LVN – Licensed Vocational Nurse (California &
Texas) | Comprehensive Study Guide, Practice
Exam, Questions & Answers, NCLEX-PN Prep,
Fundamentals of Nursing, Medical-Surgical
Nursing, Pharmacology, Maternal-Newborn,
Pediatrics, Mental Health, Patient Care, Clinical
Judgment, Detailed Rationales, Complete Review
Question 1: A patient with a history of chronic obstructive pulmonary disease
(COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse observes
that the patient's respiratory rate has decreased to 8 breaths per minute and
they are somnolent. Which of the following is the priority nursing action?
A. Increase the oxygen flow rate to 4 L/min
B. Place the patient in a supine position
C. Remove the nasal cannula and prepare to ventilate with a bag-valve-mask
D. Administer a prescribed bronchodilator
CORRECT ANSWER: C. Remove the nasal cannula and prepare to ventilate
with a bag-valve-mask
Rationale:The patient is exhibiting signs of respiratory depression and potential carbon
dioxide narcosis, a risk for COPD patients who lose their hypoxic drive. The priority is to
remove the oxygen source and provide manual ventilation with a bag-valve-mask to
support breathing while ensuring proper oxygenation and ventilation. Increasing oxygen
or administering a bronchodilator does not address the immediate need for ventilatory
support. A supine position could worsen oxygenation.
Question 2: A 72-year-old patient is admitted with a diagnosis of dehydration.
Which of the following laboratory values is the best indicator of the patient's
fluid volume status?
A. Serum sodium
B. Serum potassium
C. Blood urea nitrogen (BUN) to creatinine ratio
D. Serum glucose
CORRECT ANSWER: C. Blood urea nitrogen (BUN) to creatinine ratio
Rationale:A BUN-to-creatinine ratio greater than 20:1 is a classic sign of prerenal
azotemia and dehydration. While serum sodium can be elevated in hypertonic
dehydration, it is not as specific as the BUN/creatinine ratio for indicating decreased
intravascular volume. Potassium and glucose are not primary indicators of fluid status.
,Question 3: A patient is receiving a continuous intravenous infusion of
heparin. Which of the following laboratory tests should the nurse monitor to
evaluate the effectiveness of this therapy?
A. Prothrombin time (PT)
B. International normalized ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
CORRECT ANSWER: C. Activated partial thromboplastin time (aPTT)
Rationale:Heparin affects the intrinsic pathway of the coagulation cascade, which is
monitored by the aPTT. The therapeutic goal is typically 1.5 to 2.5 times the control
value. PT and INR are used to monitor warfarin therapy. Platelet count is monitored to
detect heparin-induced thrombocytopenia (HIT), not the therapeutic effect.
Question 4: When providing discharge teaching to a patient with a new
colostomy, which of the following observations by the patient indicates that
they require further education regarding stoma care?
A. The patient states they will avoid eating foods like popcorn and nuts
B. The patient reports that the stoma should be pink and moist
C. The patient describes the plan to change the appliance when it is one-third full of gas
D. The patient states that they will cut the skin barrier one-quarter inch larger than the
stoma
CORRECT ANSWER: D. The patient states that they will cut the skin barrier
one-quarter inch larger than the stoma
Rationale:The skin barrier should be cut to fit the stoma exactly, or no more than 1/8
inch larger, to protect the peristomal skin from effluent. Cutting it one-quarter inch
larger leaves skin exposed to digestive enzymes and can cause breakdown. A healthy
stoma is pink and moist, and restrictive or gas-producing foods are often avoided.
Changing the appliance when one-third full prevents leakage.
Question 5: A patient is exhibiting signs of anaphylaxis following an IV
antibiotic infusion. After stopping the infusion, which of the following is the
nurse's first priority?
