LVN Documentation and Communication 2

Question 1

When documenting a patient's pain using the SOAP format, where would you record the patient's verbal report of pain severity?

Accepted Answer

Subjective

Answer

Subjective data includes information reported by the patient, such as their verbal description of pain.

Question 2

An LVN notes 'Pt. ambulated to BR without assistance' in the chart. Which documentation principle does this reflect?

Accepted Answer

Use of approved abbreviations and factual language

Answer

Documentation should use approved abbreviations and factual, observable language rather than interpretation.

Question 3

A physician's written order is illegible. What is the most appropriate action for the LVN?

Accepted Answer

Call the physician to clarify the order before proceeding

Answer

The LVN must contact the prescriber directly to clarify any illegible or unclear orders before carrying them out.

Question 4

Which of the following is an example of objective data to document in a patient's chart?

Accepted Answer

Blood pressure 148/92 mmHg

Answer

Objective data is measurable and observable; a specific blood pressure reading is a clear example.

Question 5

The LVN made a documentation error in a paper chart. What is the correct way to correct it?

Accepted Answer

Draw a single line through the error, write 'error,' initial, and date it

Answer

The correct method is a single line through the error with 'error,' the nurse's initials, and date — never obliterate original entries.

(LVN) Licensed Vocational Nurse Practice Test