Editing Medical-Surgical Nursing – LPN Practice Questions (section)

==Question 3==
While collecting data on a patient with heart failure, the licensed practical nurse notes several findings. Which findings should be reported to the registered nurse? '''Select all that apply.'''
# Weight gain of 3 pounds since yesterday morning.
# New crackles heard in both lung bases.
# The patient sleeps on two pillows, as he has for the past year.
# Oxygen saturation of 88 percent on room air, down from 96 percent.
# Ankle edema that decreases overnight, unchanged from admission.

'''Answer:''' Options 1, 2, and 4.

''Rationale:'' A gain of 2 to 3 pounds in one day indicates acute fluid retention. New crackles indicate fluid backing up into the lungs. A drop in oxygen saturation to 88 percent is significant and must be reported. Options 3 and 5 describe chronic, unchanged findings that are already known and expected in heart failure, so they are documented rather than reported urgently.