A. Administer diphenhydramine
B. Administer epinephrine
C. Administer an inhaled bronchodilator
D. Apply a tourniquet proximal to the infusion site
CORRECT ANSWER: B. Administer epinephrine
,Rationale:In anaphylaxis, epinephrine is the first-line treatment to reverse vasodilation,
bronchoconstriction, and hypotension. Diphenhydramine and bronchodilators are
secondary treatments. While maintaining the airway is the overall priority in the ABCs,
epinephrine is the immediate pharmacological intervention needed to stop the
progression of the reaction.
Question 6: The physician orders 1000 mL of 0.9% normal saline to infuse over
8 hours. The drop factor is 15 gtt/mL. What is the initial flow rate in drops per
minute?
A. 31 gtt/min
B. 21 gtt/min
C. 125 gtt/min
D. 15 gtt/min
CORRECT ANSWER: A. 31 gtt/min
Rationale:The formula is (Total volume / Total time in minutes) x Drop factor. Total
time in minutes is 8 hours x 60 minutes = 480 minutes. 1000 mL / 480 minutes = 2.08
mL/min. 2.08 mL/min x 15 gtt/mL = 31.2 gtt/min, rounded down to 31 gtt/min.
Question 7: A patient is prescribed digoxin for heart failure. Which of the
following findings is a classic sign of digoxin toxicity that the nurse should
assess for?
A. Tachycardia
B. Yellow-green halos around visual fields
C. Hypertension
D. Hyperkalemia
CORRECT ANSWER: B. Yellow-green halos around visual fields
Rationale:Visual disturbances, such as seeing yellow-green halos, are classic and
specific signs of digoxin toxicity. Other signs include bradycardia, not tachycardia, and
hypokalemia (which predisposes to toxicity). Hypertension is not a typical sign;
hypotension or arrhythmias are more common.
Question 8: A patient on a medical-surgical unit suddenly becomes short of
breath, and the nurse notes that the trachea is deviated to the right. Based on
this assessment, which of the following conditions is most likely occurring?
A. Atelectasis on the left
B. Tension pneumothorax on the left
C. Pleural effusion on the right
D. Pulmonary embolism
, CORRECT ANSWER: B. Tension pneumothorax on the left
Rationale:A tension pneumothorax causes a shift of the mediastinum and trachea to the
contralateral side (away from the injury). In this case, the left side injury is pushing the
trachea to the right. Atelectasis causes a shift toward the affected side (left). A pleural
effusion may cause a shift away, but tension pneumothorax is the most emergent and
classic cause.
Question 9: A patient is scheduled for an intravenous pyelogram (IVP). Which
of the following is the most critical pre-procedure nursing action?
A. Administer a cleansing enema
B. Assess for a history of allergy to shellfish or iodine
C. Ensure the patient is NPO for 24 hours
D. Administer a sedative
CORRECT ANSWER: B. Assess for a history of allergy to shellfish or iodine
Rationale:An IVP uses an iodinated contrast medium. A severe allergic reaction
(anaphylaxis) is a significant risk for patients with shellfish or iodine allergies. While a
bowel prep may be ordered, assessing for an allergy is the priority to ensure patient
safety. NPO requirements are usually for 4-8 hours, not 24.
Question 10: The LVN is assisting the RN in the care of a patient with a chest
tube connected to a water-seal drainage system. Which of the following
observations requires immediate intervention?
A. Intermittent bubbling in the water-seal chamber
B. Continuous bubbling in the water-seal chamber
C. Tidaling in the water-seal chamber with inspiration
D. Fluctuation of fluid in the tubing with the patient's respirations
CORRECT ANSWER: B. Continuous bubbling in the water-seal chamber
Rationale:Continuous bubbling in the water-seal chamber indicates an air leak, likely
from the patient, the tube, or the system. This requires immediate assessment and
intervention to prevent the loss of negative pressure and potential lung collapse.
Intermittent bubbling and tidaling are expected findings indicating the system is intact
and the lung is re-expanding.
Question 11: A patient is diagnosed with hypothyroidism. Which of the
following manifestations would the nurse expect to find during the
assessment?
