LVN Patient Care & Clinical Procedures 2 — Questions and Answers
Question 1: When inserting a urinary catheter in a female patient, which step is performed immediately before inserting the catheter into the urethra?
- Apply sterile lubricant to the catheter tip
- Clean the urethral meatus with antiseptic solution (Correct answer)
- Inflate the balloon with sterile water
- Position the drainage bag below bladder level
Correct answer: Clean the urethral meatus with antiseptic solution
The urethral meatus must be cleaned with antiseptic from front to back immediately before catheter insertion to reduce infection risk.
Question 2: A patient's NG tube feeding is running at 60 mL/hr. Before beginning the next feeding, the nurse aspirates 250 mL of residual. The facility's threshold is 200 mL. What is the priority action?
- Discard the residual and continue the feeding
- Return the aspirate and hold the feeding, then reassess in 1 hour (Correct answer)
- Increase the infusion rate to clear the residual
- Remove the NG tube and notify the provider
Correct answer: Return the aspirate and hold the feeding, then reassess in 1 hour
When gastric residual exceeds the facility threshold, the aspirate is returned to prevent electrolyte loss, the feeding is held, and the patient is reassessed.
Question 3: While performing a sterile dressing change, the nurse accidentally touches the sterile field with an ungloved hand. What should the nurse do?
- Continue if only the edge was touched
- Apply hand sanitizer and resume the procedure
- Discard the sterile field and obtain new supplies (Correct answer)
- Don sterile gloves and proceed
Correct answer: Discard the sterile field and obtain new supplies
Any contact of a non-sterile item with the sterile field contaminates it entirely; the field must be discarded and a new sterile setup obtained.
Question 4: Which position is most appropriate for a patient experiencing an acute asthma attack?
- Supine with legs elevated
- High Fowler's (90 degrees) (Correct answer)
- Left lateral (Sims') position
- Trendelenburg position
Correct answer: High Fowler's (90 degrees)
High Fowler's position maximizes lung expansion and reduces the work of breathing during respiratory distress.
Question 5: A patient has a prescribed PRN analgesic. She rates her pain 7/10 and requests medication. The nurse notes she last received the dose 3 hours ago and the interval is every 4 hours. What is the correct action?
- Administer the medication because pain is subjective
- Ask the patient to wait one more hour, reassess, and offer non-pharmacologic comfort measures (Correct answer)
- Contact the provider for a new order with a shorter interval
- Document that the medication was withheld without notifying anyone
Correct answer: Ask the patient to wait one more hour, reassess, and offer non-pharmacologic comfort measures
The prescribed interval has not elapsed, so the nurse should inform the patient, offer comfort measures, and reassess at the appropriate time.
Question 6: When collecting a midstream clean-catch urine specimen, which instruction is most important to give the patient?
- Collect the first stream of urine in the container
- Begin urinating, then collect mid-flow urine in the sterile cup (Correct answer)
- Collect urine after 8 hours of fluid restriction
- Refrigerate the specimen for 24 hours before submission
Correct answer: Begin urinating, then collect mid-flow urine in the sterile cup
A midstream sample is collected after the initial urine flow has flushed urethral contaminants, improving specimen accuracy.
Question 7: The nurse is preparing to administer a subcutaneous injection. Which gauge and length needle is most appropriate for a subcutaneous injection in an average-sized adult?
- 18 gauge, 1.5 inches
- 25 gauge, 5/8 inch (Correct answer)
- 14 gauge, 1 inch
- 21 gauge, 1 inch
Correct answer: 25 gauge, 5/8 inch
Subcutaneous injections require a fine-gauge (25–27 G), short (5/8–1/2 inch) needle to reach the subcutaneous tissue without penetrating muscle.
LVN Patient Care & Clinical Procedures 2
When inserting a urinary catheter in a female patient, which step is performed immediately before inserting the catheter into the urethra?