,GCN|NSG 3100 Exam 1 | Diagnostic Testing, Elimination &
Procedures | Galen College | Latest 26/27 (PDF)
1. A nurse is preparing to perform a sterile dressing change. Which action is essential to maintain
surgical asepsis?
A) Wear clean gloves during the procedure
B) Keep sterile items above waist level and within the nurse's line of sight at all times
C) Use tap water to moisten the sterile field
D) Turn away from the sterile field to open additional supplies
Correct Answer: Keep sterile items above waist level and within the nurse's line of sight at all times
Rationale: To maintain a sterile field, all sterile items must be kept above waist level and within the
nurse's line of sight. Sterile gloves (not clean) are required. Sterile water (not tap) must be used.
Turning away from the sterile field contaminates it because it is no longer in the nurse's direct view.
2. A client has a wound with purulent drainage and surrounding erythema. What is the priority
nursing action before applying a new dressing?
A) Apply a cold compress to the wound
B) Obtain a wound culture as prescribed
C) Administer an oral antibiotic
D) Document the wound appearance
Correct Answer: Obtain a wound culture as prescribed
Rationale: Purulent drainage and erythema indicate wound infection. A wound culture should be
obtained before starting antibiotics to identify the causative organism and guide appropriate
antibiotic therapy. Documentation is important but secondary to obtaining the culture.
3. The nurse is changing a surgical wound dressing and notes the wound edges are well approximated
with a small amount of serosanguineous drainage. This wound is healing by which intention?
A) Primary intention
,B) Secondary intention
C) Tertiary intention
D) Delayed primary closure
Correct Answer: Primary intention
Rationale: Primary intention healing occurs when wound edges are well approximated (as in surgical
incisions) with minimal tissue loss and drainage. Secondary intention involves open wounds healing
by granulation tissue. Tertiary intention involves delayed closure.
4. A client has a wound with undermining. Which nursing action is correct when packing this wound?
A) Pack the wound tightly to eliminate dead space
B) Loosely pack the wound to fill the dead space and allow drainage absorption
C) Leave the wound open to air
D) Apply a dry dressing over the wound without packing
Correct Answer: Loosely pack the wound to fill the dead space and allow drainage absorption
Rationale: Wounds with undermining should be loosely packed to fill the dead space and allow
drainage to be absorbed while preventing the wound from closing at the surface before the deeper
tissue heals.
5. A nurse is caring for a client with an abdominal wound evisceration. What is the priority action?
A) Attempt to replace the protruding organs
B) Cover the wound with a sterile saline-moistened dressing
C) Apply a dry sterile dressing over the wound
D) Notify the healthcare provider after applying the dressing
Correct Answer: Cover the wound with a sterile saline-moistened dressing
, Rationale: Evisceration is a medical emergency. The nurse should cover the wound with a sterile
saline-moistened dressing to keep the organs moist and prevent drying. The nurse should not attempt
to replace the organs. Notifying the provider should occur after initial management.
6. A nurse is assessing a client's wound. Which type of drainage is described as thick, yellow, green, or
brown, and indicates infection?
A) Serous
B) Sanguineous
C) Serosanguineous
D) Purulent
Correct Answer: Purulent
Rationale: Purulent drainage is thick, yellow, green, or brown and indicates infection. Serous drainage
is clear and watery. Sanguineous drainage is bright red and bloody. Serosanguineous drainage is
pinkish and bloody-tinged.
7. A nurse is preparing a sterile field. Which action would contaminate the sterile field?
A) Placing a sterile instrument on the center of the field
B) Pouring sterile solution from 4 inches above the field
C) Keeping the field at waist level
D) Turning away from the field to answer a question
Correct Answer: Turning away from the field to answer a question
Rationale: Turning away from a sterile field contaminates it because the nurse's back is not considered
sterile and the field is no longer within the nurse's direct line of sight. The 1-inch border is considered
contaminated, sterile instruments should be placed in the center, and pouring from 4 inches is correct.
