LVN Physiological Integrity Test 2

Question 1

A patient with chronic obstructive pulmonary disease (COPD) is prescribed oxygen therapy. Which assessment finding requires immediate nursing intervention?

Accepted Answer

O2 saturation of 92%

Answer

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?

Accepted Answer

Complaints of thirst and polyuria

Answer

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?

Accepted Answer

Hyponatremia

Answer

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?

Accepted Answer

Assess respiratory status

Answer

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?

Accepted Answer

Chills and fever

Answer

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.

Uncategorized Practice Test

Uncategorized Practice Test

LVN Physiological Integrity Test 2