LVN – Licensed Vocational Nurse (California & Texas) |
Comprehensive Study Guide, Practice Exam, Questions &
Answers, Exam Prep Test Bank, NCLEX-PN Review,
Fundamentals of Nursing, Medical-Surgical Nursing,
Pharmacology, Maternal-Newborn, Pediatrics, Mental Health,
Leadership, 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 notes 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. Prepare for immediate intubation
C. Assess the patient's oxygen saturation and level of consciousness
D. Decrease the oxygen flow rate to 1 L/min
CORRECT ANSWER: D. Decrease the oxygen flow rate to 1 L/min
Rationale:Patients with severe COPD may rely on a hypoxic drive to stimulate
breathing. High oxygen concentrations can depress this drive, leading to
hypoventilation, hypercapnia, and respiratory acidosis. The priority is to decrease the
oxygen flow rate to a level that maintains an SpO2 of 88-92% while monitoring for
improved ventilation.
Question 2: A licensed vocational nurse is preparing to administer an enteral
feeding via a nasogastric tube. Which of the following actions is essential to
perform immediately before initiating the feeding?
A. Flush the tube with 30 mL of sterile water
B. Verify tube placement by aspirating gastric contents and checking pH
C. Warm the formula to body temperature in a microwave
D. Elevate the head of the bed to 15 degrees
CORRECT ANSWER: B. Verify tube placement by aspirating gastric contents
and checking pH
Rationale:Verification of tube placement is critical before each intermittent feeding or
medication administration to prevent accidental pulmonary aspiration. Aspirating gastric
contents and checking pH (typically ≤ 5) is a standard method to confirm gastric
placement. Auscultation of injected air is no longer considered a reliable method.
Question 3: A patient is admitted with a deep vein thrombosis and is started
on a continuous heparin infusion. Which of the following laboratory values is
the most important for the nurse to monitor to evaluate the therapeutic effect
of the heparin?
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 coagulation pathway, 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 counts are monitored to assess for heparin-
induced thrombocytopenia (HIT), which is a complication but not a measure of
therapeutic effect.
Question 4: A patient is 2 days post-operative following a total hip
replacement. The nurse observes that the patient's left calf is swollen, warm,
and tender to touch. Which of the following is the nurse's priority action?
A. Apply a warm compress to the calf to reduce pain
B. Massage the calf to promote venous return
C. Instruct the patient to perform ankle pumps
D. Measure the circumference of the calf and notify the provider
CORRECT ANSWER: D. Measure the circumference of the calf and notify the
provider
Rationale:These signs are indicative of a potential deep vein thrombosis (DVT). The
nurse should measure the circumference of the leg to obtain an objective baseline and
notify the provider immediately. Massaging or applying heat to an extremity with a
suspected DVT is contraindicated as it could dislodge the clot.
Question 5: A nurse is reinforcing education to a patient prescribed a
monoamine oxidase inhibitor (MAOI) for depression. Which of the following
dietary items should the nurse emphasize the patient must avoid?
A. Aged cheese and cured meats
B. Green leafy vegetables
C. High-fiber cereals
D. Grapefruit juice
CORRECT ANSWER: A. Aged cheese and cured meats
Rationale:MAOIs can cause a hypertensive crisis when combined with foods high in
tyramine. Tyramine is found in aged cheeses, cured meats (e.g., salami, pepperoni),
fermented soy products, and certain alcoholic beverages. Grapefruit juice is a concern
with statins and some calcium channel blockers, not MAOIs.
Question 6: A patient with type 1 diabetes is experiencing nausea, vomiting,
and diarrhea. The patient's blood glucose level is 320 mg/dL. Which of the
following is the most appropriate instruction for the nurse to reinforce?
A. Hold the insulin until the nausea subsides
B. Check urine for ketones and drink clear liquids with sugar every hour
,C. Drink regular soda to maintain hydration
D. Administer an extra dose of NPH insulin immediately
CORRECT ANSWER: B. Check urine for ketones and drink clear liquids with
sugar every hour
Rationale:In a patient with type 1 diabetes who is ill, the risk of diabetic ketoacidosis
(DKA) is high. The patient should check for ketones. To prevent dehydration and
provide calories, they should consume clear liquids that contain sugar (e.g., regular
ginger ale, juice) in small amounts every hour, and continue to take their insulin. Insulin
should never be held during illness.
