Coordinated Care (LPN/LVN Scope): Practice Questions & Explanations

LPN/LVN scope of practice is more limited than RN scope. The RN is responsible for INITIAL assessments, developing care plans, and providing initial teaching. The LPN's role is to REINFORCE existing teaching, contribute to data collection, and provide care within established plans. Key LPN scope principles tested on NCLEX-PN: (1) Cannot perform initial assessments of unstable or complex clients (LPN can reassess stable clients); (2) Cannot create the initial nursing care plan (LPN contributes data, RN creates plan); (3) Cannot provide initial teaching (LPN reinforces RN's teaching); (4) Cannot administer IV push medications in most states (state-specific); (5) Cannot perform triage independently in most settings; (6) Cannot hang blood (in most states); (7) CAN administer most medications, perform routine procedures, monitor stable clients, reinforce teaching, document care. Scope varies by state — when in doubt on NCLEX-PN, choose the answer that keeps the LPN within the traditional supportive role under RN supervision.

Priority-setting questions are heavily tested on NCLEX-PN. Use the ABC framework: Airway, Breathing, Circulation. The client with new-onset shortness of breath and chest pain has potential airway/breathing/circulation compromise — this could be MI, PE, pulmonary edema, or another life-threatening emergency. This client is assessed FIRST. Other clients have non-urgent needs: (1) Pain medication can wait a few minutes for the priority assessment; (2) Hygiene assistance is important but not urgent; (3) Discharge teaching is also important but not urgent. Maslow's hierarchy is another tool: physiological needs (especially airway, breathing, circulation) come before safety, love/belonging, esteem, and self-actualization. When multiple physiological needs compete, ABC + life threats first. Always ask: 'Which client is at greatest risk of harm in the next 5-15 minutes?' That client is first.

SBAR is the standard structured communication framework in healthcare, especially for nurse-to-physician reports, handoffs, and urgent situations. S = SITUATION — brief statement of the immediate problem: 'I'm calling about Mr. Smith in 412, who has new shortness of breath.' B = BACKGROUND — relevant clinical context: '78-year-old male admitted 2 days ago for CHF exacerbation, history of MI 2020, on furosemide and metoprolol.' A = ASSESSMENT — your findings and clinical concern: 'BP 180/100, HR 110, RR 28, O2 sat 88% on room air, crackles bilaterally, increased work of breathing. I think he may be in acute pulmonary edema.' R = RECOMMENDATION — what you need: 'Could you come evaluate? In the meantime, I'm going to apply oxygen and elevate the head of bed. Do you want a stat chest X-ray and an EKG?' Benefits: (1) Reduces communication errors; (2) Ensures critical information is shared; (3) Empowers nurses to make recommendations; (4) Documented in record; (5) Improves patient safety. Variants: ISBAR (adds Identify yourself first), SBAR-R (adds Repeat-back). Other handoff tools: I-PASS (Illness severity, Patient summary, Action list, Situation awareness, Synthesis). SBAR is the most tested on NCLEX.

Suicide risk with PLAN + MEANS is a psychiatric emergency requiring immediate intervention. Risk assessment (SAD PERSONS or other tools): higher risk with (S)ex (male higher completion), (A)ge (older), (D)epression, (P)revious attempts, (E)thanol/drug use, (R)ational thinking loss, (S)ocial support absent, (O)rganized plan, (N)o spouse, (S)ickness. Immediate actions for suicidal client with plan and means: (1) DO NOT LEAVE THE CLIENT ALONE — 1:1 observation by trained staff until risk reassessed; (2) NOTIFY — charge nurse, provider, psychiatric consultation team; (3) REMOVE MEANS — secure access to medications (especially the client's own), sharp objects, cords, belts, plastic bags; window restrictions; vehicle keys; (4) DOCUMENT — exact statements, behaviors, interventions, who was notified; (5) THERAPEUTIC COMMUNICATION — direct, non-judgmental questions ('Are you thinking about killing yourself? Do you have a plan? Do you have access to means?'); listen actively; do not promise to keep it secret; (6) SAFETY CONTRACT (controversial — limited evidence but sometimes used) — verbal or written agreement to not self-harm and to alert staff if urges arise; (7) MENTAL HEALTH EVALUATION — typically required for involuntary or voluntary psychiatric admission per state laws; (8) FAMILY/SUPPORT NOTIFICATION — with client permission when possible. Asking about suicide does NOT increase the risk — research consistently shows direct questioning is appropriate and reduces stigma. Once safety is established, ongoing care includes treatment of underlying conditions, safety planning, follow-up.

