LPN Health Evaluation & Monitoring 3 — Questions and Answers
Question 1: An LPN is assessing lung sounds and hears a high-pitched, continuous musical sound over the right lower lobe. This finding is best described as:
- Crackles
- Rhonchi
- Wheezing (Correct answer)
- Pleural friction rub
Correct answer: Wheezing
Wheezing is a high-pitched, continuous, musical sound caused by narrowed or obstructed airways.
Question 2: A patient with heart failure has pitting edema graded 3+. What does this finding indicate?
- A 2 mm indentation that disappears rapidly
- A 4 mm indentation lasting up to 15 seconds
- A 6 mm indentation persisting up to 1 minute (Correct answer)
- An 8 mm deep indentation lasting more than 2 minutes
Correct answer: A 6 mm indentation persisting up to 1 minute
3+ pitting edema is characterized by a 6 mm deep indentation that persists for up to 1 minute before rebounding.
Question 3: When assessing a patient's pupils, the LPN notes one pupil is 6 mm and non-reactive while the other is 3 mm and reactive. The correct documentation is:
- PERRL 3 mm bilaterally
- Anisocoria with right pupil fixed and dilated (Correct answer)
- Pupils equal and sluggish bilaterally
- Miosis bilaterally, no cause identified
Correct answer: Anisocoria with right pupil fixed and dilated
Anisocoria refers to unequal pupils; a fixed and dilated pupil is a critical neurological sign that must be documented and reported immediately.
Question 4: The LPN is reviewing intake and output for a patient who received 1,200 mL IV fluid, drank 600 mL, and had 850 mL urine, 200 mL wound drainage, and 100 mL emesis. What is the 24-hour fluid balance?
- +1,800 mL
- +650 mL (Correct answer)
- +450 mL
- +1,150 mL
Correct answer: +650 mL
Total intake is 1,800 mL; total output is 1,150 mL (850+200+100); fluid balance = +650 mL.
Question 5: A patient is receiving a blood transfusion and develops chills, back pain, and tea-colored urine 30 minutes after starting. The LPN's priority action is:
- Slow the infusion rate and apply warm blankets
- Stop the transfusion and infuse normal saline through new tubing (Correct answer)
- Administer diphenhydramine per standing order and continue transfusion
- Increase the flow rate to complete the transfusion faster
Correct answer: Stop the transfusion and infuse normal saline through new tubing
These signs indicate a hemolytic transfusion reaction; the transfusion must be stopped immediately and normal saline started through new IV tubing.
Question 6: During a skin assessment, the LPN notes a wound with black, hard, dry necrotic tissue. This tissue type is classified as:
- Slough
- Granulation tissue
- Eschar (Correct answer)
- Fibrinous exudate
Correct answer: Eschar
Eschar is black, hard, dry necrotic tissue that must be documented accurately to guide wound care decisions.
Question 7: A patient's telemetry shows a heart rate of 42 bpm with P waves before each QRS complex and regular rhythm. The LPN should first:
- Administer atropine 0.5 mg IV per standing orders
- Assess the patient for symptoms such as dizziness or hypotension (Correct answer)
- Cardiovert the patient immediately
- Document the rhythm and continue routine monitoring
Correct answer: Assess the patient for symptoms such as dizziness or hypotension
Before any intervention, the LPN must assess whether the bradycardia is causing symptoms, as asymptomatic sinus bradycardia may not require treatment.
LPN Health Evaluation & Monitoring 3
An LPN is assessing lung sounds and hears a high-pitched, continuous musical sound over the right lower lobe.
This finding is best described as: