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Chapter 48 P&P
ASSESSING WOUNDS QUIZ
MULTIPLE CHOICE
1. The priority intervention when a wound assessment suggests the presence of an infection is to:
1. Notify the physician immediately.
2. Draw blood for a white blood cell count.
3. Don treatment gloves to prevent contamination.
4. Measure the patient’s temperature to confirm the infection.
ANS: 1
1
2
3
4
Feedback
This is the priority intervention because the plan of care regarding infections is a
medical responsibility.
This is not the priority intervention because the diagnostic test must be ordered by a
primary health care provider.
Although this is required to prevent cross-contamination, it is not the priority
intervention because the primary issue at this point is treatment of the infection.
This is not the priority intervention because the diagnosis of an infection will not
depend solely on the patient’s temperature.
2. Which of the following wounds is the best example of tertiary wound healing?
1. Cleft lip repair
2. Eviscerated hysterectomy incision
3. Exploratory laparoscopy incision
4. Facial laceration caused by a knife
ANS: 2
1
2
3
4
Feedback
This is not the best example because it is a surgical procedure.
This is the correct option because the likelihood of infection is great.
This is not the best example because it is a surgical procedure.
This is not the best example because there is no tissue loss.
3. Which of the following statements shows the best understanding of the nursing actions appropriate for
infection control regarding a surgical wound?
1. "If it’s a surgical wound, then it’s always sterile technique."
2. "It takes a physician’s order to initially remove a surgical dressing."
3. "The primary reason to assess a surgical wound is to monitor for infection."
4. "Monitoring the post-surgical patient’s temperature is vital in detecting an infection"
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ANS: 1
1
2
3
4
Feedback
This is the correct option because it identifies the proper infection control technique
for surgical wounds.
This is not the correct option; although it deals with the issue, it does not present a
nursing action.
This is not the correct option; although it deals with the issue, it does not present a
nursing action.
This is not the correct option because another option has a more direct connection to
nursing actions.
4. Which of the following interventions can the nurse delegate to ancillary staff regarding the care of a
patient with a leg laceration that has been sutured and dressed?
1. Assessing the site for signs of redness or swelling
2. Measuring the patient’s temperature every 4 hours
3. Removing the outer dressing when it becomes soiled
4. Opening sterile dressings during the dressing change
ANS: 2
1
2
3
4
Feedback
This is not the correct option because assessing is not a task that can be delegated to
ancillary staff.
This is the correct option because measuring temperature is a task that can be
delegated to ancillary staff.
This is not the correct option because it is not within the ancillary staff’s scope of
practice.
This is not the correct option because it is not within the ancillary staff’s scope of
practice.
5. Which of the following observations noted of a surgical suture line during the initial dressing change is
the best indicator of a complication that should be reported to the physician immediately?
1. Edema at the outer edges
2. Bruising around the wound
3. Redness around the sutures
4. Frank bleeding from the wound
ANS: 4
Feedback
3
1
2
3
4
This option is not the correct option because it is not unusual for the first 2 to 3 days
after surgery.
This option is not the correct option because it is not unusual for the first 2 to 3 days
after surgery.
This option is not the correct option because it is not unusual for the first 2 to 3 days
after surgery.
This is the correct option because frank (new) bleeding is not an expected observation
and requires the immediate attention of the patient’s physician.
CARING FOR PRESSURE ULCERS QUIZ
MULTIPLE CHOICE
1. Which of the following actions is most likely to protect the staff during the dressing change of an
infected pressure ulcer?
1. Beginning antibiotic therapy before the dressing change
2. Using appropriate personal protective equipment
3. Adhering to sterile technique during the intervention
4. Completing the dressing change in an effective, time-efficient manner
ANS: 2
1
2
3
4
Feedback
This is not the correct option because the wound is infected.
This is the correct option because it will minimize staff contact with contaminated
items and fluids during the dressing change.
This is not the correct option because it is directed toward minimizing the patient’s risk
of infection.
This is not the correct option because it is standard for all dressing changes and is not
as effective for infection control as another available option.
2. Which of the following assessment observations would be most indicative of healthy wound healing?
1. Absence of eschar
2. Presence of slough
3. Presence of granulation
4. Small wound size compared with original wound
ANS: 4
1
2
Feedback
This is not the correct option because the absence of eschar is not representative of
healthy healing.
This is not the correct option because the presence of slough is not representative of
healthy healing.
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3
4
This is not the correct option because another available option is a better indicator of
healthy wound healing.
This is the correct option because there is evidence of actual wound healing.
3. Which of the following characteristics is most likely that of a Stage 2 pressure ulcer?
1. Eschar
2. Blister
3. Deep crater
4. Nonblanchable redness
ANS: 2
1
2
3
4
Feedback
This is not the correct option because eschar is not characteristic of a Stage 2 pressure
ulcer.
This is the correct option because it includes a typical Stage 2 characteristic.
This is not the correct option because a deep crater is not characteristic of a Stage 2
pressure ulcer.
This is not the correct option because nonblanchable redness is not characteristic of a
Stage 2 pressure ulcer.
4. Which of the following statements best addresses the need to safely apply an enzyme débridement
ointment?
1. "Enzyme ointments attach the dead tissue so healing can occur."
2. "Place the ointment on a tongue blade and gently spread it on the wound."
3. "Apply the ointment, being careful to avoid contact with surrounding skin."
4. "Cover the wound with a gauze dressing to ensure contact with the ointment."
ANS: 3
1
2
3
4
Feedback
This is not the correct option because it does not deal with safe application of the
enzymatic ointment.
This is not the correct option because another available option deals with a more
important safety issue.
This is the correct option because it deals with preventing unnecessary tissue damage
from the débridement of healthy surrounding skin.
This is not the correct option because another available option deals with a more
important safety issue.
5. Which of the following interventions can the nurse delegate to ancillary staff regarding the prevention
of pressure ulcers on an elderly dependent patient?
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1.
2.
3.
4.
Repositioning the patient at least every 2 hours
Assessing the patient’s bony prominences every shift
Educating the family to the importance of healthy skin
Assisting the patient in the selection of high-protein foods
ANS: 1
1
2
3
4
Feedback
This is the correct option because repositioning is within the ancillary staff’s scope of
practice and will help minimize the pressure to which the patient’s bony prominences
will be subjected.
This is not the correct option because it is not within the ancillary staff’s scope of
practice.
This is not the correct option because it is not within the ancillary staff’s scope of
practice.
This is not the correct option because it is not within the ancillary staff’s scope of
practice.
CHANGING A DRESSING QUIZ
MULTIPLE CHOICE
1. Which of these interventions is most likely to minimize pain caused by the dressing change?
1. Pre-medicating the patient with an analgesic 30-45 minutes before the intervention
2. Using distraction techniques to divert the patient during the procedure
3. Placing the patient in a comfortable position in preparation for the change
4. Providing the patient with a thorough explanation of the procedure
ANS: 1
1
2
3
4
Feedback
This is the correct option because it will directly affect the pain the patient will
experience during the dressing change
This is not the correct option because another available option is the primary
intervention for managing the patient’s pain during the procedure.
This is not the correct option because another available option is the primary
intervention for managing the patient’s pain during the procedure.
This is not the correct option because another available option is the primary
intervention for managing the patient’s pain during the procedure.
2. Which of the following actions is most likely to protect the staff during the dressing change of an
infected abdominal wound?
1. Beginning antibiotic therapy before the surgical procedure
2. Using appropriate personal protective equipment
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3. Adhering to sterile technique during the intervention
4. Completing the dressing change in an effective, time-efficient manner
ANS: 2
1
2
3
4
Feedback
This is not the correct option because the wound is infected.