ABC (Airway, Breathing, Circulation) is the foundational priority framework in nursing and emergency care. The order reflects time-to-death: without airway, death in 4-6 minutes (brain damage starts in 3 min); without breathing, similar; without circulation, similar but slightly longer. A — AIRWAY: Is it open? Is it protected (gag reflex, consciousness sufficient to clear secretions)? Signs of compromise: stridor, gurgling, snoring, choking, drooling, inability to speak. Interventions: position (head-tilt-chin-lift, jaw thrust if trauma), suction, oral/nasal airway, intubation. B — BREATHING: Rate (12-20 normal adult), depth, effort, symmetry, oxygenation (SpO2). Signs of compromise: tachypnea/bradypnea, accessory muscle use, retractions, paradoxical chest movement, cyanosis, decreased breath sounds, wheezing/crackles/rhonchi. Interventions: positioning (Fowler's), oxygen, nebulizers, ventilation support, chest tube. C — CIRCULATION: Heart rate, rhythm, blood pressure, capillary refill, skin color/temperature, pulses, mental status (early sign of perfusion problems), urine output, bleeding. Signs of compromise: tachycardia/bradycardia, hypotension, weak/absent pulses, cool/pale/diaphoretic skin, altered mental status, delayed cap refill. Interventions: control bleeding, IV access, fluids, vasopressors, CPR if pulseless. Extended frameworks: ABCDE adds D = Disability (neurological assessment), E = Exposure (full body exam, environmental control); ABCDEFG adds F = Fluids/Family, G = Glucose. Maslow's hierarchy supplements ABC: physiological needs (air, water, food, sleep, shelter, warmth) → safety → love/belonging → esteem → self-actualization. When prioritizing among clients: airway problems before breathing before circulation before disability; acute problems before chronic; unstable before stable; new findings before known issues. ABC overrides Maslow when both apply.

INTERDISCIPLINARY TEAM COORDINATION and knowing when to involve each team member is a core NCLEX-PN coordinated care competency. SOCIAL WORKER ROLE in discharge planning:

Insurance and benefits: expertise in Medicare, Medicaid, private insurance coverage for home health, skilled nursing facility, and rehabilitation services.

Community resources: knowledge of local agencies, support groups, meals programs (Meals on Wheels), transportation, housing assistance.

Home health coordination: can arrange skilled nursing visits, physical therapy, occupational therapy, speech therapy, home health aide services.

Complex social situations: homelessness, domestic violence, elder abuse, substance use, mental health resources.

Financial assistance: medication assistance programs, patient assistance foundations.

Advance care planning: assistance with advance directives, health care proxies, living wills. THE PN'S ROLE IN DISCHARGE: assess the client's understanding of discharge instructions; reinforce teaching; identify concerns or needs to report to the RN or social worker; document; the PN does NOT independently coordinate complex discharge arrangements — that is above PN scope. INTERDISCIPLINARY TEAM MEMBERS AND THEIR PRIMARY ROLES: RN — clinical coordination, complex discharge assessment, care coordination; LPN/LVN — implementing care plan, assessment under RN supervision, patient education (reinforcement), reporting; SOCIAL WORKER — psychosocial assessment, community resources, discharge planning; PHYSICAL THERAPIST — mobility, strength, balance, gait training; OCCUPATIONAL THERAPIST — ADLs, adaptive equipment, home safety; SPEECH-LANGUAGE PATHOLOGIST — swallowing, communication; DIETITIAN — nutritional assessment and counseling; CHAPLAIN — spiritual care; PHARMACIST — medication reconciliation and counseling; CASE MANAGER — insurance authorization, utilization review.

RECOGNIZING AND REPORTING SIGNIFICANT CHANGES is the most fundamental PN nursing responsibility. A blood pressure of 168/102 in a client whose baseline is 130/82 represents a clinically significant CHANGE FROM BASELINE that requires prompt assessment.

Why this is a priority report: (1) The CHANGE MATTERS as much as the absolute value — this client's normal is 130/82; a jump to 168/102 is unexpected and concerning regardless of whether 168/102 would be concerning in a client whose baseline was 165/100; (2) HYPERTENSIVE URGENCY (BP ≥180/120 without end-organ damage) and HYPERTENSIVE EMERGENCY (BP ≥180/120 with end-organ damage — headache, visual changes, chest pain, altered mental status, AKI, pulmonary edema) are serious conditions; this BP is approaching that range; (3) ASSOCIATED SYMPTOMS greatly change the urgency level.

What to report to the RN: BP reading with both numbers; the client's recent baseline; any associated symptoms (headache — assess quality and severity; visual disturbances; chest pain or pressure; confusion or altered mental status; shortness of breath; nausea); time of measurement; recent activity level.

Why not to act independently: ADMINISTERING MEDICATION (Option C) is NOT within PN scope — the PN administers medications per the provider order; administering an extra dose without an order is a serious medication error; WAITING (Option A) or DOCUMENTING ONLY (Option D) delay necessary assessment of a potentially serious condition.

