Licensed Practical Nurse Skills Assessment Questionnaire
Assess practical nursing skills, clinical judgment, and work preferences for Licensed Practical Nurse roles.
Candidate Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Job Title or Role
*
Years of Nursing Experience
*
Highest Nursing Education Completed
*
Please Select
Diploma in Practical Nursing
Associate Degree in Nursing
Bachelor of Science in Nursing
Master of Science in Nursing
Doctor of Nursing Practice
Other
Clinical Skills Assessment
Primary care settings worked in
Long-term care
Skilled nursing
Assisted living
Acute care
Outpatient
Home health
Other
Clinical skill competency rating
*
Rows
Novice
Developing
Competent
Proficient
Expert
Vital signs
1
2
3
4
5
Medication administration
6
7
8
9
10
Wound care
11
12
13
14
15
Infection control
16
17
18
19
20
Patient hygiene
21
22
23
24
25
Mobility assistance
26
27
28
29
30
Specimen collection
31
32
33
34
35
Documentation/charting
36
37
38
39
40
Basic emergency response
41
42
43
44
45
Confidence with vital signs
*
1
2
3
4
5
Confidence with medication administration
*
1
2
3
4
5
Confidence with wound care
*
1
2
3
4
5
Confidence with infection control procedures
*
1
2
3
4
5
Confidence with patient hygiene assistance
*
1
2
3
4
5
Confidence with mobility assistance
*
1
2
3
4
5
Confidence with specimen collection
*
1
2
3
4
5
Confidence with documentation and charting
*
1
2
3
4
5
Confidence with basic emergency response
*
1
2
3
4
5
Knowledge and Scenario Evaluation
Medication safety: If a patient questions a newly prescribed medication, what should you do first?
*
Verify the order and patient identity
Explain the medication and proceed if appropriate
Hold the medication and document only
Ask the patient to decide whether to take it
Recognizing changes in condition: A patient becomes short of breath and their oxygen saturation drops. What is the best next action?
*
Escalate immediately to the supervising nurse or provider
Recheck in 30 minutes
Offer fluids and continue routine care
Document the finding and wait for the next round
Infection prevention: Which actions help reduce the spread of infection?
*
Perform hand hygiene before and after patient contact
Use the correct personal protective equipment
Clean shared equipment between patients
Reuse disposable supplies if they look clean
Follow isolation precautions as ordered
Delegation and reporting: Which task is appropriate to delegate to an unlicensed assistive personnel while you remain responsible for follow-up?
*
Obtain routine vital signs on a stable patient
Assess a new chest pain complaint
Teach discharge medication instructions
Evaluate a wound for signs of infection
Prioritizing care: Which patient should you see first?
*
A patient reporting new chest pain
A patient requesting a blanket
A patient due for routine daily hygiene
A patient asking for a meal tray
Brief clinical response: In one or two sentences, describe how you would respond if a patient suddenly becomes confused and more difficult to arouse.
*
Work Preferences and Availability
Preferred Work Setting
*
Hospital
Long-Term Care
Assisted Living
Home Health
Clinic/Outpatient
Rehabilitation
Other
Shift Preference
*
Day Shift
Evening Shift
Night Shift
Rotating Shifts
Flexible
Availability
*
Days
Evenings
Nights
Weekends
Willingness to Work Additional Hours
Overtime
On-Call
Both
Neither
Earliest Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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