This is the correct option because these measures will minimize staff contact with
contaminated items and fluids during the dressing change.
This is not the correct option because these measure are directed toward minimizing
the patient’s risk of infection.
This is not the correct option because these measures are standard for all dressing
changes and are not as effective in infection control as another available option.
3. Which of the following measures should be taken when the nurse observes additional bloody drainage
on the initial abdominal dressing of a patient who had surgery 7 hours ago?
1. Notify the patient’s physician of the bleeding.
2. Remove the dressing and assess the wound.
3. Assess the patient for signs of shock.
4. Reinforce the dressing externally.
ANS: 4
1
2
3
4
Feedback
This is not the correct option because such drainage does not indicate a surgical
complication at this point in the patient’s recovery.
This is not the correct option because removing the initial surgical dressing should not
be done without a physician’s order to do so.
This is not the correct option because such assessment observations are not unusual at
this point in the patient’s recovery.
This is the correct option because it suggests the appropriate action, adding additional
dressing materials to the outside of the initial dressing.
4. When changing a surgical dressing, the appropriate time to don sterile gloves is:
1. After performing the initial hand hygiene.
2. Before removing the inner layer of dressings.
3. After removing the original dressing materials.
4. Before cleansing the wound with sterile water.
ANS: 3
Feedback
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1
2
3
4
This is not the correct option because this will compromise the sterility of the gloves.
This is not the correct option because this will compromise the sterility of the gloves.
This is the correct option because all of the contaminated materials have been
removed.
This is not the correct option because this action occurs after actions that require
sterile technique.
5. Which of the following actions will minimize the risk of cross-contamination during the cleansing process
of an infected abdominal surgical wound?
1. Using sterile water for the cleansing process
2. Using dry gauze to blot the incisional area dry
3. Using sterile gloves when cleansing the wound
4. Using a new gauze pad for each cleansing stroke
ANS: 4
1
2
3
4
Feedback
This is not the correct option because it is direct toward providing a pathogen-free
cleaning fluid.
This is not the correct option because it is directed toward drying, not cleansing.
This is not the correct option because the presence of sterile gloves minimizes the
introduction of pathogens, not the cross-contamination of pathogens already within
the wound.
This is the correct option because this measure minimizes cross-contamination by not
reintroducing contaminated gauze into other areas of the wound.
IRRIGATING WOUNDS QUIZ
MULTIPLE CHOICE
1. When irrigating a wound, the pressure of the lavage should be:
1. Determined by wound size.
2. Kept to between 4 and 15 psi.
3. Minimal enough to not cause pain.
4. Cooled to discourage pathogen growth.
ANS: 2
1
2
3
Feedback
The amount of irrigant, not the pressure, is determined by wound size.
This is the correct option; less pressure would not be effective, although more is likely
to cause tissue damage.
Irrigation is likely to cause pain; pre-intervention administration of an analgesic is often
recommended.
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4
This is not encouraged because it is not likely to be effective and can increase the
discomfort of the intervention.
2. Which of the following actions should be addressed first when preparing to irrigate a patient's foot
wound for the first time?
1. Assess the patient for a history of allergies to tapes and irrigating solutions.
2. Review the physician’s order for the type of irrigation solution to be used.
3. Assess the patient’s pain on a scale of 0 to 10.
4. Warm the irrigant to body temperature.
ANS: 2
1
2
3
4
Feedback
This is not the first action because the other available options represent actions
required before this one can be effectively addressed.
This is the correct option because the order must be reviewed for clarity and
completeness before initiating the intervention.
Although appropriate before the initiation of the intervention, other options represent
actions that have priority over this one.
Although appropriate before the initiation of the intervention, other options represent
actions that have priority over this one.
3. Which of the following devices should be used to ensure the appropriate amount of irrigating pressure
during a wound irrigation?
1. 10-ml syringe with a 19-gauge needle attached
2. 35-ml syringe with a 19-gauge needle attached
3. Steady flow of fluid from a height of 12 inches above the wound
4. Steady but gentle squirt of irrigant through a Foley irrigating syringe
ANS: 2
1
2
3
4
Feedback
This is not the correct option because it suggests the use of a syringe that will not be
effective in producing a sufficient quantity of irrigant and/or pressure within the
recommended limits.
This is the correct option because it will produce a sufficient quantity of irrigant and/or
pressure within the recommended limits.
This is not the correct option because it suggests the use of a syringe that will not be
effective in producing a sufficient quantity of irrigant and/or pressure within the
recommended limits.
This is not the correct option because it suggests the use of a syringe that will not be
effective in producing a sufficient quantity of irrigant and/or pressure within the
recommended limits.
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4. When initiating irrigation of a pressure ulcer located on a patient’s left heel, which diagnostic result
should be reviewed to determine the patient’s risk or infection?
1. White blood cell (WBC) count
2. Complete blood cell count
3. Radiology report of left foot X-ray
4. Culture and sensitivity of the wound
ANS: 4
1
2
3
4
Feedback
Although an elevated WBC count indicates an infection, another more related option is
available.
This is not the correct option because another more related option is available.
This is not the correct option because an X-ray is not useful in determining risk for
infection.
This is the correct option because this diagnostic test is directly related to the
identification of a local infection that could be present in the wound.
5. Which of the following observations noted during the irrigation of a patient's 2-day post-surgical
abdominal wound should be reported to the physician immediately?
1. Drainage that was not present previously
2. Redness observed at the abdominal suture line
3. Presence of granulation tissue in the wound bed
4. Patient reporting pain of 6 out of 10 after the intervention
ANS: 1
1
2
3
4
Feedback
This option is the correct option because the presence of new drainage indicates a
complication in the healing process.
This option is not the correct option because the presence of redness at the incision
site does not necessarily indicate a complication in the healing process at this time.
This option is not the correct option because granulation is a positive sign of wound
healing.
This is not the correct option because pain is an expected outcome of surgery and
wound care at this time.
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USING WOUND DRAINAGE SYSTEMS QUIZ
MULTIPLE CHOICE
1. Which of the following actions is the proper method for cleaning the evacuation port of a wound drainage system?
1. Cleanse with normal saline
2. Wash it with soap, warm water
3. Rinse it only with sterile water
4. Wipe it with an alcohol sponge
ANS: 4
Feedback
1
2
3
4
This is not the correct option; there is another available option that is the recommended as the
proper cleaning method
This is not the correct option; there is another available option that is the recommended as the
proper cleaning method
This is not the correct option; there is another available option that is the recommended as the
proper cleaning method
This is the correct option; it is recommended that the nurse, with a clean gloved hand, cleanse
the port and plug with the alcohol sponge.
2.
Which of the following actions is correct when the order for a Hemovac did not include specific instructions
regarding the amount of suction to be used?
1.
2.
3.
4.
Set the suction at the lowest level
Assume that there is to be no suction applied
Begin at low and gradually increase the pressure until drainage is noted in the tubing
Call the physician to clarify the prescription regarding the amount of suction to be applied
ANS: 1
Feedback
1
2
3
4
This is the correct option
This is not the correct option since the Hemovac’s purpose is to apply suction to the wound
This is not the correct option: there is an available option that suggests the proper action
This is not the correct option: there is an available option that suggests the proper action
3. Which of the following statements made by ancillary staff assigned the responsibility of emptying a Jackson Pratt
drain reflects the best understanding regarding the need to report possible abnormalities related to the patient’s
wound and it drainage?
1. “There is no odor from the drainage.”
2. “The drainage has changed to a straw color.”
3. “The patient doesn’t like looking at the drainage tubing.”
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4. “There was more drainage today than there was yesterday.”
