LVN Physiological Integrity Test 2 — Questions and Answers
Question 1: A patient with chronic obstructive pulmonary disease (COPD) is prescribed oxygen therapy. Which assessment finding requires immediate nursing intervention?
- Heart rate of 90 bpm
- O2 saturation of 92% (Correct answer)
- Respiratory rate of 24 breaths/min
- Blood pressure of 140/88 mmHg
Correct answer: O2 saturation of 92%
For patients with COPD, the target oxygen saturation is typically 88-92% to avoid suppressing the hypoxic drive. While 92% is within this range, if a patient on prescribed oxygen therapy is only achieving this level, it warrants immediate assessment. This could indicate that the oxygen therapy needs adjustment or that the patient's respiratory status is still compromised and requires closer monitoring.
Question 2: When caring for a patient with diabetes mellitus, which finding indicates the need for immediate action?
- Blood glucose level of 150 mg/dL
- Capillary refill less than 3 seconds
- Urine output of 60 mL/hr
- Complaints of thirst and polyuria (Correct answer)
Correct answer: Complaints of thirst and polyuria
Complaints of thirst (polydipsia) and excessive urination (polyuria) are classic symptoms of hyperglycemia in diabetes mellitus. These signs indicate the body is attempting to excrete excess glucose, which can lead to dehydration and potentially severe complications. Prompt assessment of blood glucose and intervention are crucial to prevent diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS).
Question 3: A patient with hypertension is prescribed hydrochlorothiazide. The nurse should monitor for which potential adverse effect?
- Hyperkalemia
- Hypoglycemia
- Hypotension
- Hyponatremia (Correct answer)
Correct answer: Hyponatremia
Hydrochlorothiazide is a thiazide diuretic that increases the excretion of sodium and water from the body through the kidneys. A significant adverse effect of this medication is hyponatremia, which is a dangerously low level of sodium in the blood. Nurses must closely monitor the patient's electrolyte levels to prevent this and other electrolyte imbalances.
Question 4: During a physical assessment, the nurse notes bilateral pitting edema of the lower extremities in a patient with heart failure. Which action should the nurse take first?
- Elevate the legs
- Assess respiratory status (Correct answer)
- Document the finding
- Measure the circumference of the calves
Correct answer: Assess respiratory status
Bilateral pitting edema in a patient with heart failure indicates significant fluid volume overload throughout the body. This excess fluid can rapidly shift into the lungs, leading to acute pulmonary edema and severe respiratory distress. Therefore, the nurse's priority is to immediately assess the patient's respiratory status to detect any signs of this life-threatening complication.
Question 5: A patient is receiving a blood transfusion. The nurse should monitor the patient closely for which immediate transfusion reaction?
- Chills and fever (Correct answer)
- Bradycardia
- Hypertension
- Urine output increase
Correct answer: Chills and fever
Chills and fever are common and often the earliest signs of an acute transfusion reaction, such as a febrile non-hemolytic reaction or a more severe acute hemolytic reaction. These symptoms indicate the body's immune response to the transfused blood product. Upon observing these, the nurse must immediately stop the transfusion and initiate appropriate interventions to ensure patient safety.
Question 6: Which assessment finding is a potential complication of immobility in a hospitalized patient?
- Increased appetite
- Increased muscle strength
- Decreased lung sounds (Correct answer)
- Increased urine output
Correct answer: Decreased lung sounds
Immobility significantly reduces lung expansion and the effectiveness of coughing, leading to the pooling of respiratory secretions and decreased ventilation in the lower lung fields. This increases the risk for atelectasis (collapse of alveoli) and pneumonia, which would manifest as decreased or absent lung sounds upon auscultation. Therefore, monitoring lung sounds is crucial for immobile patients.
Question 7: A patient with a head injury is suspected of having increased intracranial pressure (ICP). The nurse should monitor the patient for which early sign of increased ICP?
- Bradycardia
- Hypotension
- Bradypnea
- Change in level of consciousness (Correct answer)
Correct answer: Change in level of consciousness
A change in the patient's level of consciousness (LOC) is the earliest and most sensitive indicator of increased intracranial pressure (ICP). As ICP rises, cerebral perfusion is compromised, directly affecting brain function and leading to subtle but critical alterations in mental status. This can manifest as restlessness, confusion, or a decreased response to stimuli, requiring immediate assessment.
Question 8: When administering medications via a nasogastric tube, the nurse should take which action to ensure proper medication delivery?
- Crush all medications
- Use a large syringe to administer the medication
- Flush the tube with 30 mL of water before and after medication administration (Correct answer)
- Administer medications rapidly
Correct answer: Flush the tube with 30 mL of water before and after medication administration
Flushing the nasogastric tube with 30 mL of water before and after medication administration is essential for several reasons. It ensures the tube's patency, prevents medication from adhering to the tube walls, and clears any residual medication, ensuring the full dose reaches the stomach. This practice also helps prevent tube occlusion and maintains proper hydration.
Question 9: Which vital sign should prioritize assessing first in a patient experiencing shortness of breath?
- Blood pressure
- Temperature
- Respiratory rate (Correct answer)
- Pulse
Correct answer: Respiratory rate
When a patient is experiencing shortness of breath, the most immediate and relevant vital sign to assess is the respiratory rate. This directly reflects the patient's ventilatory effort and the severity of their respiratory distress. Changes in respiratory rate can indicate worsening respiratory compromise and guide immediate interventions to support breathing.
Question 10: Which needle gauge is typically used for subcutaneous injections?
- 18 gauge
- 22 gauge
- 25 gauge (Correct answer)
- 30 gauge
Correct answer: 25 gauge
For subcutaneous injections, a smaller gauge needle, typically 25 to 27 gauge, is preferred. These needles are finer and cause less pain and tissue trauma when penetrating the subcutaneous fat layer. This gauge is appropriate for the small volumes of medication administered subcutaneously and helps ensure patient comfort.
Question 11: During a neurovascular assessment of a patient with a casted arm, which finding requires immediate intervention by the LVN?
- Capillary refill less than 3 seconds
- Tingling sensation reported by the patient (Correct answer)
- Warmth and mild swelling of the fingers
- Pulse rate within normal range
Correct answer: Tingling sensation reported by the patient
A tingling sensation (paresthesia) in a casted extremity is a critical sign of potential neurovascular compromise, such as nerve compression or impaired circulation. This symptom can indicate the onset of compartment syndrome or other serious complications that could lead to permanent nerve damage or tissue ischemia. Immediate intervention is required to prevent further injury and preserve limb function.
LVN Physiological Integrity Test 2
A patient with chronic obstructive pulmonary disease (COPD) is prescribed oxygen therapy.
Which assessment finding requires immediate nursing intervention?