Week 4

Question 1

The nurse is placing supplies on a sterile field that is being prepared for a dressing change. Which action is likely to contaminate the field?

Answer 1

Placing the needed supplies near the back of the sterile field

Question 2

A patient requires all of the following interventions. Which one would the nurse perform last?

Answer 2

Change the dressing on the patient’s newly established suprapubic catheter.

Question 3

Which direction to an unregulated care provider (UCP) would help to maintain a sterile field while conducting a sterile procedure?

Answer 3

“I’d like you to make sure that the patient doesn’t reach toward the sterile field while I’m changing the dressing.”

Question 4

While preparing supplies on a sterile field, a gauze pad falls off the sterile field. What should the nurse do?

Answer 4

nothing, The gauze fell outside the sterile field, and the field has not been contaminated. The nurse can leave the gauze where it is and discard it with the other used supplies at the conclusion of the procedure

Question 5

Which action would minimize the risk of infection when placing prepackaged supplies on an established sterile field?

Answer 5

Do not allow the wrapper to touch the sterile field

Question 6

A nurse is assessing a patient’s neck. Which of the following is considered an expected finding?

Answer 6

Midline trachea

Question 7

Which symptom found when examining the head would be a cause for concern?

Answer 7

Bruits in the temporal arteries may indicate a vascular anomaly in the brain.

Question 8

What information should be included when entering documentation of an enlarged lymph node?

Answer 8

Location, size, and shape
Consistency and tenderness
Discreteness and movability
All of these choices Correct

Question 9

When assessing lymph nodes, it is important to do which of the following?

Answer 9

Both comparing the lymph nodes bilaterally and providing privacy for the patient.

Question 10

Which lymph nodes are located in the depression above and posterior to the medial condyle of the humerus?

Answer 10

Epitrochlear lymph nodes are found in the forearms.

Question 11

In which position should the patient be placed in order to palpate the popliteal pulse?

Answer 11

Have the patient lie prone with the knee flexed.

Question 12

Hearing a bruit in an artery is a sign of which of the following conditions?

Answer 12

An obstruction

Question 13

What is a depression that is left after pressing a finger or thumb on swollen tissue called?

Answer 13

Pitting edema

Question 14

Normal capillary refill is less than 2 seconds and is assessed by

Answer 14

pressing on the nail bed until it blanches, and observing how quickly full colour returns.

Question 15

Normal capillary refill in an infant is

Answer 15

<1 second.

Question 16

A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse’s responsibility in assessing this patient’s wound?

Answer 16

Wait until the health care provider prescribes the removal of the surgical dressing.

Question 17

Which wound would be allowed to heal by secondary intention?

Answer 17

Infected hysterectomy incision because it is an infected surgical wound.

Question 18

Before performing a wound assessment, which nursing action would reduce the patient’s risk for infection?

Answer 18

Applying clean gloves

Question 19

Which intervention can the nurse delegate to the unregulated care provider (UCP) in caring for a patient with a wound?

Answer 19

Reporting the presence of wound odour

Question 20

The nurse notes that a patient’s surgical wound is healing slowly. Which health problem would contribute to slow wound healing?

Answer 20

Diabetes mellitus

Question 21

The health care provider writes a prescription for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first?

Answer 21

Review the prescription to determine the type of specimen to be collected

Question 22

Which action would the nurse take to minimize exposure to microorganisms when collecting a specimen for culture?

Answer 22

Collect the specimen while wearing clean gloves.

Question 23

Which question might the nurse ask the patient when an aerobic wound culture has been prescribed?

Answer 23

“Do you have any pain at the wound site?

Question 24

Which instruction might the nurse give to the unregulated care provider (UCP) to help ensure that a wound culture specimen will be transported properly?

Answer 24

“Take this specimen to the lab immediately.”

Question 25

which nursing action demonstrates proper procedure in the collection of a wound culture specimen?

Answer 25

Wearing clean gloves to remove soiled dressings

Question 26

What is the best reason for a nurse to select a prepackaged sterile kit for a sterile procedure?

Answer 26

The wrapper of the sterile kit can be used as a sterile field.

Question 27

which action is the most important step the nurse can take to keep the field sterile when using an overbed table as the work surface for a sterile field?

Answer 27

Position the height of the table to be above waist level.

Question 28

While opening a prepackaged sterile kit, a package of sterile 4 × 4-in gauze pads falls to the floor. What will the nurse ask ancillary staff to do to ensure the integrity of the sterile field?

Answer 28

“Please go to the clean utility room and get me a package of sterile 4 × 4-in gauze pads.”

Question 29

When preparing a sterile field using a prepackaged sterile kit, what will influence the nurse’s placement of the kit on the overbed table?

Answer 29

The outermost flap can be opened away from the nurse’s body.

Question 30

Before setting up a sterile field for a sterile procedure in a patient’s room, why would the nurse ask any visitors to please leave the patient’s bedside?

Answer 30

Ensures that no unnecessary movement occurs that could contaminate the sterile field.

Question 31

The nurse is preparing to perform a sterile procedure for a patient. Which action will best minimize the risk of infection during the procedure?

Answer 31

Follow sterile technique during the procedure.

Question 32

While preparing a sterile field, the nurse determines that additional supplies are needed. What will the nurse do to ensure that the sterile field is maintained?

Answer 32

Ask the assistant who has been helping with the procedure to bring the necessary supplies.

Question 33

What direction would the nurse provide to the unregulated care provider (UCP) while establishing and maintaining a sterile field?

Answer 33

“Remember, reaching over the sterile field constitutes a break in sterile technique.”

Question 34

While preparing a sterile field, the nurse notes that a portion of the sterile drape has come into contact with the patient’s gown. Which action is most appropriate in this situation?

Answer 34

Collect the supplies necessary and establish a new sterile field.

Question 35

Why might the nurse offer the patient a bedpan before establishing a sterile field?

Answer 35

Anticipating what the patient might need during a lengthy sterile procedure will minimize patient movement.

Question 36

Which practice protects the nurse from infection when changing the dressing on an infected pressure injury?

Answer 36

Use appropriate personal protective equipment.

Question 37

The wound bed of a patient’s pressure injury is red. What does this finding indicate to the nurse?

Answer 37

Granulation tissue

Question 38

Which measurements would the nurse use to calculate the surface area of a patient’s pressure injury?

Answer 38

Length and width

Question 39

How would the nurse safely apply an enzyme debridement ointment?

Answer 39

Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.