ANS: 4
Feedback
1
This is not the correct option; there is an available option that includes information that needs
to be immediately reported to the nurse.
2
This is not the correct option since it is not an unusual occurrence; there is an available option
that includes information that needs to be immediately reported to the nurse.
3
This is not the correct option since it is not an unusual occurrence; there is an available option
that includes information that needs to be immediately reported to the nurse.
This is the correct option since it contains information regarding a possible complication
4
4. Which of the following interventions is most likely to minimize the pain felt by the patient that is caused by the
removal of a wound drain?
1. Pre medicating the patient with an analgesic 30 minutes prior to the intervention
2. Utilizing distraction techniques to divert the patient during the procedure
3. Place the patient is a comfortable position in preparation for the change
4. Providing the patient with a thorough explanation of the procedure
ANS: 1
Feedback
1
2
3
4
This is the correct option since it will directly affect the pain the patient will experience during
the removal of the wound drain
This is not the correct option; there is another available option that is the primary intervention
for managing the patient’s pain during the procedure
This is not the correct option; there is another available option that is the primary intervention
for managing the patient’s pain during the procedure
This is not the correct option; there is another available option that is the primary intervention
for managing the patient’s pain during the procedure
5. Which of the following actions will maximize the suction produced by the Jackson-Pratt drainage system after the
system has been emptied?
1. Pinning the tubing to the patient’s hospital gown
2. Compressing the bulb while replacing the port cap
3. Emptying the drainage container only when it is 90% full
4. Placing the drainage container below the site of the wound
ANS: 2
12
1
2
3
4
Feedback
This is not the correct option since this action will not affect suction but rather
minimizing tension on the drain.
This is the correct option.
This is not the correct option; frequent emptying will assist in the monitoring of the patient’s
drainage.
This is not the correct option since it will have encourage only drainage by gravity
Chapter 28 P&P
PERFORMING HAND HYGIENE QUIZ
MULTIPLE CHOICE
1. When using an alcohol-based, waterless, antiseptic hand rub, it is necessary to:
1. Rinse hands with warm, running water.
2. Continue to rub hands together until completely dry.
3. Apply moisturizing lotion to prevent skin dryness.
4. Keep fingernails closely trimmed to prevent bacteria growth.
ANS: 2
1
2
3
4
Feedback
When used appropriately, it is not necessary to rinse hands after application.
This is part of the appropriate technique when using an alcohol-based, waterless,
antiseptic hand rub.
The application of moisturizing lotion is not a part of the recommended technique for
the appropriate use of an alcohol-based, waterless, antiseptic hand rub.
This is a general recommendation, not one that is specific to the appropriate use of an
alcohol-based, waterless, antiseptic hand rub.
2. The nurse knows that the primary reason for appropriate hand washing is to:
1. Remove all microorganisms from the care giver's hands.
2. Control the transmission of infectious microorganisms.
3. Provide a protective antimicrobial skin barrier on the care giver's hands.
4. Minimize the possible transfer of microorganisms from patient to care giver.
ANS: 2
1
Feedback
By definition, the removal of all microorganisms from the hands would render the
hands sterile. Proper hand washing can only reduce the number of microorganisms
present on the skin.
13
2
3
4
The stated purpose of proper hand washing is to prevent and/or control the
transmission of infection.
Hand washing with an antimicrobial soap adds in the removal of microorganisms but
does not result in the creation of a skin barrier.
Hand washing is directed at transmission control related to both care giver and
patient.
3. An antiseptic hand rub may be effectively used when the hands:
1. Exhibit dry, cracked skin.
2. Are not visibly contaminated.
3. Are sensitive to antimicrobial soap.
4. Have been exposed to a protein-based contaminant.
ANS: 2
1
2
3
4
Feedback
An antiseptic hand rub is not recommended in this situation.
An antiseptic hand rub may be used only when hands are not visibly contaminated.
An antiseptic hand rub is not recommended in this situation.
An antiseptic hand rub is not recommended in this situation.
4. The nurse is discussing the guidelines for proper hand washing with assistive personnel. Which of the
following statements made by the assistive personnel requires follow-up by the nurse?
1. "I always wash my hands when entering a patient’s room."
2. "To prevent dry skin I apply lotion each time I wash my hands."
3. "It takes at least 15 seconds of scrubbing to wash hands properly."
4. "Like I tell the new personnel, when in doubt–wash your hands."
ANS: 2
1
2
3
4
Feedback
This is an appropriate hand-washing guideline and so does not require follow-up.
Hand lotion should be applied only after hand washing at the end of a shift, not during
patient care activities.
This is an appropriate hand-washing guideline and so does not require follow-up.
This is an appropriate hand-washing guideline and so does not require follow-up.
5. The nurse is discussing the need for proper hand washing with assistive personnel. Which of the
following patients is at greatest susceptibility to infection?
1. A patient receiving chemotherapy for lung cancer
2. A patient who experienced a myocardial infarction 3 days ago
3. A patient who fractured his ankle from a fall caused when he became dizzy
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4. A patient who is scheduled for exploratory abdominal surgery in the morning
ANS: 1
1
2
3
4
Feedback
This patient is immunosuppressed as a result of the chemotherapy and is at greatest
risk.
This patient has not necessarily increased his susceptibility to infection.
Neither his closed fracture nor his dizziness has necessarily increased his susceptibility
to infection.
While this patient has an increased susceptibility to infection, she does not have the
greatest risk.
USING PERSONAL PROTECTIVE EQUIPMENT QUIZ
MULTIPLE CHOICE
1. The nurse is caring for a patient with vancomycin-resistant enterococcus (VRE). The nurse should realize
that the primary reason that equipment used in delivering nursing care remains in the patient's room is
to:
1. Improve personnel safety in the health care environment.
2. Conform with institutional policies and procedures related to infection control.
3. Prevent exposure to and transmission of infectious organisms based on the type of
contact expected.
4. Comply with OSHA and CDC regulations and recommendations regarding personal
protective equipment (PPE).
ANS: 3
1
2
3
4
Feedback
Dedicating equipment for use only with this patient will improve personnel safety in
the health care environment, but its primary focus is the prevention of exposure to
and the transmission of this drug-resistant strain of Enterococcus.
The nurse must follow institutional policies regarding infection control, but this
particular action is directed toward the prevention of exposure to and the transmission
of this drug-resistant strain of Enterococcus.
Dedication of equipment that has been used for direct patient care is primarily
directed toward the prevention of exposure to and the transmission of this drugresistant strain of Enterococcus.
Compliance with regulatory agency recommendations is not a goal but rather a path to
the primary focus of preventing exposure to and transmission of VRE.
2. To ensure the effective application of the PPE being used in patient care requiring contact precautions,
the nurse should:
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1.
2.
3.
4.
Perform hand hygiene before donning gloves.
Tie the top strings first when applying a mask.
Apply eyewear and goggles snugly around the eyes.
Clean the diaphragm of a stethoscope with 70% alcohol.
ANS: 1
1
2
3
4
Feedback
Appropriately performed hand hygiene is required before applying gloves, which are
required for patient care requiring contact precautions.
Although the top ties of a mask should be secured first, a mask is not required for
patient care requiring contact precautions.
Although eyewear and goggles should be applied snugly around the eyes, they are not
required for patient care requiring contact precautions.
Cleansing the diaphragm of a stethoscope with 70% alcohol will minimize the chance
of spreading infectious agents between patients, but it is not related to the effective
application of PPE.
3. The nurse is discussing the guidelines for proper use of PPE by assistive personnel. Which of the
following statements made by the assistive personnel requires follow-up by the nurse?
1. "Like I tell the new personnel, when in doubt, wear gloves."
2. "I really dislike wearing a mask, so it’s the first thing I take off."
3. "I always wash my hands when entering and leaving a patient’s room."
4. "I wear a mask whenever I am caring for a patient who is coughing."
ANS: 2
1
2
3
4
Feedback
This is an appropriate statement and requires no follow-up.
This statement requires follow-up because, when removing PPE, the gloves should be
removed first to minimize the chance of contaminating both the mask and the face.
This is an appropriate hand-washing guideline and requires no follow-up.
This is an appropriate statement and requires no follow-up.
4. The nurse should prepare to wear a fit-tested respirator or mask under which circumstances?
1. If exposure to bodily fluids is likely
2. Anytime a gown and cap are called for.
3. When there is a risk of exposure to an airborne infectious agent.
4. If you need to assess areas of the patient’s body that show signs of edema.
ANS: 3
16
1
2
3
4
Feedback
Exposure to bodily fluids alone does not require the use of a respirator. Cap, gown,
mask, and gloves provide adequate protection in this circumstance.
The need for a gown and cap does not indicate the need for a respirator.
The respirator is intended to protect the nurse from exposure to airborne infectious
agents.
A respirator is not needed to examine areas of the patient’s body that exhibit edema
only, though gloves would be recommended in case the skin has been compromised as
well.
5. When delegating patient care that requires the use of PPE by assistive personnel, it is necessary to:
1. Review the type of isolation precautions required.
2. Document that the care was delegated to assistive personnel.
3. Assess the patient’s need for a specific type of isolation precaution.
4. Observe the assistive personnel appropriately donning the required PPE.
ANS: 1
1
2
3
4
Feedback
When delegating patient care that requires the implementation of isolation
precautions, the nurse must discuss and review the specific precautions with the
assistive personnel.
Such documentation is not usually required.
The need for such precautions should have been determined before delegating the
task.
Observation is not necessary unless the nurse has sufficient doubt regarding the
assistive personnel’s ability to execute the precautions appropriately.
ESTABLISHING AND MAINTAINING A STERILE FIELD QUIZ
MULTIPLE CHOICE
1. The nurse is preparing to insert a Foley catheter. Which of the following actions will minimize the risk of
infection during this invasive insertion process?
1. Administering an antibiotic before the insertion
2. Following sterile technique during the Foley insertion
3. Ensuring good hand hygiene before the initiation of the insertion
4. Closing the privacy curtains to minimize airflow during the insertion
ANS: 2
1
Feedback
This is not the correct option because it is not a valid reason to administer an
antibiotic.
17
2
3
4
This is the correct option because sterile technique is designed to prevent the
introduction of pathogens into the human body during invasive techniques.
This is not the correct option. Although appropriate, this measure by itself will not
maximize the efforts to prevent infection during this procedure .
This is not the correct option. Although appropriate, this action is directed toward
respecting and providing patient privacy, not infection control.
2. The nurse is preparing to insert a Foley catheter when it is determined that additional supplies are
needed. Which of the following actions taken by the nurse is appropriate in the maintaining of a sterile
field under these circumstances?
1. Covering the field with a sterile drape before leaving the room
2. Preparing a new sterile field after collecting the needed supplies
3. Instructing the patient to not touch anything on the field until you get back
4. Going to the doorway and asking the ancillary staff to bring the needed supplies
ANS: 2
1
2
3
4
Feedback
This is not the correct option because it does not ensure the maintenance of the field’s
sterility.
This is the correct option because any action that prevents the nurse from having
constant visual contact with the field constitutes a break in the sterile technique.
This is not the correct option. Although not improper, it does not ensure the
maintenance of the field’s sterility.
This is not the correct option because any action that prevents the nurse from having
constant visual contact with the field constitutes a break in the sterile technique
3. The nurse is preparing to insert a Foley catheter. Which of the following statements best reflects the
appropriate understanding of the proper delegation of responsibilities related to the establishment and
maintenance of a sterile field to unlicensed ancillary staff?
1. "Please bring me two additional packages of sterile 4-by-4s."
2. "Begin to establish the sterile field here on the overbed table."
3. "Be careful to touch only the outer 1-inch edge of the sterile drape."
4. "Remember, the field remains sterile if only sterile objects touch it."
ANS: 1
1
2
Feedback
This is the correct option because unlicensed ancillary staff may not be delegated the
responsibility of establishing or maintaining a sterile field. This task relates to the preestablishment and thus may be delegated.
This is not the correct option because unlicensed ancillary staff may not be delegated
the responsibility of establishing or maintaining a sterile field.
18
3
4
This is not the correct option because unlicensed ancillary staff may not be delegated
the responsibility of establishing or maintaining a sterile field.
This is not the correct option because unlicensed ancillary staff may not be delegated
the responsibility of establishing or maintaining a sterile field.
4. A nurse preparing a sterile field for a dressing change of a central catheter site notes that a portion of
the drape comes into contact with the patient's gown. Which of the following nursing actions is most
appropriate in this situation?
1. Obtain a new sterile drape from the supply room.
2. Collect the needed supplies for a new sterile field.
3. Determine if the contact was within the outer 1 inch edge of the drape.
4. Be sure to position that side of the drape toward the surface of the patient’s bed.
ANS: 2
1
2
3
4
Feedback
This is not the correct option because another available option addresses this situation
in a manner that will ensure the sterility of the field.
This is the correct option because any breech in sterile technique requires the
establishment of a new sterile field.
This is not the correct option because any breech in sterile technique requires the
establishment of a new sterile field.
This is not the correct option because any breech in sterile technique requires the
establishment of a new sterile field.
5. To best minimize the risk of infection when initially preparing to establish a sterile field, the nurse
should:
1. Ensure that the supplies’ expiration dates have not expired.
2. Collect all the needed supplies before beginning the process.
3. Inspect the packaging of supplies for moisture or puncture damage.
4. Assess the patient’s ability to follow instructions regarding the sterile field.
ANS: 1
1
2
3
4
Feedback
This is the correct option because it will help ensure the sterility of the needed
supplies.
This is not the correct option because another available option appropriately
addresses this risk.
This is not the correct option; although appropriate, another available option is more
effective at minimizing this particular risk.
This is not the correct option; although appropriate, another available option is more
effective at minimizing this particular risk.
19
ADDING ITEMS TO A STERILE FIELD QUIZ
MULTIPLE CHOICE
1. The nurse is adding supplies to a sterile field prepared for a dressing change. Which of the following
actions will result in contamination of the field?
1. Dropping a linen-wrapped item onto the sterile field after first removing the outer
wrapping
2. Holding a prepackaged sterile pack in the nondominant hand while opening it
3. Adding supplies with a usable period that expires in 2 days
4. Adding the larger supplies to the back of the sterile field
ANS: 4
1
2
3
4
Feedback
This is not the correct option because it is correct technique.
This is not the correct option because it is correct technique.
This is not the correct option because it is correct technique.
This is the correct option because sterile technique requires the avoidance of reaching
over the field to introduce supplies.
2. To best minimize the risk of infection when preparing to initially add items to a sterile field, the nurse
should:
1. Ensure that the expiration dates on the supplies have not passed.
2. Collect all needed supplies before opening any of the supplies.
3. Inspect the packaging of supplies for discoloration or tear damage.
4. Be careful to touch only the outer 1-inch edge of the sterile drape.
ANS: 1
1
2
3
4
Feedback
This is the correct option because it will help ensure the sterility of the needed
supplies.
This is not the correct option. Although appropriate, another available option better
addresses this risk initially.
This is not the correct option. Although appropriate, another available option is more
effective at minimizing this risk initially.
This is not the correct option. Although appropriate, another available option is more
effective at minimizing this risk initially.
20
3. The nurse is preparing to insert a Foley catheter. Which of the following statements best reflects the
appropriate understanding of the proper delegation of responsibilities related to the establishment and
maintenance of a sterile field to unlicensed ancillary staff?
1. "Please watch that nothing contaminates this sterile field while I get some additional
supplies."
2. "I’d like you to ensure that the patient doesn’t contaminate the sterile field while I’m
inserting the catheter."
3. "Explain to the patient the importance of remaining still during this procedures so the
sterile field won’t be contaminated."
4. "Remember, the field remains sterile if only sterile objects touch it. If it’s contaminated,
we will need to start over."
ANS: 2
1
2
3
4
Feedback
This is not the correct option because unlicensed ancillary staff may not be delegated
the responsibility of establishing or being totally responsible for maintaining a sterile
field.
This is the correct option because unlicensed ancillary staff may be delegated the
responsibility of monitoring the patient’s behavior during a sterile procedure in order
to minimize the risk of their actions contaminating the field.
This is not the correct option because unlicensed ancillary staff may not be delegated
the responsibility of educating the patient regarding an invasive nursing intervention.
This is not the correct option. Although it is appropriate to instruct the ancillary staff,
the maintenance of the sterile field is not a delegated responsibility.
4. The nurse preparing a sterile field for a dressing change of a central catheter site notices that the 4
× 4s being introduced to the sterile field are dropped within a ½ inch of the outer edge of the
field itself. Which of the following nursing actions is most appropriate in this situation?
1. Obtain a package of new 4 × 4s from the supply room.
2. Collect the needed supplies for a new sterile field including 4 × 4s.
3. Use sterile forceps to move the 4 × 4s toward the center of the sterile field.
4. Add addition 4 × 4s so that those in question will not be needed for the procedure.
ANS: 2
1
2
3
Feedback
This is not the correct option because another available option addresses this situation
in a manner that will ensure the sterility of the field.
This is the correct option because any breech in sterile technique requires the
establishment of a new sterile field.
This is not the correct option because any breech in sterile technique requires the
establishment of a new sterile field.
21
4
This is not the correct option because any breech in sterile technique requires the
establishment of a new sterile field.
5. To best minimize the risk of infection when adding prepackaged supplies to an established sterile field,
the nurse should:
1. Don clean treatment gloves.
2. Collect all needed supplies before beginning the process.
3. Be careful not to allow the wrapper to touch the sterile field.
4. Place the supplies well inside the 1-inch edge of the sterile field.
ANS: 3
1
2
3
4
Feedback
This is not the correct option because it is not required when adding prepackaged
supplies to the sterile field.
This is not the correct option. Although appropriate, another available option more
appropriately addresses this particular risk.
This is the correct option because allowing contact of the prepackaged wrapper with
the sterile field would result in contamination.
This is not the correct option. Although appropriate, another available option is more
effective at minimizing this particular risk.
POURING A STERILE SOLUTION QUIZ
MULTIPLE CHOICE
1. The nurse is adding sterile liquids to a sterile field prepared for a dressing change. Which of the
following actions will result in contamination of the field?
1. Reaching over the sterile field to pour the liquid into the receptacle
2. Placing the cap of the liquid on a nonsterile surface with the edge side up
3. Adding a liquid with a usable period that expires in 2 days
4. Placing the receptacle in front of the sterile field
ANS: 1
1
2
3
4
Feedback
This is the correct option because sterile technique requires the avoidance of reaching
over the field to introduce supplies.
This is not the correct option because it is correct technique.
This is not the correct option because it is correct technique.
This is not the correct option because it is correct technique.
22
2. Which of the following statements reflects an understanding regarding the management of liquids in a
manner that best minimizes the risk of infection when used during a sterile procedure?
1. "A solution properly recapped is considered sterile for only 24 hours after it has been
opened."
2. "Take care to avoid any splashing when pouring sterile liquids onto your sterile field."
3. "Be sure to compare the label of the solution with the specific solution prescribed by the
physician."
4. "Assess the patient for any known allergies to the sterile solution prescribed for the
intervention."
ANS: 1
1
2
3
4
Feedback
This is the correct option because it reflects standard policy for the use of opened
sterile liquids.
This is not the correct option. Although appropriate, another available option better
addresses the stated risk. This is directed toward the contamination of a sterile field.
This is not the correct option. Although appropriate, another available option is more
effective at minimizing the stated risk. This is more directed toward preventing a
medication error.
This is not the correct option. Although appropriate, another available option is more
effective at minimizing the stated risk initially. This is more directed toward patient
safety.
3. The nurse is preparing to cleanse and reinsert a tracheotomy tube. Which of the following statements
made by the nurse to unlicensed ancillary staff best reflects the appropriate understanding of the
proper delegation of responsibilities related to the maintenance of a sterile field regarding the
introduction of liquids?
1. "Please watch that nothing contaminates this sterile field while I get some additional
sterile water."
2. "I’d like you to ensure that the patient doesn’t contaminate the sterile field while I’m
adding this sterile water."
3. "Remember, the field remains sterile if only sterile objects touch it. If it’s contaminated
with this sterile water, we will need to start over."
4. "Explain to the patient the importance of remaining still during this procedures so the
sterile field won’t be contaminated while I finish adding this sterile water."
ANS: 2
1
Feedback
This is not the correct option because unlicensed ancillary staff may not be delegated
the responsibility of establishing or being totally responsible for maintaining a sterile
field.
23
2
3
4
This is the correct option because unlicensed ancillary staff may be delegated the
responsibility of monitoring the patient’s behavior during a sterile procedure in order
to minimize the risk of their actions contaminating the field.
This is not the correct option because unlicensed ancillary staff may not be delegated
the responsibility of educating the patient regarding an invasive nursing intervention.
This is not the correct option. Although it is appropriate to instruct the ancillary staff,
the maintenance of the sterile field is not a delegated responsibility.
4. The nurse preparing a sterile field for a dressing change notices that the sterile solution has splashed
onto the sterile field. Which of the following nursing actions is most appropriate in this situation?
1. Continue with the dressing change in a time-efficient manner.
2. Collect the necessary supplies, and prepare another sterile field.
3. Pour the remaining required liquid from a distance of only 1 to 2 inches above the
receptacle.
4. Reposition the receiving receptacle near the edge of the sterile field to minimize splash.
ANS: 2
1
2
3
4
Feedback
This is not the correct option because another available option addresses this situation
in a manner that will ensure the sterility of the field.
This is the correct option because any breech in sterile technique requires the
establishment of a new sterile field.
This is not the correct option because any breech in sterile technique requires the
establishment of a new sterile field.
This is not the correct option because any breech in sterile technique requires the
establishment of a new sterile field.
5. To best minimize the risk of contaminating the sterile field when adding sterile liquids to an established
sterile field, the nurse should:
1. Collect all needed supplies before beginning the process.
2. Pour the liquid from a distance no greater than 1 to 2 inches.
3. Be careful not to allow the fluid container to touch the sterile field.
4. Place the receptacle well inside the 1-inch edge of the sterile field.
ANS: 2
1
2
Feedback
This is not the correct option. Although appropriate, another available option
appropriately addresses this particular risk.
This is the correct option because pouring from this distance minimizes the risk of
splashing, which contaminates the field.
24
3
4
This is not the correct option. Although appropriate, another available option better
addresses this particular risk.
This is not the correct option. Although appropriate, another available option is more
effective at minimizing this particular risk.
