Nokea
Your patient has severe peripheral vascular disease (poor circulation) in both lower extremities. You document that the patient's pedal pulses are absent. Which assessment technique did you use to obtain these data?
- A. Inspection
- B. Palpation
- C. Auscultation
- D. Percussion
Correct Answer: B
Rationale: Palpation is used to feel for pedal pulses, determining their presence or absence.
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You have passed your NCLEX-PN examination and have just been employed as an LPN on a medical surgical unit. The registered nurse (RN) in charge asks you to do the admission assessment on a new patient who has just arrived by ambulance from a long-term care facility. The patient had undergone a total hip replacement within the previous 2 weeks and has developed a fever. You tell the nurse you thought an LPN could not do the admission assessment or, at most, could do only certain portions of it. The nurse, who is very busy, says, 'Please just do it. I'll cosign it, so it will be fine.' Which of the following actions should you take next?
- A. Call the supervisor to discuss the nurse's instructions to you.
- B. Refuse to do the admission assessment but offer to get the patient settled in, take his vital signs, and review the chart for orders.
- C. Check the facility's policy manual.
- D. Do the assessment as requested.
Correct Answer: B,C
Rationale: Checking the facility's policy manual (C) ensures you act within your scope of practice. Refusing to do the admission assessment but offering to perform tasks within your role (B) is appropriate, as LPNs typically cannot perform initial admission assessments, which are reserved for RNs.
Implementation means putting the plan into action and performing the interventions.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Implementation involves executing the planned nursing interventions to achieve patient goals.
Nursing diagnoses and medical diagnoses both use the names of diseases.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. Nursing diagnoses focus on patient responses to health conditions, not disease names, which are used in medical diagnoses.
In which step of the nursing process do you label problems?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: B
Rationale: Diagnosis is the step where nurses analyze assessment data to identify and label patient problems as nursing diagnoses.
Improvement in a patient's health problem is measured by how much progress the patient makes toward the goal, which is set by the nurse.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. Goals are set collaboratively with the patient, not solely by the nurse, to ensure patient-centered care.