Editing Management of Care – LPN Practice Questions (section)

==Question 4==
A licensed practical nurse is caring for four clients. Which finding should be reported to the supervising registered nurse '''immediately'''?
# A client with heart failure whose weight has increased 1 kg (2.2 lb) since yesterday morning.
# A client with an indwelling urinary catheter whose output was 60 mL over the past hour.
# A client 1 day postoperative who reports incisional pain of 5 on a 0 to 10 scale, relieved by the ordered analgesic.
# A client with type 2 diabetes mellitus whose fasting blood glucose is 118 mg/dL.

'''Answer:''' 1. The client with heart failure whose weight has increased 1 kg (2.2 lb) since yesterday morning.

''Rationale:'' A 1 kg gain in 24 hours corresponds to roughly 1 L of retained fluid and signals worsening heart failure before crackles or dyspnea may be evident. This is an unexpected change that requires the registered nurse's assessment. Option 2 is adequate output, since 60 mL/hr exceeds the minimum of about 30 mL/hr. Option 3 is expected postoperative pain that responded to treatment. Option 4 is a mildly elevated but non-urgent fasting glucose. The LPN's central responsibility is to distinguish an expected finding from a change that must be escalated.