USING A PREPACKAGED STERILE KIT QUIZ
MULTIPLE CHOICE
1. The primary advantage of a prepackaged sterile procedure kit is that:
1. The sterility of the included items is guaranteed.
2. The sterile kit container can be used as a sterile field.
3. The time required to gather task-oriented items is reduced.
4. They conserve storage space in the acute care and outpatient settings.
ANS: 2
1
2
3
4
Feedback
This is not the correct option because there is an assumption but not a guarantee.
This is the correct option because the container is designed to provide a readily
accessible sterile field.
This is not the correct option. Although it may be correct, another available option
identifies the primary advantage.
This is not the correct option. Although it may be correct, another available option
identifies the primary advantage.
2. When considering the principles of sterile technique, which of the following actions should the nurse
take when using of an overbed table as the surface for a sterile field?
1. Position the table outside of the patient’s reach.
2. Assess the table for stability and adequate size.
3. Position the height of the table to be waist high.
4. Place the table within easy reach of the patient’s bed.
ANS: 3
1
2
3
4
Feedback
This is not the correct option. Although not inappropriate, another available option is
more relevant to the question.
This is not the correct option. Although appropriate, another available option is more
relevant to the question. This is directed toward safety, not sterile technique.
This is the correct option because it is a stated principle of sterile technique.
This is not the correct option. Although appropriate, another available option is more
relevant to the question. This is directed toward efficacy, not sterile technique.
25
3. The nurse is preparing to cleanse and reinsert a tracheotomy tube. Which of the following statements
made by the nurse to unlicensed ancillary staff at the bedside best reflects the appropriate
understanding of the proper delegation of responsibilities related to the maintenance of a sterile field
when a sterile item falls to the floor?
1. "I will have to set up another sterile field; please take these items away."
2. "Please go to the clean utility room and get me a package of sterile 4 × 4s."
3. "Please watch that nothing contaminates this sterile field while I go and get a
replacement item."
4. "Explain to the patient the importance of remaining still during this procedures so no
other items are contaminated."
ANS: 2
1
2
3
4
Feedback
This is not the correct option because it does not require the setting up of another
sterile field.
This is the correct option because unlicensed ancillary staff may be delegated the
responsibility of retrieving items required for the sterile field from storage.
This is not the correct option because unlicensed ancillary staff may not be delegated
the responsibility of the maintenance of the sterile field.
This is not the correct option because unlicensed ancillary staff may not be delegated
the responsibility of educating the patient regarding an invasive nursing intervention.
4. The nurse, adhering to sterile technique while preparing a sterile field using a prepackaged dressing kit,
removes the dust cover of a dressing kit and positions the container on the overbed table so that the:
1. Tips of the flaps are easily accessible.
2. Kit is positioned in the center of the table.
3. Sterile contents of the kit are readily available.
4. Outermost flap can be opened away from the nurse’s body.
ANS: 4
1
2
3
4
Feedback
This is not the correct option because another available option addresses technique.
This is not the correct option because another available option addresses technique.
This is not the correct option because another available option addresses technique.
This is the correct option because it is reflective of proper technique when opening a
prepackaged sterile kit.
5. To best minimize the risk of infection when preparing to use a prepackaged sterile dressing kit, the nurse
should initially:
1. Ensure that the expiration dates on the supplies have not passed.
26
2. Inspect the packaging of supplies for discoloration or tear damage.
3. Collect all needed supplies before opening any of the kit.
4. Open the kit on a surface that is waist high.
ANS: 1
1
2
3
4
Feedback
This is the correct option because it will help ensure the sterility of the needed
supplies.
This is not the correct option. Although appropriate, another available option better
addresses this risk initially.
This is not the correct option. Although appropriate, another available option is more
effective at minimizing this particular risk initially.
This is not the correct option. Although appropriate, another available option is more
effective at minimizing this particular risk initially.
PERFORMING STERILE GLOVING QUIZ
MULTIPLE CHOICE
1. The initial action when preparing to apply sterile gloves is to:
1. Perform appropriate hand hygiene.
2. Place the package on a stable, flat surface.
3. Assess the glove packaging for wetness or tears.
4. Explain to the patient the reason sterile gloves are needed.
ANS: 3
1
2
3
4
Feedback
This is not the correct option. Although appropriate, another available option should
be accomplished before this.
This is not the correct option. Although appropriate, another available option should
be accomplished before this.
This is the correct option because any breech in the packaging compromises the
sterility of the gloves.
This is not the correct option. Although not inappropriate, a more relevant option is
available.
2. The use of non-latex gloves should be considered primarily when:
1. There is a possible sensitivity issue.
2. The staff member prefers them.
3. Latex gloves are not available.
4. The patient prefers them.
27
ANS: 1
1
2
3
4
Feedback
This is the correct option because there is a possibility of a serious allergic reaction to
latex.
This is not the correct option because another available option addresses this issue
appropriately.
This is not the correct option. Although not inappropriate, another available option
addresses this issue more appropriately.
This is not the correct option because another available option addresses this issue
appropriately.
3. To best minimize the risk of tearing the sterile glove, the nurse should:
1. Use powdered sterile gloves.
2. Keep fingernails well trimmed.
3. Select the proper-sized gloves.
4. Dry the hands before applying gloves.
ANS: 3
1
2
3
4
Feedback
This is not the correct option because another option addresses this question more
directly.
This is not the correct option. Although appropriate, this is not the best action to take
to minimize the risk of tears.
This is the correct option because improper glove size is the leading cause of gloving
tears.
This is not the correct option. Although appropriate, this is not the best action to take
to minimize the risk of tears.
4. The nurse, adhering to sterile technique while waiting as a patient is positioned for a sterile dressing
change, should:
1. Keep hands donned with sterile gloves clasped at chest level about 12 inches from the
body.
2. Position arms at the sides with elbows bent and gloved hands pointing upward.
3. Clasp gloved hands to prevent contamination of the gloves.
4. Double-glove with sterile gloves to maximize protection.
ANS: 1
1
Feedback
This is the correct option because it is proper sterile technique.
28
2
3
4
This is not the correct option because it is not appropriate sterile technique.
This is not the correct option because another available option better addresses sterile
technique.
This is not the correct option because it is not appropriate sterile technique.
5. Which of the following statements provides the best guideline for determining the possible
contamination of sterile gloves?
1. "Keep gloved hands above wrist level."
2. "Poorly sized gloves are easily contaminated."
3. "Remember to avoid touching nonsterile items with sterile gloves."
4. "When you can’t see your sterile gloves, they are considered contaminated."
ANS: 4
1
2
3
4
Feedback
This is not the correct option. Although appropriate, another option is more effective
at addressing the stated issue of possible contamination.
This is not the correct option. Although appropriate; another option is more effective
at addressing the stated issue of possible contamination.
This is not the correct option. Although appropriate, another option is more effective
at addressing the stated issue of possible contamination.
This is the correct option because it is a principle of sterile technique.
COLLECTING A SPECIMEN FOR WOUND CULTURE
MULTIPLE CHOICE
1. The nurse has received an order to collect a wound culture from a patient who was bitten by a dog on
the left thigh 3 days ago. Which of the following actions should be taken initially?
1. Explain the purpose of the test to the patient.
2. Assess the patient’s level of pain at the wound site.
3. Assess the patient for signs and symptoms of infection.
4. Gather supplies appropriate for the type of specimen ordered.
ANS: 4
1
2
3
Feedback
This is not the correct option. Although appropriate, it is not the initial action that
should be taken when culturing a wound.
This is not the correct option. Although appropriate, it is not the initial action that
should be taken when culturing a wound.
This is not the correct option. Although appropriate, it is not the initial action that
should be taken when culturing a wound.
29
4
This is the correct option because equipment and technique differ depending on
whether an anaerobic or an aerobic specimen is ordered.
