LVN Patient Care & Clinical Procedures 5 — Questions and Answers
Question 1: The nurse is preparing a patient for a colonoscopy. Which patient statement indicates a need for further teaching?
- I will drink only clear liquids the day before the procedure
- I need to take the bowel prep solution as instructed
- I can eat a light breakfast the morning of the procedure (Correct answer)
- I should arrange for someone to drive me home afterward
Correct answer: I can eat a light breakfast the morning of the procedure
Patients undergoing colonoscopy must have nothing by mouth (NPO) after midnight or per facility policy; eating breakfast would contraindicate the procedure.
Question 2: A nurse notes that a patient's indwelling urinary catheter drainage bag contains 30 mL of urine over 2 hours. What is the priority action?
- Document the finding as normal output
- Check for catheter kinks or obstruction, then notify the provider (Correct answer)
- Increase IV fluids without a provider order
- Remove and replace the catheter immediately
Correct answer: Check for catheter kinks or obstruction, then notify the provider
Output less than 30 mL/hr suggests oliguria; the nurse should first check for mechanical obstruction, then report to the provider.
Question 3: Which technique should the nurse use to confirm correct nasogastric tube placement before initiating a feeding?
- Instill air and listen for gurgling over the stomach, then confirm with an X-ray reading
- Observe for bubbling when the tube end is placed in water
- Test the pH of aspirated contents — a pH of 0–4 indicates gastric placement (Correct answer)
- Pull back slightly on the tube and observe for resistance
Correct answer: Test the pH of aspirated contents — a pH of 0–4 indicates gastric placement
Aspirate pH of 0–4 is the most reliable bedside method to confirm gastric placement; radiographic confirmation is the gold standard initially.
Question 4: A patient receiving a blood transfusion develops chills, fever, and back pain 15 minutes into the infusion. What is the nurse's first action?
- Slow the transfusion rate and monitor closely
- Stop the transfusion and keep the IV line open with normal saline (Correct answer)
- Administer diphenhydramine and continue the transfusion
- Increase the transfusion rate to complete it quickly
Correct answer: Stop the transfusion and keep the IV line open with normal saline
These are signs of a hemolytic transfusion reaction; the transfusion must be stopped immediately and the IV kept open with NS for possible medications.
Question 5: When performing range-of-motion exercises on a patient's shoulder, the nurse moves the arm in a large circle. This motion is called:
- Abduction
- Circumduction (Correct answer)
- Pronation
- Supination
Correct answer: Circumduction
Circumduction is the movement of a limb in a circular pattern, combining flexion, extension, abduction, and adduction.
Question 6: A patient has an order for a warm soak to the right hand for 20 minutes. Which water temperature is appropriate for this procedure?
- 98–100°F (36.7–37.8°C)
- 105–110°F (40.6–43.3°C) (Correct answer)
- 115–120°F (46.1–48.9°C)
- 90–95°F (32.2–35°C)
Correct answer: 105–110°F (40.6–43.3°C)
The recommended temperature for warm soaks is 105–110°F to provide therapeutic warmth without risking tissue damage.
Question 7: The nurse is caring for a patient with a wound drain (Jackson-Pratt). Which action is correct when emptying the drain?
- Squeeze the bulb, cap it while compressed to re-establish suction, then record the output (Correct answer)
- Leave the bulb uncapped to allow continuous drainage
- Irrigate the drain with normal saline before re-capping
- Empty the drain only when it is completely full
Correct answer: Squeeze the bulb, cap it while compressed to re-establish suction, then record the output
JP drains work by negative pressure; the bulb must be squeezed, then capped while compressed so suction draws wound drainage into the collection chamber.
LVN Patient Care & Clinical Procedures 5
The nurse is preparing a patient for a colonoscopy.
Which patient statement indicates a need for further teaching?