LVN Documentation and Communication 3

Question 1

An LVN witnesses a patient fall in the hallway. After ensuring patient safety, what is the NEXT priority documentation action?

Accepted Answer

File an incident/occurrence report and document in the chart separately

Answer

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?

Accepted Answer

Current vital signs, significant changes, and pending orders

Answer

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?

Accepted Answer

Write the order, read it back to the physician for confirmation, then carry it out

Answer

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?

Accepted Answer

Situation, Background, Assessment, Recommendation

Answer

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?

Accepted Answer

Writing 'Late Entry' with the current date/time and the time the event occurred

Answer

Late entries must be labeled 'Late Entry' with the actual time of writing and the original time of the event to maintain accuracy.

(LVN) Licensed Vocational Nurse Practice Test

(LVN) Licensed Vocational Nurse Practice Test

LVN Documentation and Communication 3