Texas) | Comprehensive Study Guide, Practice
Exam, Questions & Answers, NCLEX-PN Prep,
Fundamentals of Nursing, Medical-Surgical
Nursing, Pharmacology, Maternal-Newborn,
Pediatrics, Mental Health, Patient Care, Clinical
Judgment, Detailed Rationales, Complete Review
Question 1: A patient with a history of chronic obstructive pulmonary disease
(COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse observes
that the patient's respiratory rate has decreased to 8 breaths per minute and
they are somnolent. Which of the following is the priority nursing action?
A. Increase the oxygen flow rate to 4 L/min
B. Place the patient in a supine position
C. Remove the nasal cannula and prepare to ventilate with a bag-valve-mask
D. Administer a prescribed bronchodilator
CORRECT ANSWER: C. Remove the nasal cannula and prepare to ventilate
with a bag-valve-mask
Rationale:The patient is exhibiting signs of respiratory depression and potential carbon
dioxide narcosis, a risk for COPD patients who lose their hypoxic drive. The priority is to
remove the oxygen source and provide manual ventilation with a bag-valve-mask to
support breathing while ensuring proper oxygenation and ventilation. Increasing oxygen
or administering a bronchodilator does not address the immediate need for ventilatory
support. A supine position could worsen oxygenation.
Question 2: A 72-year-old patient is admitted with a diagnosis of dehydration.
Which of the following laboratory values is the best indicator of the patient's
fluid volume status?
A. Serum sodium
B. Serum potassium
C. Blood urea nitrogen (BUN) to creatinine ratio
D. Serum glucose
CORRECT ANSWER: C. Blood urea nitrogen (BUN) to creatinine ratio
Rationale:A BUN-to-creatinine ratio greater than 20:1 is a classic sign of prerenal
azotemia and dehydration. While serum sodium can be elevated in hypertonic
dehydration, it is not as specific as the BUN/creatinine ratio for indicating decreased
intravascular volume. Potassium and glucose are not primary indicators of fluid status.
,Question 3: A patient is receiving a continuous intravenous infusion of
heparin. Which of the following laboratory tests should the nurse monitor to
evaluate the effectiveness of this therapy?
A. Prothrombin time (PT)
B. International normalized ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
CORRECT ANSWER: C. Activated partial thromboplastin time (aPTT)
Rationale:Heparin affects the intrinsic pathway of the coagulation cascade, which is
monitored by the aPTT. The therapeutic goal is typically 1.5 to 2.5 times the control
value. PT and INR are used to monitor warfarin therapy. Platelet count is monitored to
detect heparin-induced thrombocytopenia (HIT), not the therapeutic effect.
Question 4: When providing discharge teaching to a patient with a new
colostomy, which of the following observations by the patient indicates that
they require further education regarding stoma care?
A. The patient states they will avoid eating foods like popcorn and nuts
B. The patient reports that the stoma should be pink and moist
C. The patient describes the plan to change the appliance when it is one-third full of gas
D. The patient states that they will cut the skin barrier one-quarter inch larger than the
stoma
CORRECT ANSWER: D. The patient states that they will cut the skin barrier
one-quarter inch larger than the stoma
Rationale:The skin barrier should be cut to fit the stoma exactly, or no more than 1/8
inch larger, to protect the peristomal skin from effluent. Cutting it one-quarter inch
larger leaves skin exposed to digestive enzymes and can cause breakdown. A healthy
stoma is pink and moist, and restrictive or gas-producing foods are often avoided.
Changing the appliance when one-third full prevents leakage.
Question 5: A patient is exhibiting signs of anaphylaxis following an IV
antibiotic infusion. After stopping the infusion, which of the following is the
nurse's first priority?