Sbar communication: Situation: 'Mrs. Smith's BP is 168/102'; Background: 'Her recent baseline has been 130/82'; Assessment: 'She's also complaining of a mild headache'; Recommendation: 'I think she needs to be assessed by the provider.'.

Nclex-pn principle: the PN's role in changing clinical situations is to RECOGNIZE and REPORT — assessment of complex clinical situations and medical management decisions are RN/provider scope.

Telephone/verbal order procedure:

Safety: High error risk due to misheard words or numbers — standardised read-back prevents most errors.

Correct process: Write the order as spoken; read the COMPLETE order back to the prescriber; wait for confirmation ('That is correct' or correction); document as telephone/verbal order with: date, time, complete order, prescriber's name, and your name/credentials.

Physician co-signature: Required within facility timeframe (typically 24 hours to 72 hours depending on facility policy and state law).

Never: Modify the order; delay reading back; execute before writing.

Specific cautions: Numbers (say 'one-five' not '15' for high-risk numbers); medication names (spell it); 'U' for units must be written as 'units' — 'U' can be misread as zero.

Pn scope: LPNs may receive telephone orders within their scope of practice — check facility policy; some facilities restrict certain order types.

Jcaho/cms: Require read-back of all verbal and telephone orders for medications.

LPN delegation to uap:

The delegation framework: The LPN may delegate TASKS (not nursing judgment) to UAPs within the UAP's competency, in the appropriate setting, with proper supervision.

Appropriate to delegate: Vital signs on stable patients; height/weight; routine ADL assistance (bathing, dressing, hygiene); bed making; transport (stable patients); simple specimen collection; I&O measurement; non-invasive hygiene procedures.

Should not delegate: Initial assessments; unstable patients; invasive procedures; medication administration; tasks requiring nursing judgment or clinical decision-making.

Catheter insertion: LPN can perform catheter insertion in most states; UAP generally cannot.

Oral medications: LPN tasks; not delegatable to UAP.

Remember the 5 rights of delegation: Right task; right circumstances; right person; right direction/communication; right supervision.

LPN supervision responsibility: Even after delegating, the LPN remains responsible for the outcome — monitor the UAP's performance and patient response.

SBAR HAND-OFF REPORT — PRIORITY ELEMENTS:

Situation: What procedure was done, current condition.

Background: Relevant history, reason for surgery.

Assessment: Current vital signs, pain level, assessment findings.

Recommendations: Orders, next steps, urgent concerns.

Critical to verify: ALLERGIES (safety — can't give anything until verified); current medications (what was given in surgery, what is ordered post-op); IV access (locations, condition, current infusions); drains and tubes (type, location, output since surgery); post-op orders (diet, activity, medications, wound care); last vital signs and pain assessment; relevant lab values (glucose, haemoglobin).

Hand-off communication: Standardised hand-off (SBAR or I-PASS) reduces communication errors; read-back of critical values; opportunity to ask questions.

Use of i-pass: Illness severity; Patient summary; Action list; Situation awareness/contingency planning; Synthesis by receiver.

Right to refuse treatment:

Legal and ethical foundation: Competent adults have an absolute legal and ethical right to refuse any medical treatment or procedure, including life-saving treatments.

Exceptions: Emergency situations where the patient is unconscious or incapacitated and no advance directive exists; court orders for involuntary treatment (specific narrow circumstances); NURSE'S ROLE: Ensure the client understands the consequences of refusal (informed refusal documentation); assess whether the client is competent to make decisions; notify the RN and physician; document thoroughly (client's statement, understanding of risks, notifications made).

Never: Proceed without consent; coerce; manipulate.

Informed refusal: Must document that: the client was informed of the risks; alternative options were presented; the client's decision was voluntary and free of coercion; a family override is NOT valid — family cannot override a competent adult's decisions.

Advance directives: A living will or healthcare proxy comes into play when the patient is no longer competent — not while the patient can make their own decisions.

Advance directive and DNR orders:

Legal status: A valid advance directive and physician's do-not-resuscitate order is a LEGAL DOCUMENT that must be honoured; CPR against a DNR order is assault.

Validity check: Is the document current? Is it in the medical record? Is there a corresponding physician's order (the advance directive alone is not sufficient — a physician's order translating it to a specific DNR order is usually required in hospitals); DNR ≠ NO CARE: DNR means no CPR — all other comfort care, pain management, dignity care continue; NURSE'S ROLE: Know the DNR/advance directive status of all patients before a crisis; ensure the order is properly documented; follow the order; notify the team; support the family.

Discrepancies: If family members are demanding resuscitation despite a valid DNR — this is a care conference/ethics consultation situation; the physician and team should be contacted; the DNR order is valid.

Documentation: Time of death; assessment; notifications; comfort measures provided.