Uncategorized LVN Safe and Effective Care Environment 1 — Questions and Answers
Question 1: A nurse is caring for a patient who refuses a prescribed medication. What is the most appropriate initial action?
- Administer the medication anyway to ensure patient safety
- Document the refusal and notify the physician (Correct answer)
- Contact the patient's family to persuade them
- Discontinue the medication from the care plan
Correct answer: Document the refusal and notify the physician
Patients have the right to refuse treatment. The nurse must respect this right, document the refusal thoroughly, and notify the physician so the care plan can be adjusted appropriately.
Question 2: When applying restraints to a patient, how often must the nurse reassess the patient and document the findings?
- Every 30 minutes
- Every 1–2 hours (Correct answer)
- Every 4 hours
- Every 8 hours
Correct answer: Every 1–2 hours
Restrained patients must be reassessed at least every 1–2 hours to check circulation, skin integrity, comfort, and the continued need for restraints to prevent complications.
Question 3: A nurse notices a colleague documenting care that was not performed. What is the most appropriate action?
- Ignore it, as it is not the nurse's responsibility
- Confront the colleague privately and report to the charge nurse or supervisor (Correct answer)
- Alter the documentation to reflect what was actually done
- Discuss the situation with other staff members first
Correct answer: Confront the colleague privately and report to the charge nurse or supervisor
Falsifying medical records is illegal and unethical. The nurse has a professional and legal obligation to address the issue by speaking with the colleague and reporting it through the proper chain of command.
Question 4: Which nursing action best prevents a urinary catheter-associated infection (CAUTI)?
- Irrigating the catheter daily with saline
- Maintaining the drainage bag above the level of the bladder
- Using aseptic technique during insertion and keeping the system closed (Correct answer)
- Changing the catheter every 48 hours
Correct answer: Using aseptic technique during insertion and keeping the system closed
Strict aseptic technique during insertion and maintaining a closed drainage system are the most effective measures for preventing CAUTI by minimizing pathogen entry into the urinary tract.
Question 5: A nurse is preparing to administer a blood transfusion. Which action must be completed immediately before starting the infusion?
- Take the patient's temperature only
- Have the patient sign a refusal form
- Verify the blood product with another licensed nurse at the bedside (Correct answer)
- Flush the IV line with dextrose solution
Correct answer: Verify the blood product with another licensed nurse at the bedside
Before initiating a transfusion, two licensed nurses must independently verify the blood product, patient identification, blood type, and expiration date at the bedside to prevent a potentially fatal transfusion reaction.
Question 6: A patient is found lying on the floor after a fall. After ensuring the patient's safety, what is the nurse's next priority action?
- Help the patient back to bed immediately without assessment
- Notify the physician and complete an incident report (Correct answer)
- Inform the family before documenting anything
- Reassign the patient to another nurse
Correct answer: Notify the physician and complete an incident report
After stabilizing the patient, the nurse must notify the physician of the fall and complete an incident report to document the event, ensure proper follow-up care, and support facility quality improvement efforts.
Uncategorized LVN Safe and Effective Care Environment 1
A nurse is caring for a patient who refuses a prescribed medication.
What is the most appropriate initial action?