LVN Documentation and Communication 3 — Questions and Answers
Question 1: An LVN witnesses a patient fall in the hallway. After ensuring patient safety, what is the NEXT priority documentation action?
- Complete a nursing note in the chart only
- File an incident/occurrence report and document in the chart separately (Correct answer)
- Ask another nurse to document the event
- Wait until end of shift to document
Correct answer: File an incident/occurrence report and document in the chart separately
An incident report (occurrence report) must be filed separately from the chart, and the event is also documented in the nursing notes.
Question 2: During change-of-shift report, which information is most critical for the oncoming nurse to receive?
- The patient's insurance information
- Current vital signs, significant changes, and pending orders (Correct answer)
- Housekeeping requests for the room
- Dietary preferences from the previous week
Correct answer: Current vital signs, significant changes, and pending orders
Change-of-shift report must include current clinical status, significant changes, and any pending or new orders to ensure continuity of care.
Question 3: A physician gives the LVN a verbal order over the phone. What is the correct procedure?
- Carry out the order immediately and document it later
- Write the order, read it back to the physician for confirmation, then carry it out (Correct answer)
- Refuse verbal orders and request a written order only
- Have another nurse listen and co-sign the verbal order before acting
Correct answer: Write the order, read it back to the physician for confirmation, then carry it out
Verbal orders require a read-back verification to confirm accuracy before implementation, then must be signed by the physician within facility-defined timeframes.
Question 4: The SBAR communication tool stands for which of the following?
- Situation, Background, Assessment, Recommendation (Correct answer)
- Subject, Brief, Action, Result
- Status, Background, Assessment, Report
- Situation, Brief, Analysis, Response
Correct answer: Situation, Background, Assessment, Recommendation
SBAR stands for Situation, Background, Assessment, Recommendation — a structured format for clinical handoffs and escalations.
Question 5: Which entry demonstrates appropriate late-entry documentation in a patient's chart?
- Inserting the note between earlier entries as if written on time
- Writing 'Late Entry' with the current date/time and the time the event occurred (Correct answer)
- Backdating the entry to match when the event occurred
- Asking a colleague to sign the late entry as if they were present
Correct answer: Writing 'Late Entry' with the current date/time and the time the event occurred
Late entries must be labeled 'Late Entry' with the actual time of writing and the original time of the event to maintain accuracy.
Question 6: An LVN notices a pattern of a patient's blood pressure readings trending upward over several shifts. The most appropriate communication action is to:
- Document only in the flow sheet and say nothing
- Continue monitoring and report at the end of the week
- Notify the charge nurse and document the trend and notification (Correct answer)
- Wait for the physician to review the chart independently
Correct answer: Notify the charge nurse and document the trend and notification
Trending vital signs that may indicate deterioration must be reported promptly to the charge nurse, with documentation of the pattern and the communication.
Question 7: Which of the following is NOT appropriate to include in an incident report?
- Time and location of the incident
- Names of witnesses
- Opinion about whose fault the incident was (Correct answer)
- Description of what was observed
Correct answer: Opinion about whose fault the incident was
Incident reports should contain factual information only — opinions, blame, or assumptions about fault are inappropriate and potentially harmful.
LVN Documentation and Communication 3
An LVN witnesses a patient fall in the hallway.
After ensuring patient safety, what is the NEXT priority documentation action?