LPN Health Evaluation & Monitoring 2 — Questions and Answers
Question 1: A patient's oxygen saturation drops from 97% to 89% over 30 minutes. What is the nurse's priority action?
- Document the finding and reassess in 1 hour
- Apply supplemental oxygen and notify the provider (Correct answer)
- Encourage the patient to take deep breaths
- Reposition the pulse oximeter probe and recheck
Correct answer: Apply supplemental oxygen and notify the provider
An SpO2 of 89% is below the acceptable threshold of 95% and requires immediate oxygen supplementation and provider notification.
Question 2: When performing a head-to-toe assessment, the LPN notes the patient has periorbital edema. This finding is most associated with which condition?
- Cushing's syndrome
- Nephrotic syndrome (Correct answer)
- Addison's disease
- Hyperthyroidism
Correct answer: Nephrotic syndrome
Periorbital edema is a classic sign of nephrotic syndrome due to significant protein loss and decreased oncotic pressure.
Question 3: A patient reports pain rated 7/10 with movement and 3/10 at rest. Which nursing action is most appropriate before administering PRN analgesics?
- Administer the maximum PRN dose immediately
- Assess the character, location, and precipitating factors of pain (Correct answer)
- Wait until the pain is consistently rated above 5/10
- Apply a cold pack to the area without further assessment
Correct answer: Assess the character, location, and precipitating factors of pain
A thorough pain assessment including character, location, and triggers guides safe and effective pain management decisions.
Question 4: Which urine output value over 8 hours should the LPN immediately report to the charge nurse or provider?
- 320 mL
- 280 mL
- 180 mL (Correct answer)
- 400 mL
Correct answer: 180 mL
Urine output below 30 mL/hour (240 mL over 8 hours) indicates oliguria; 180 mL over 8 hours is critically low and requires urgent reporting.
Question 5: During a neurological check, the LPN asks the patient to squeeze both hands simultaneously and notices the left grip is significantly weaker. What should the nurse document?
- Bilateral grip strength equal and strong
- Left-sided hemiparesis with decreased grip strength (Correct answer)
- Patient uncooperative with assessment
- Normal neurological findings
Correct answer: Left-sided hemiparesis with decreased grip strength
Asymmetrical grip strength with left-sided weakness must be documented as left-sided hemiparesis and reported promptly.
Question 6: A post-operative patient has a blood pressure of 88/54 mmHg and heart rate of 118 bpm. Which additional assessment finding would best confirm hypovolemic shock?
- Warm, flushed skin with bounding pulses
- Cool, clammy skin with delayed capillary refill (Correct answer)
- Bradycardia with widened pulse pressure
- Hypertension with bounding peripheral pulses
Correct answer: Cool, clammy skin with delayed capillary refill
Cool, clammy skin and delayed capillary refill indicate peripheral vasoconstriction from hypovolemia, confirming early hypovolemic shock.
Question 7: The LPN is monitoring a diabetic patient's blood glucose before meals. A fasting reading of 52 mg/dL requires which immediate action?
- Administer the scheduled insulin dose and recheck in 30 minutes
- Give 15-20 grams of fast-acting carbohydrate and recheck in 15 minutes (Correct answer)
- Encourage a large meal immediately and notify the provider later
- Hold all food until the provider orders a glucose tolerance test
Correct answer: Give 15-20 grams of fast-acting carbohydrate and recheck in 15 minutes
A blood glucose of 52 mg/dL indicates hypoglycemia; the 15-15 rule requires administering 15 grams of fast-acting carbohydrate and rechecking in 15 minutes.
LPN Health Evaluation & Monitoring 2
A patient's oxygen saturation drops from 97% to 89% over 30 minutes.
What is the nurse's priority action?