2. The nurse has collected a wound culture from a patient who was bitten by a dog on the left thigh 3 days
ago. Which of the following actions best addresses the issue of risk for infection regarding the
transportation of the specimen?
1. Double bagging the specimen with biohazard bags
2. Transporting the specimen immediately to the laboratory
3. Wearing the appropriate personal protective equipment (PPE)
4. Wearing treatment gloves when transporting the specimen to the lab
ANS: 1
1
2
3
4
Feedback
This is the correct option because it attempts to minimize potential contact with the
possibly infectious material.
This is not the correct option. Although appropriate, it is not the most reflective of
actions to minimize the risk for infection during the transportation of the specimen.
This is not the correct option because it relates to the actual collection process.
This is not the correct option because it is not required when the specimen has been
managed appropriately.
3. Which of the following statements made by a nurse is most reflective of the proper understanding of
the role unlicensed ancillary staff may play regarding the collection of a wound culture for a patient with
a Stage 3 pressure ulcer?
1. "Please get both an aerobic and an anaerobic culture kit for me."
2. "Have you ever collected an aerobic wound culture before?"
3. "Has the patient’s wound been showing signs of infection?"
4. "Remember to wear gloves for this procedure."
ANS: 1
1
2
3
4
Feedback
This is the correct option because a wound collect may not be delegated to unlicensed
ancillary staff, but collection of materials when specifically identified may be
delegated.
This is not the correct option because wound culture collection may not be delegated
to unlicensed ancillary staff.
This is not the correct option because neither assessment nor any aspect of wound
culture collection may be delegated to unlicensed ancillary staff.
This is not the correct option because no aspect of culture collection may be delegated
to unlicensed ancillary staff.
30
4. Which of the following statements shows the best understanding of the importance of proper
transportation of a wound culture specimen in order to ensure reliable results?
1. "I’ll need two biohazard bags to transport the specimen."
2. "Is anyone available to take this to the lab immediately?"
3. "I had to borrow the appropriate collection kit from another unit."
4. "Did you identify the antibiotic the patient is taking on the lab slip?"
ANS: 2
1
2
3
4
Feedback
This is not the correct option. Although appropriate, it is directed more toward
minimizing contamination.
This is the correct option because the collection swab must be transported to the lab
within 15 minutes of its collection.
This is not the correct option. Although appropriate, it is directed more toward proper
collection technique.
This is not the correct option. Although appropriate, it is not directed toward
transporting the specimen but rather proper identification of the specimen.
5. Which of the following nursing actions is best suited to address the patient's risk for injury related to the
collection of a wound culture specimen?
1. Wearing clean gloves to remove soiled dressings and sterile gloves when collecting the
culture specimen
2. Being careful to use proper technique when swabbing within the wound when collecting
the specimen
3. Cleaning the area around the wound edges with an appropriate antiseptic before
collecting the specimen
4. Medicating the patient with an analgesic before collecting the specimen if it is expected
to be painful
ANS: 1
1
2
3
4
Feedback
This is the correct option because it is specifically directed toward minimizing the
patient’s risk for injury related to cross-contamination of the wound.
This is not the correct option. Although appropriate, another option is specifically
directed toward minimizing the patient’s risk for injury.
This is not the correct option. Although appropriate, another option is specifically
directed toward minimizing the patient’s risk for injury.
This is not the correct option. Although appropriate, this option is directed toward
patient comfort, not minimizing the patient’s risk for injury.
PERFORMING BLOOD GLUCOSE TESTING
31
MULTIPLE CHOICE
1. The nurse is preparing to test the morning blood glucose level of a patient diagnosed with both type 2
diabetes mellitus and peripheral vascular disease. Which of the following techniques will be of particular
benefit for this patient?
1. Reviewing the medications the patient is currently taking
2. Inspecting the selected finger for signs of tissue damage
3. Wiping away the first drop of blood resulting from the stick
4. Keeping the finger in a dependent position before the puncture
ANS: 4
1
2
3
4
Feedback
This is not the correct option because it is appropriate for all patients receiving a finger
stick for blood glucose testing.
This is not the correct option because it is appropriate for all patients receiving a finger
stick for blood glucose testing.
This is not the correct option because it is appropriate for all patients receiving a finger
stick for blood glucose testing.
This is the correct option because it will encourage blood flow to the area that will be
punctured.
2. For which of the following patients can the nurse delegate the task of routine blood glucose monitoring
to assistive staff?
1. Non–insulin-dependent diabetic who is ordered steroid therapy
2. Type 2 diabetic who required insulin coverage at her last testing
3. Type 1 diabetic who has been experiencing nausea and vomiting for 24 hours
4. Type 2 diabetic who has had a closed reduction of a fracture of her right wrist
ANS: 4
1
2
3
4
Feedback
This is not the correct option because this patient’s medication makes the diabetes
potentially unstable.
This is not the correct option because this patient’s need for insulin coverage precludes
delegation of the blood glucose testing.
This is not the correct option because this patient’s nausea and vomiting make the
diabetes potentially unstable.
This is the correct option because this patient’s current condition is affected only by
the inability to self-perform the testing.
32
3. Which of the following statements made by a nurse is most reflective of the proper understanding of
the role that unlicensed ancillary staff may play regarding the performance of a blood glucose test 2
hours after the patient has eaten breakfast?
1. "Did you remember to check her last glucose reading?"
2. "Remember to wear treatment gloves when you do her finger stick."
3. "Is it still difficult to find an acceptable site on her fingers to puncture?"
4. "It’s time to test blood sugars. Have her use warm, soapy water to clean her hands."
ANS: 4
1
2
3
4
Feedback
This is not the correct option because blood glucose monitoring may not be delegated
to unlicensed ancillary staff.
This is not the correct option because blood glucose monitoring may not be delegated
to unlicensed ancillary staff.
This is not the correct option because blood glucose monitoring may not be delegated
to unlicensed ancillary staff.
This is the correct option. Although no aspect of the actual procedure of blood glucose
monitoring can be delegated, observing the patient for appropriate hand hygiene is a
task that is appropriate for unlicensed ancillary staff.
4. The nurse is caring for a patient diagnosed with type 2 diabetes mellitus. The patient tells the nurse that
he has been testing his own blood glucose level 6 times a day for the last 3 years. Which of the following
actions would be most appropriate initially regarding the performance of this testing for this particular
patient?
1. Observe the patient’s testing technique for accuracy.
2. Allow the patient to perform his own blood glucose testing.
3. Check with the patient’s physician concerning the patient’s self-testing.
4. Explain to the patient that a nurse must be present while the testing is being done.
ANS: 1
1
2
3
4
Feedback
This is the correct option because it is important to evaluate the patient’s technique
for both accuracy and appropriateness.
This is not the correct option. Although it may become appropriate, it is not the initial
action for this particular patient.
This is not the correct option because at this point there is no reason to discuss the
situation with the physician.
This is not the correct option because it is not a universally held policy in medical
facilities.
33
5. Which of the following nursing actions should be preformed initially when performing a blood glucose
test on a type 1 diabetic?
1. Wearing clean gloves to minimize the risk of contamination
2. Assessing the patient’s skin for possible puncture sites
3. Having the patient wash his or her hands in warm, soapy water
4. Determining the patient’s preferred puncture site
ANS: 2
1
2
3
4
Feedback
This is not the correct option. Although appropriate, it is not the initial action.
This is the correct option because assessment of appropriate sites must occur first in
order to proceed effectively with the testing.
This is not the correct option. Although appropriate, it is not the initial action.
This is not the correct option. Although appropriate, it is not the initial action.