Question 7: A nurse is assisting with a sterile procedure and a sterile field has
been established. Which of the following actions by a team member indicates a
breach in sterile technique?
A. Placing a sterile item within 1 inch of the edge of the sterile field
B. The scrub nurse's sterile gown sleeve touches the edge of the sterile field
C. Pouring sterile solution from a bottle into a sterile basin on the field
D. Keeping hands above the waist while wearing sterile gloves
CORRECT ANSWER: B. The scrub nurse's sterile gown sleeve touches the edge
of the sterile field
Rationale:The 1-inch border of a sterile field is considered non-sterile. If a sterile item
touches this border, the item becomes contaminated. The scrub nurse's sleeve
becoming contaminated at the edge of the field breaks sterile technique. Pouring sterile
solution is acceptable if the bottle is not touched to the basin.
Question 8: A patient is receiving furosemide (Lasix) for heart failure. Which
of the following assessment findings is most indicative of a therapeutic
response to the medication?
A. Decreased blood pressure and increased heart rate
B. Weight loss of 2 pounds in 24 hours and clear lung sounds
C. Increased urinary output and elevated potassium level
D. Decrease in pedal edema and increase in jugular venous distention
CORRECT ANSWER: B. Weight loss of 2 pounds in 24 hours and clear lung
sounds
Rationale:Furosemide is a loop diuretic that reduces fluid volume overload. A
therapeutic response is demonstrated by a reduction in weight (indicative of fluid loss),
decreased peripheral edema, and clear lung sounds (indicative of resolution of
pulmonary congestion). Furosemide causes potassium loss, not elevation.
Question 9: A nurse is reinforcing education about home safety for a patient
with peripheral neuropathy in both feet. Which of the following statements by
the patient indicates an understanding of the teaching?
, A. "I will soak my feet in hot water every day to improve circulation."
B. "I will check the water temperature with my hands before bathing."
C. "I can use a heating pad on my feet to keep them warm at night."
D. "It is safe to walk barefoot inside my house to avoid falls."
CORRECT ANSWER: B. "I will check the water temperature with my hands
before bathing."
Rationale:Peripheral neuropathy leads to decreased sensation. The patient should use a
non-affected body part (like a hand or thermometer) to test water temperature to
prevent burns. Soaking feet, using heating pads, and walking barefoot all increase the
risk of injury and infection in patients with impaired sensation.
Question 10: A patient is being discharged with a prescription for digoxin and
hydrochlorothiazide. Which of the following signs or symptoms should the
nurse reinforce as an adverse effect to report to the provider?
A. Weight gain of 1 pound in a week
B. Visual disturbances such as seeing halos or yellow-green color
C. Muscle cramps and weakness
D. Increased urinary frequency
CORRECT ANSWER: B. Visual disturbances such as seeing halos or yellow-
green color
Rationale:Visual disturbances (e.g., halos, yellow-green color perception, blurred vision)
are classic signs of digoxin toxicity. The patient should report this to the provider
immediately. The combination of hydrochlorothiazide (which can cause hypokalemia)
and digoxin increases the risk of digoxin toxicity.
Question 11: A patient is admitted with a diagnosis of bacterial meningitis.
Which of the following infection control precautions should the nurse
implement immediately?
A. Standard Precautions only
B. Droplet Precautions
C. Contact Precautions
D. Airborne Precautions
CORRECT ANSWER: B. Droplet Precautions
Rationale:Bacterial meningitis is transmitted via respiratory droplets. Droplet
Precautions (private room or cohort, and mask within 3 feet of the patient) are required
until the patient has been on antibiotics for 24 hours. Airborne Precautions are for
diseases like tuberculosis and measles, while Contact Precautions are for conditions like
C. difficile or MRSA.
Question 12: A nurse is reinforcing instructions to a patient who is starting a
low-sodium diet. Which of the following foods is the most appropriate to
include in the patient's diet plan?
