LVN Patient Care & Clinical Procedures 4 — Questions and Answers
Question 1: A patient is prescribed heparin 5,000 units subcutaneously. The vial contains 10,000 units/mL. How many mL should the nurse administer?
- 0.25 mL
- 0.5 mL (Correct answer)
- 1 mL
- 2 mL
Correct answer: 0.5 mL
5,000 units ÷ 10,000 units/mL = 0.5 mL, the correct dose calculation.
Question 2: Which action by the LVN best demonstrates correct technique when performing nasotracheal suctioning?
- Apply suction continuously while inserting the catheter
- Limit each suction pass to 10–15 seconds (Correct answer)
- Suction the patient every hour regardless of clinical signs
- Use a higher suction pressure to clear secretions quickly
Correct answer: Limit each suction pass to 10–15 seconds
Each suction pass must be limited to 10–15 seconds to prevent hypoxia and mucosal trauma.
Question 3: A nurse is assessing a stage 2 pressure injury. Which finding is consistent with this stage?
- Full-thickness tissue loss with exposed bone
- Partial-thickness loss of dermis presenting as a shallow open ulcer (Correct answer)
- Intact skin with non-blanchable redness
- Deep tissue injury with purple discoloration
Correct answer: Partial-thickness loss of dermis presenting as a shallow open ulcer
Stage 2 pressure injuries involve partial-thickness skin loss affecting the epidermis and/or dermis, presenting as a shallow open ulcer or intact blister.
Question 4: Which action should the nurse take when administering a tube feeding to prevent aspiration?
- Place the patient supine with the head of bed flat
- Elevate the head of the bed to at least 30–45 degrees (Correct answer)
- Administer feedings rapidly to reduce exposure time
- Clamp the tube immediately after feeding without flushing
Correct answer: Elevate the head of the bed to at least 30–45 degrees
Elevating the head of the bed 30–45 degrees uses gravity to reduce the risk of gastric reflux and aspiration.
Question 5: A patient who has been on bed rest for 5 days is being assisted to ambulate for the first time. She reports feeling lightheaded when she stands. What is the nurse's best response?
- Help the patient walk quickly to overcome the dizziness
- Have the patient sit back down, take vital signs, and notify the provider (Correct answer)
- Reassure the patient that dizziness is normal and continue walking
- Apply oxygen via nasal cannula and proceed with ambulation
Correct answer: Have the patient sit back down, take vital signs, and notify the provider
Lightheadedness on standing may indicate orthostatic hypotension; the patient should sit down and vital signs should be taken before proceeding.
Question 6: When performing a two-person transfer from bed to wheelchair, where should the wheelchair be positioned?
- Directly in front of the bed at a 90-degree angle
- On the patient's weaker side at a 45-degree angle to the bed
- On the patient's stronger side at a 45-degree angle to the bed (Correct answer)
- At the foot of the bed parallel to it
Correct answer: On the patient's stronger side at a 45-degree angle to the bed
Positioning the wheelchair on the patient's stronger side allows the stronger limb to bear weight and pivot, making the transfer safer.
Question 7: A patient's IV infusion infiltrates. The fluid being infused is a vesicant. What is the priority nursing action?
- Slow the infusion rate and continue monitoring
- Stop the infusion and remove the IV catheter immediately (Correct answer)
- Apply a warm compress to improve absorption
- Aspirate from the catheter before removing it
Correct answer: Stop the infusion and remove the IV catheter immediately
Vesicant solutions cause tissue necrosis if they infiltrate; the infusion must be stopped and the catheter removed immediately to minimize tissue damage.
LVN Patient Care & Clinical Procedures 4
A patient is prescribed heparin 5,000 units subcutaneously.
The vial contains 10,000 units/mL.
How many mL should the nurse administer?