Documentation and Reporting

1. At the rehabilitation unit, an LPN visits a patient who has just returned from his physiotherapy session. It is 10 am, and the patient is discouraged and in tears. He says he will never be able to get through life with only one leg. Two weeks ago, his left leg was amputated just above the knee as a result of diabetes. The patient says that his leg is very sore and rates his pain at 8/10. He says he feels a stinging sensation, as if he has needles under his bandage and in the thigh. He says he has been feeling this way ever since he woke up this morning, but the pain has gotten worse since going to physiotherapy. He refuses to look at his leg and wants to stay in his chair. He also grimaces at every movement. The elastic bandage at the stump is clean.
Which of the following progress notes meets the requirements for describing pain caused by amputation? *
2. A beneficiary from the prosthetics unit is very agitated at lunchtime. She constantly gets out of her chair follows LPN everywhere and speaks loudly. She yelled another beneficiary to shut up until another to stop looking at her she repeatedly shouts “Mom! Mom!”. She also wants to have her coat and calls and LPN a “big fat idiot”. At 1 PM the beneficiaries, and smiling she is rocking chair in her room.
Which of the following progress notes meets the requirements for describing of behavioral follow-up? *
3. A paraplegic patient has a long at the top of her left foot. The patient says she feels a burning sensation while the dressing is being changed. The LPN changes the dressing which was soiled at 25% with clear liquid, she estimates her pain 6/10. he LPN wraps the new dressing according to the instructions in the TNP. She then goes to the workstation to write her progress note. Which of the following progress notes meet the requirements for describing wound care? *
4. A 38-year-old man is hospitalized in the surgery unit to treat an pneumothorax caused by falling in his shower. He has two broken ribs on his right side. He receives 02 at 1 L/minute via nasal cannula as well as a solution of 5% dextrose and 0.45% NACL at 80 ml/hour. he also has a chest drain on his right side. The LPN makes her first round and upstairs at the dressing at the side of the chest drain is clean. There is no liquid in the drain circuit. The patient says that the skin under his right armpit is soft and swollen and that he hears the crackling sound when he presses his fingers on the swollen skin. The LPN delineates the swollen part of using a pen. The patient asked the LPN when he can go outside to smoke. Which of the following problems notes and meets the requirements for describing information related to a chest drain? *
5. A 76-year-old woman is hospitalized after falling on the outside staircase of the residence. She has a fracture in her right hip arthroplasty is plan for the next day the patient is diabetic, and is receiving a solution of 5% Dextros and 0.45% NaCl by pump at 80ml/hr. At 5 AM, she receives a dose of narcotic analgesic, which provides relief.
At 5:30 am, the LPN monitors the patient’s vital signs and her capillary blood glucose. The results are as follows: BP at 110/70, pulse at 88 bpm, RR 16bpm, SpO2 97% and blood glucose at 4.3 mmol/L. The LPN completes her night shift at the surgery unit and informs the RN of the patient’s condition. What is the most important information that should be given to the RN before leaving the unit? *
6. A 37-year-old patient is admitted to the psychiatric unit for depression with suicidal thoughts. Her martial situation is difficult. The patient says that her husband does not look after her and that he spends their money without consulting her, even though he is currently unemployed and she is a stay-at-home mother of four-year- old, a two-and-a-half year old and a ten-month-old. She would like to take couples therapy sessions with her husband, but he refuses. While speaking to the LPN, the patient says that before calling the friend who brought her to the hospital, she had thrown a tantrum in the shower. She says that she shouted so much, she developed a sore throat. Her throat feels a bit better today, but she does not give more information. The patient says that when she was at home, she noticed many sharp objects and became afraid of what she could do. She says that she understands why some mothers kill their children and take their own lives. She admires them and wishes she had the courage to be like them. She says she feels safe in the hospital, but knows that she can’t stay there forever and will eventually have to leave. Which of the following notes describe the situation accurately and clearly to the physician? *
7. A patient has been hospitalized for four days because his diabetes is unbalanced. He has a wound on the first toe of his left foot and on the outer malleolus of his right foot. The dressings are clean and in place. Le LPN wonders if she needs to replace the dressing today. Which of the following documents should be consulted before applying a dressing? *
8. At the CLSC, a woman must receive a vaccine prescribed by her physician, as she plans to take a trip abroad soon. The LPN prepares to administer the prescription in the presence of an RN. Which of the following document should be consulted before administering the vaccine? *
9. An LPN has just taken a blood glucose measurement for a hospitalized surgery patient. The patient has insulin- dependent diabetes, and the endocrinologist has just prescribed a QID adjustment protocol. Which of the following documents should be consulted before preparing the insulin? *
10. An LPN who has just begun her 8:30 am shift is about to administer an inter-dose injection of opioid analgesic to a young boy in palliative care. Which of the following documents should be consulted before preparing the opioid analgesic? *