Comprehensive Study Guide, Practice Exam, Questions &
Answers, Exam Prep Test Bank, NCLEX-PN Review,
Fundamentals of Nursing, Medical-Surgical Nursing,
Pharmacology, Maternal-Newborn, Pediatrics, Mental Health,
Leadership, 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 notes 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. Prepare for immediate intubation
C. Assess the patient's oxygen saturation and level of consciousness
D. Decrease the oxygen flow rate to 1 L/min
CORRECT ANSWER: D. Decrease the oxygen flow rate to 1 L/min
Rationale:Patients with severe COPD may rely on a hypoxic drive to stimulate
breathing. High oxygen concentrations can depress this drive, leading to
hypoventilation, hypercapnia, and respiratory acidosis. The priority is to decrease the
oxygen flow rate to a level that maintains an SpO2 of 88-92% while monitoring for
improved ventilation.
Question 2: A licensed vocational nurse is preparing to administer an enteral
feeding via a nasogastric tube. Which of the following actions is essential to
perform immediately before initiating the feeding?
A. Flush the tube with 30 mL of sterile water
B. Verify tube placement by aspirating gastric contents and checking pH
C. Warm the formula to body temperature in a microwave
D. Elevate the head of the bed to 15 degrees
CORRECT ANSWER: B. Verify tube placement by aspirating gastric contents
and checking pH
Rationale:Verification of tube placement is critical before each intermittent feeding or
medication administration to prevent accidental pulmonary aspiration. Aspirating gastric
contents and checking pH (typically ≤ 5) is a standard method to confirm gastric
placement. Auscultation of injected air is no longer considered a reliable method.
Question 3: A patient is admitted with a deep vein thrombosis and is started
on a continuous heparin infusion. Which of the following laboratory values is
the most important for the nurse to monitor to evaluate the therapeutic effect
of the heparin?
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 coagulation pathway, 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 counts are monitored to assess for heparin-
induced thrombocytopenia (HIT), which is a complication but not a measure of
therapeutic effect.
Question 4: A patient is 2 days post-operative following a total hip
replacement. The nurse observes that the patient's left calf is swollen, warm,
and tender to touch. Which of the following is the nurse's priority action?
A. Apply a warm compress to the calf to reduce pain
B. Massage the calf to promote venous return
C. Instruct the patient to perform ankle pumps
D. Measure the circumference of the calf and notify the provider
CORRECT ANSWER: D. Measure the circumference of the calf and notify the
provider
Rationale:These signs are indicative of a potential deep vein thrombosis (DVT). The
nurse should measure the circumference of the leg to obtain an objective baseline and
notify the provider immediately. Massaging or applying heat to an extremity with a
suspected DVT is contraindicated as it could dislodge the clot.
Question 5: A nurse is reinforcing education to a patient prescribed a
monoamine oxidase inhibitor (MAOI) for depression. Which of the following
dietary items should the nurse emphasize the patient must avoid?
A. Aged cheese and cured meats
B. Green leafy vegetables
C. High-fiber cereals
D. Grapefruit juice
CORRECT ANSWER: A. Aged cheese and cured meats
Rationale:MAOIs can cause a hypertensive crisis when combined with foods high in
tyramine. Tyramine is found in aged cheeses, cured meats (e.g., salami, pepperoni),
fermented soy products, and certain alcoholic beverages. Grapefruit juice is a concern
with statins and some calcium channel blockers, not MAOIs.
Question 6: A patient with type 1 diabetes is experiencing nausea, vomiting,
and diarrhea. The patient's blood glucose level is 320 mg/dL. Which of the
following is the most appropriate instruction for the nurse to reinforce?
A. Hold the insulin until the nausea subsides
B. Check urine for ketones and drink clear liquids with sugar every hour
,C. Drink regular soda to maintain hydration
D. Administer an extra dose of NPH insulin immediately
CORRECT ANSWER: B. Check urine for ketones and drink clear liquids with
sugar every hour
Rationale:In a patient with type 1 diabetes who is ill, the risk of diabetic ketoacidosis
(DKA) is high. The patient should check for ketones. To prevent dehydration and
provide calories, they should consume clear liquids that contain sugar (e.g., regular
ginger ale, juice) in small amounts every hour, and continue to take their insulin. Insulin
should never be held during illness.