PERFORMING FECAL OCCULT BLOOD TESTING
MULTIPLE CHOICE
1. The initial step in the preparation of a fecal occult blood test is to:
1. Determine the patient’s ability to assist with securing the sample.
2. Gather both a Hemoccult slide and developing solution.
3. Provide the patient with a specimen “hat” or bedpan.
4. Perform hand hygiene and don treatment gloves.
ANS: 1
1
2
3
4
Feedback
This is the correct option because completion of this action will determine the extent
of the nurse’s involvement in the collection of the required sample.
This is not the correct option. Although appropriate, this would not be the initial step
in the preparation of a fecal occult blood test.
This is not the correct option. Although appropriate, this would not be the initial step
in the preparation of a fecal occult blood test.
This is not the correct option. Although appropriate, this would not be the initial step
in the preparation of a fecal occult blood test.
2. The nurse has delegated the task of performing fecal occult blood tests on the stool of a patient with a
history of positive results to ancillary staff. Which of the following instructions is most relevant to the
performance of this testing for this particular patient?
1. "Notify me immediately if the test is positive."
2. "Remember to re-test each positive stool sample."
3. "Remind the patient that we need to test each bowel movement."
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4. "Don’t confuse Gastroccult developer with Hemoccult developer."
ANS: 2
1
2
3
4
Feedback
This is not the correct option because this action is appropriate for all patients being
tested for occult fecal bleeding.
This is the correct option because all positive stool samples should be re-tested.
This is not the correct option because this action is appropriate for all patients being
tested for occult fecal bleeding.
This is not the correct option because this instruction is appropriate for all Hemoccult
testing.
3. Which of the following statements made by a nurse providing information to unlicensed ancillary staff is
most relevant to the proper performance of a fecal occult blood test on the stool of a patient with a low
hemoglobin and hematocrit?
1. "Have you used the new Hemoccult testing system?"
2. "Re-enforce the need to use the “hat” with the patient."
3. "Is the patient capable of assisting with the collection?"
4. "Remember to take samples from two different areas of the specimen."
ANS: 1
1
2
3
4
Feedback
This is the correct option because it attempts to identify the staff’s familiarity with the
proper performance of the test.
This is not the correct option. Although appropriate, another option is more relevant
to the proper performance of the test.
This is not the correct option. Although appropriate, another option is more relevant
to the proper performance of the test.
This is not the correct option. Although appropriate, another option is more relevant
to the proper performance of the test.
4. Which of the following statements shows an understanding of the proper interpretation of the results of
a positive fecal occult blood test?
1. "If the sample turns blue, it is positive for blood."
2. "The sample turned blue after about 45 seconds."
3. "The results were positive both times I tested the sample."
4. "Because it was positive, I asked when he last ate red meat."
ANS: 4
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1
2
3
4
Feedback
This is not the correct option because a positive result is not always indicative of
gastrointestinal bleeding.
This is not the correct option because it is more indicative of an understanding of
proper technique than of proper interpretation.
This is not the correct option because it is more indicative of an understanding of
proper technique than of proper interpretation.
This is the correct option because it shows an understanding that all positive results
are not indicative of gastrointestinal bleeding and that further testing is warranted.
5. Which of the following nursing actions addresses the risk for infection related to the performance of a
fecal occult blood test?
1. Maintaining aseptic technique while performing the test
2. Performing the fecal occult blood testing in the patient’s bathroom
3. Ensuring appropriate hand hygiene and donning treatment gloves while testing
4. Assessing the patient’s ability to provide an uncontaminated fecal specimen
ANS: 3
1
2
3
4
Feedback
This is not the correct option because this procedure does not require aseptic
technique.
This is not the correct option. Although not inappropriate, other locations (dirty utility
room) would be acceptable.
This is the correct option because it represents the most effective method for
minimizing the risk of infection.
This is not the correct option. Although appropriate, it does not address the issue of
the risk of infection.
SCREENING URINE FOR CHEMICAL PROPERTIES
MULTIPLE CHOICE
1. The nurse has received an order to test the urine of a newly admitted patient with a Multistix test strip.
The initial results indicate that the sample was positive for protein, and negative for glucose and blood
with a pH of 8.2. Which of the following nursing actions is appropriate in response to these results?
1. Check the physician’s orders for instructions.
2. Notify the physician of the results of the test.
3. Repeat the testing on the patient’s next voided urine.
4. Note the results on the patient’s urine testing flow sheet.
ANS: 2
Feedback
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1
2
3
4
This is not the correct option because it is not likely to provide the nurse with the
appropriate reaction.
This is the correct option because of abnormal responses in the measurements.
This is not the correct option because it is not appropriate in response to this situation.
This is not the correct option because it is not appropriate in response to this situation.
2. Which of the following actions will best ensure an accurate chemical reaction when testing urine with a
Multistix test strip?
1. Discarding all expired Multistix test strips
2. Storing the test strips in the original container
3. Wearing clean treatment gloves while handling the strip
4. Holding the test strip horizontally while timing the process
ANS: 4
1
2
3
4
Feedback
This is not the correct option. Although appropriate, it is to be taken before, not
during, the testing process
This is not the correct option. Although appropriate, it is to be taken before, not
during, the testing process.
This is not the correct option. Although appropriate, it is to be taken to protect the
tester from contact with the chemicals and the urine.
This is the correct option because it will minimize the mixing of the chemical by the
flow of the urine.
3. Which of the following statements made by a nurse is most reflective of the proper understanding of
the role that unlicensed ancillary staff may play regarding the performance of a glucose test on the urine
of a type 2 diabetic?
1. "Remind the patient that we need a urine sample."
2. "Did you remember to check her last glucose reading?"
3. "Have we received a new supply of urine glucose testing strips?"
4. "Don’t forget to get a double-voided specimen when you test her urine."
ANS: 4
1
2
3
Feedback
This is not the correct option because the entire process of blood glucose monitoring
may be delegated to trained unlicensed ancillary staff.
This is not the correct option because the entire process of blood glucose monitoring
may be delegated to trained unlicensed ancillary staff.
This is not the correct option because the entire process of blood glucose monitoring
may be delegated to trained unlicensed ancillary staff.
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4
This is the correct option because it shows an understanding that the entire process of
blood glucose monitoring may be delegated to trained unlicensed ancillary staff.
4. Which of the following statements best describes the appropriate technique used to obtain a doublevoided urine specimen required when testing a patient's urine glucose level?
1. Any urine sample that is not contaminated with either feces or toilet tissue is usable.
2. After discarding a random sample, wait 30 minutes for a second usable sample.
3. Discard the first of two samples obtained from the patient’s first voiding of the day.
4. Separate a urine sample between two clean containers to be tested separately.
ANS: 2
1
2
3
4
Feedback
This is not the correct option because it does not describe a double-voided urine
specimen.
This is the correct option because it is a description of a double-voided specimen.
This is not the correct option because it does not describe a double-voided urine
specimen.
This is not the correct option because it does not describe a double-voided urine
specimen.
5. Which of the following nursing actions should be preformed initially when screening the urine of a type
1 diabetic for glucose?
1. Perform hand hygiene and don clean treatment gloves.
2. Check the expiration date on the reagent test strip container.
3. Remind the patient that a urine sample will be needed for glucose testing.
4. Encourage the patient to drink a glass of liquids 30 minutes before testing.
ANS: 2
1
2
3
4
Feedback
This is not the correct option. Although appropriate, it is not the initial action to be
considered when performing the test.
This is the correct option because checking expiration dates when gathering timesensitive equipment is vital to the effectiveness of the testing results.
This is not the correct option. Although appropriate, it is not the initial action to be
considered when performing the test.
This is not the correct option. Although appropriate, it is not the initial action to be
considered when performing the test.