A. Administer diphenhydramine
B. Administer epinephrine
C. Administer an inhaled bronchodilator
D. Apply a tourniquet proximal to the infusion site
CORRECT ANSWER: B. Administer epinephrine
,Rationale:In anaphylaxis, epinephrine is the first-line treatment to reverse vasodilation,
bronchoconstriction, and hypotension. Diphenhydramine and bronchodilators are
secondary treatments. While maintaining the airway is the overall priority in the ABCs,
epinephrine is the immediate pharmacological intervention needed to stop the
progression of the reaction.
Question 6: The physician orders 1000 mL of 0.9% normal saline to infuse over
8 hours. The drop factor is 15 gtt/mL. What is the initial flow rate in drops per
minute?
A. 31 gtt/min
B. 21 gtt/min
C. 125 gtt/min
D. 15 gtt/min
CORRECT ANSWER: A. 31 gtt/min
Rationale:The formula is (Total volume / Total time in minutes) x Drop factor. Total
time in minutes is 8 hours x 60 minutes = 480 minutes. 1000 mL / 480 minutes = 2.08
mL/min. 2.08 mL/min x 15 gtt/mL = 31.2 gtt/min, rounded down to 31 gtt/min.
Question 7: A patient is prescribed digoxin for heart failure. Which of the
following findings is a classic sign of digoxin toxicity that the nurse should
assess for?
A. Tachycardia
B. Yellow-green halos around visual fields
C. Hypertension
D. Hyperkalemia
CORRECT ANSWER: B. Yellow-green halos around visual fields
Rationale:Visual disturbances, such as seeing yellow-green halos, are classic and
specific signs of digoxin toxicity. Other signs include bradycardia, not tachycardia, and
hypokalemia (which predisposes to toxicity). Hypertension is not a typical sign;
hypotension or arrhythmias are more common.
Question 8: A patient on a medical-surgical unit suddenly becomes short of
breath, and the nurse notes that the trachea is deviated to the right. Based on
this assessment, which of the following conditions is most likely occurring?
A. Atelectasis on the left
B. Tension pneumothorax on the left
C. Pleural effusion on the right
D. Pulmonary embolism
, CORRECT ANSWER: B. Tension pneumothorax on the left
Rationale:A tension pneumothorax causes a shift of the mediastinum and trachea to the
contralateral side (away from the injury). In this case, the left side injury is pushing the
trachea to the right. Atelectasis causes a shift toward the affected side (left). A pleural
effusion may cause a shift away, but tension pneumothorax is the most emergent and
classic cause.
Question 9: A patient is scheduled for an intravenous pyelogram (IVP). Which
of the following is the most critical pre-procedure nursing action?
A. Administer a cleansing enema
B. Assess for a history of allergy to shellfish or iodine
C. Ensure the patient is NPO for 24 hours
D. Administer a sedative
CORRECT ANSWER: B. Assess for a history of allergy to shellfish or iodine
Rationale:An IVP uses an iodinated contrast medium. A severe allergic reaction
(anaphylaxis) is a significant risk for patients with shellfish or iodine allergies. While a
bowel prep may be ordered, assessing for an allergy is the priority to ensure patient
safety. NPO requirements are usually for 4-8 hours, not 24.
Question 10: The LVN is assisting the RN in the care of a patient with a chest
tube connected to a water-seal drainage system. Which of the following
observations requires immediate intervention?
A. Intermittent bubbling in the water-seal chamber
B. Continuous bubbling in the water-seal chamber
C. Tidaling in the water-seal chamber with inspiration
D. Fluctuation of fluid in the tubing with the patient's respirations
CORRECT ANSWER: B. Continuous bubbling in the water-seal chamber
Rationale:Continuous bubbling in the water-seal chamber indicates an air leak, likely
from the patient, the tube, or the system. This requires immediate assessment and
intervention to prevent the loss of negative pressure and potential lung collapse.
Intermittent bubbling and tidaling are expected findings indicating the system is intact
and the lung is re-expanding.
Question 11: A patient is diagnosed with hypothyroidism. Which of the
following manifestations would the nurse expect to find during the
assessment?
