approach.
What is give oxygen (Airway/Breathing takes priority)?
This corticosteroid medication can cause blood glucose levels to increase.
What is prednisone?
This screening test should be performed for male patients over age 50 to check for prostate issues.
What is PSA (Prostate-Specific Antigen)?
A patient has an SpO2 of 87%, BP of 88/52, and blood glucose of 65 mg/dL. Name the priority interventions for each abnormal finding.
What is: give O2 for low SpO2, give IV fluids for low BP, and give sugar/glucose for low blood glucose?
An LVN can administer medications via these three routes.
What is IM (intramuscular), SQ (subcutaneous), and PO (by mouth)?
This lab value is a marker for heart failure and would be elevated in a patient with HF exacerbation.
What is BNP (B-type Natriuretic Peptide)?
Before administering polystyrene sulfonate (Kayexalate), you must perform this physical assessment.
What is bowel sounds/abdominal assessment? (Kayexalate works in the GI tract and shouldn't be given if there's a bowel obstruction)
After a hip replacement surgery, patients should not bend over more than this many degrees.
What is 90 degrees? (Should not flex hip beyond 90 degrees)
This physical assessment technique involves grasping a fold of skin on the back of the forearm or sternal area with fingertips and releasing it to check fluid status.
What is skin turgor assessment?
These four critical nursing actions can ONLY be performed by an RN, not an LVN or CNA.
What is teach, assess, evaluate, and determine? (also accept: IVP meds and administer blood products)
Before administering Lasix (furosemide), you should check this specific lab value.
What is a potassium level (and possibly sodium)? (Lasix causes potassium loss)
This medication regimen is used to treat peptic ulcer disease caused by Helicobacter pylori.
What is therapy consisting of antibiotics (such as amoxicillin, clarithromycin, or metronidazole) plus a proton pump inhibitor (PPI)?
In the semi-restricted area of the surgical suite, staff must wear these items of protective attire.
What is scrubs, hair net (or cap), shoe covers, and mask?
A patient reports 10 loose stools in 24 hours. Name the two major complications you should assess for immediately.
What is dehydration and electrolyte imbalance?
True or False: An LVN can teach a patient how to change their wound dressing if the LVN has been taught this skill themselves.
What is True? (LVNs can teach what they have been taught, such as wound care, medication administration, and eye drops)
A patient with peripheral artery disease (PAD) would have this capillary refill assessment finding.
What is prolonged capillary refill (greater than 3 seconds)?
A patient with a CVA (stroke) is taking aspirin. Name at least two key teaching points about this medication.
What is: don't stop taking it, take with food to reduce GI upset, watch for signs of bleeding, avoid other NSAIDs, report unusual bruising? (Accept any 2 appropriate teaching points)
A stroke patient can understand what you say and follow commands, but when they try to speak, their words come out garbled. This is called this type of aphasia.
What is expressive aphasia (or Broca's aphasia)?
You assess a patient and hear crackles in the lung bases. This can be a sign of this fluid balance disorder.
What is FVE (Fluid Volume Excess)?
A stable diabetic patient needs insulin administration and education about a new blood glucose monitoring technique they've never done before. Explain how you would delegate these two tasks.
What is: The LVN can administer the insulin, but the RN must provide the teaching about the NEW technique because it involves initial patient education/assessment?
Explain the difference between peripheral artery disease (PAD) and peripheral venous disease (PVD) in terms of blood flow problem.
What is: PAD is inadequate arterial blood flow TO the extremities (ischemia), while PVD is inadequate venous return FROM the extremities (congestion)?
A patient stops taking prednisone abruptly after taking it for several months. Name at least 2 signs/symptoms of adrenal crisis that may occur.
What is fever, elevated potassium (hyperkalemia), hypotension, tachycardia, hypoglycemia, weakness, and/or confusion? (Accept any 2)
Hypotension is d/t decreased aldosterone (Na+/water) and cortisol (vasoconstriction)
For a patient with kidney stones experiencing 10/10 flank pain, this is the priority nursing intervention.
What is pain management? (Pain control is the priority for kidney stone patients as the pain is severe and can cause additional complications)