8. A nurse is preparing a sterile field. Which action maintains the sterility of the field?
A) Allowing the field to remain uncovered for 30 minutes before use
Procedures | Galen College | Latest 26/27 (PDF)
1. A nurse is preparing to perform a sterile dressing change. Which action is essential to maintain
surgical asepsis?
A) Wear clean gloves during the procedure
B) Keep sterile items above waist level and within the nurse's line of sight at all times
C) Use tap water to moisten the sterile field
D) Turn away from the sterile field to open additional supplies
Correct Answer: Keep sterile items above waist level and within the nurse's line of sight at all times
Rationale: To maintain a sterile field, all sterile items must be kept above waist level and within the
nurse's line of sight. Sterile gloves (not clean) are required. Sterile water (not tap) must be used.
Turning away from the sterile field contaminates it because it is no longer in the nurse's direct view.
2. A client has a wound with purulent drainage and surrounding erythema. What is the priority
nursing action before applying a new dressing?
A) Apply a cold compress to the wound
B) Obtain a wound culture as prescribed
C) Administer an oral antibiotic
D) Document the wound appearance
Correct Answer: Obtain a wound culture as prescribed
Rationale: Purulent drainage and erythema indicate wound infection. A wound culture should be
obtained before starting antibiotics to identify the causative organism and guide appropriate
antibiotic therapy. Documentation is important but secondary to obtaining the culture.
3. The nurse is changing a surgical wound dressing and notes the wound edges are well approximated
with a small amount of serosanguineous drainage. This wound is healing by which intention?
A) Primary intention
,B) Secondary intention
C) Tertiary intention
D) Delayed primary closure
Correct Answer: Primary intention
Rationale: Primary intention healing occurs when wound edges are well approximated (as in surgical
incisions) with minimal tissue loss and drainage. Secondary intention involves open wounds healing
by granulation tissue. Tertiary intention involves delayed closure.
4. A client has a wound with undermining. Which nursing action is correct when packing this wound?
A) Pack the wound tightly to eliminate dead space
B) Loosely pack the wound to fill the dead space and allow drainage absorption
C) Leave the wound open to air
D) Apply a dry dressing over the wound without packing
Correct Answer: Loosely pack the wound to fill the dead space and allow drainage absorption
Rationale: Wounds with undermining should be loosely packed to fill the dead space and allow
drainage to be absorbed while preventing the wound from closing at the surface before the deeper
tissue heals.
5. A nurse is caring for a client with an abdominal wound evisceration. What is the priority action?
A) Attempt to replace the protruding organs
B) Cover the wound with a sterile saline-moistened dressing
C) Apply a dry sterile dressing over the wound
D) Notify the healthcare provider after applying the dressing
Correct Answer: Cover the wound with a sterile saline-moistened dressing
, Rationale: Evisceration is a medical emergency. The nurse should cover the wound with a sterile
saline-moistened dressing to keep the organs moist and prevent drying. The nurse should not attempt
to replace the organs. Notifying the provider should occur after initial management.
6. A nurse is assessing a client's wound. Which type of drainage is described as thick, yellow, green, or
brown, and indicates infection?
A) Serous
B) Sanguineous
C) Serosanguineous
D) Purulent
Correct Answer: Purulent
Rationale: Purulent drainage is thick, yellow, green, or brown and indicates infection. Serous drainage
is clear and watery. Sanguineous drainage is bright red and bloody. Serosanguineous drainage is
pinkish and bloody-tinged.
7. A nurse is preparing a sterile field. Which action would contaminate the sterile field?
A) Placing a sterile instrument on the center of the field
B) Pouring sterile solution from 4 inches above the field
C) Keeping the field at waist level
D) Turning away from the field to answer a question
Correct Answer: Turning away from the field to answer a question
Rationale: Turning away from a sterile field contaminates it because the nurse's back is not considered
sterile and the field is no longer within the nurse's direct line of sight. The 1-inch border is considered
contaminated, sterile instruments should be placed in the center, and pouring from 4 inches is correct.
8. A nurse is preparing a sterile field. Which action maintains the sterility of the field?
A) Allowing the field to remain uncovered for 30 minutes before use
