LVN Patient Care & Clinical Procedures 3 — Questions and Answers
Question 1: A nurse is applying sequential compression devices (SCDs) to a postoperative patient. Which assessment finding is a contraindication for SCD use?
- Patient has a BMI of 30
- Patient has a deep vein thrombosis in the left leg (Correct answer)
- Patient received anticoagulants 6 hours ago
- Patient is ambulating twice daily
Correct answer: Patient has a deep vein thrombosis in the left leg
SCDs are contraindicated in confirmed DVT because the compression could dislodge a clot and cause a pulmonary embolism.
Question 2: A patient develops redness, swelling, and warmth at an IV site. The nurse stops the infusion. What is the next priority action?
- Restart the IV in the same vein distal to the site
- Apply a warm compress and document the finding
- Remove the IV catheter and apply pressure (Correct answer)
- Increase the infusion rate to flush the site
Correct answer: Remove the IV catheter and apply pressure
Signs of phlebitis or infiltration require immediate removal of the IV catheter to prevent further tissue damage.
Question 3: During a bed bath, the nurse should wash the patient's body in which sequence?
- Face → arms → chest → abdomen → perineum → legs → back (Correct answer)
- Perineum → legs → abdomen → chest → arms → face → back
- Back → face → arms → chest → abdomen → legs → perineum
- Legs → back → chest → abdomen → perineum → arms → face
Correct answer: Face → arms → chest → abdomen → perineum → legs → back
The bed bath proceeds from cleanest to most contaminated areas, starting at the face and ending with the perineum and back.
Question 4: A nurse is performing postural drainage on a patient. The patient suddenly becomes dyspneic and cyanotic. What is the priority action?
- Continue drainage because dyspnea is expected
- Return the patient to a normal anatomical position and call for help (Correct answer)
- Place the patient in Trendelenburg and suction
- Increase supplemental oxygen and continue the procedure
Correct answer: Return the patient to a normal anatomical position and call for help
Acute dyspnea and cyanosis during postural drainage indicate the procedure must be stopped immediately and the patient repositioned upright.
Question 5: When applying a transdermal medication patch, what must the nurse do before applying the new patch?
- Apply the new patch over the old site for consistent absorption
- Remove the previous patch and clean the skin thoroughly (Correct answer)
- Allow 4 hours between removing the old patch and applying the new one
- Apply the patch over a bony prominence for best absorption
Correct answer: Remove the previous patch and clean the skin thoroughly
The old patch must be removed and the skin cleaned to prevent medication accumulation and overdose.
Question 6: A patient with a tracheostomy begins coughing and the inner cannula becomes dislodged. What is the nurse's immediate action?
- Call the respiratory therapist before doing anything
- Replace the inner cannula with a clean one immediately (Correct answer)
- Insert a suction catheter through the outer cannula to maintain airway patency
- Cover the tracheostomy with a moist gauze and notify the provider
Correct answer: Replace the inner cannula with a clean one immediately
Replacing the inner cannula restores airway patency and is within the LVN's scope of care during a non-emergency dislodgment.
Question 7: The nurse is caring for a patient in Buck's traction. Which nursing action is most important to prevent skin breakdown?
- Remove the traction boot every 8 hours and inspect the skin (Correct answer)
- Increase traction weight to reduce movement
- Keep the head of the bed elevated above 60 degrees at all times
- Massage reddened bony prominences vigorously
Correct answer: Remove the traction boot every 8 hours and inspect the skin
Regular skin assessment under traction devices identifies early signs of pressure injury and allows corrective action.
LVN Patient Care & Clinical Procedures 3
A nurse is applying sequential compression devices (SCDs) to a postoperative patient.
Which assessment finding is a contraindication for SCD use?