Question 7: A nurse is assisting with a sterile procedure and a sterile field has
been established. Which of the following actions by a team member indicates a
breach in sterile technique?
A. Placing a sterile item within 1 inch of the edge of the sterile field
B. The scrub nurse's sterile gown sleeve touches the edge of the sterile field
C. Pouring sterile solution from a bottle into a sterile basin on the field
D. Keeping hands above the waist while wearing sterile gloves
CORRECT ANSWER: B. The scrub nurse's sterile gown sleeve touches the edge
of the sterile field
Rationale:The 1-inch border of a sterile field is considered non-sterile. If a sterile item
touches this border, the item becomes contaminated. The scrub nurse's sleeve
becoming contaminated at the edge of the field breaks sterile technique. Pouring sterile
solution is acceptable if the bottle is not touched to the basin.
Question 8: A patient is receiving furosemide (Lasix) for heart failure. Which
of the following assessment findings is most indicative of a therapeutic
response to the medication?
A. Decreased blood pressure and increased heart rate
B. Weight loss of 2 pounds in 24 hours and clear lung sounds
C. Increased urinary output and elevated potassium level
D. Decrease in pedal edema and increase in jugular venous distention
CORRECT ANSWER: B. Weight loss of 2 pounds in 24 hours and clear lung
sounds
Rationale:Furosemide is a loop diuretic that reduces fluid volume overload. A
therapeutic response is demonstrated by a reduction in weight (indicative of fluid loss),
decreased peripheral edema, and clear lung sounds (indicative of resolution of
pulmonary congestion). Furosemide causes potassium loss, not elevation.
Question 9: A nurse is reinforcing education about home safety for a patient
with peripheral neuropathy in both feet. Which of the following statements by
the patient indicates an understanding of the teaching?
, A. "I will soak my feet in hot water every day to improve circulation."
B. "I will check the water temperature with my hands before bathing."
C. "I can use a heating pad on my feet to keep them warm at night."
D. "It is safe to walk barefoot inside my house to avoid falls."
CORRECT ANSWER: B. "I will check the water temperature with my hands
before bathing."
Rationale:Peripheral neuropathy leads to decreased sensation. The patient should use a
non-affected body part (like a hand or thermometer) to test water temperature to
prevent burns. Soaking feet, using heating pads, and walking barefoot all increase the
risk of injury and infection in patients with impaired sensation.
Question 10: A patient is being discharged with a prescription for digoxin and
hydrochlorothiazide. Which of the following signs or symptoms should the
nurse reinforce as an adverse effect to report to the provider?
A. Weight gain of 1 pound in a week
B. Visual disturbances such as seeing halos or yellow-green color
C. Muscle cramps and weakness
D. Increased urinary frequency
CORRECT ANSWER: B. Visual disturbances such as seeing halos or yellow-
green color
Rationale:Visual disturbances (e.g., halos, yellow-green color perception, blurred vision)
are classic signs of digoxin toxicity. The patient should report this to the provider
immediately. The combination of hydrochlorothiazide (which can cause hypokalemia)
and digoxin increases the risk of digoxin toxicity.
Question 11: A patient is admitted with a diagnosis of bacterial meningitis.
Which of the following infection control precautions should the nurse
implement immediately?
A. Standard Precautions only
B. Droplet Precautions
C. Contact Precautions
D. Airborne Precautions
CORRECT ANSWER: B. Droplet Precautions
Rationale:Bacterial meningitis is transmitted via respiratory droplets. Droplet
Precautions (private room or cohort, and mask within 3 feet of the patient) are required
until the patient has been on antibiotics for 24 hours. Airborne Precautions are for
diseases like tuberculosis and measles, while Contact Precautions are for conditions like
C. difficile or MRSA.
Question 12: A nurse is reinforcing instructions to a patient who is starting a
low-sodium diet. Which of the following foods is the most appropriate to
include in the patient's diet plan?
