Patient Care Fundamentals Flashcards

Which patient is at highest risk for a fall and should be the LVN's priority for a fall prevention intervention?

Answer: A 72-year-old on diuretics and antihypertensives with a recent fall history

Older age, polypharmacy with diuretics and antihypertensives, and a recent fall history are major compounding risk factors for falls.

Before applying a physical restraint, which action is the LVN's highest priority?

Answer: Ensure a valid physician or provider order exists

Physical restraints require a valid provider order before application; this is a legal and regulatory requirement.

A patient in wrist restraints should be assessed and the restraints released for how long at minimum every 2 hours?

Answer: 10 minutes

Restraints should be released for at least 10 minutes every 2 hours to provide skin care, ROM exercises, and assess circulation.

A patient calls out that their IV site is swollen and painful. The LVN assesses cool, pale skin around the insertion site. This finding indicates:

Answer: Infiltration

Infiltration occurs when IV fluid leaks into surrounding tissue, causing swelling, pallor, and coolness at the site.

The LVN enters a room and finds a patient unresponsive. After calling for help and activating the emergency response system, what is the next step?

Answer: Check for a carotid pulse for up to 10 seconds

After activating the emergency response, the next step per basic life support protocol is to check for a carotid pulse for no more than 10 seconds.

Which safety device should always be within the patient's reach while they are in the hospital bed?

Answer: The call light

The call light must always be within patient reach to allow them to summon help quickly in an emergency.

A patient's serum potassium level returns at 2.9 mEq/L. The LVN should prioritize monitoring for which complication?

Answer: Cardiac dysrhythmias

Hypokalemia (K+ < 3.5 mEq/L) increases myocardial irritability and can cause life-threatening cardiac dysrhythmias.