CLINICAL NURSING SKILLS AND
TECHNIQUES 15TH EDITION
COMPREHENSIVE EXAM QUESTIONS
AND CORRECT ANSWERS LATEST
UPDATE
1. While preparing a sterile field, the nurse realizes that a sterile bowl is needed. Which
action by the nurse maintains the integrity of the sterile field?
A. Reaching across the sterile field to pick up the bowl from the supply cart.
B. Asking a colleague to drop the sterile bowl onto the field from the side.
C. Leaving the sterile field unattended to retrieve the bowl from the storage room.
D. Placing the sterile bowl on the 1-inch border of the sterile drape.
Answer: B
Conceptual Explanation: Items must be introduced to a sterile field from the side to avoid
reaching over it. Reaching over contaminates the field. The 1-inch border is considered
non-sterile, and a sterile field should never be left unattended.
2. A patient is receiving a continuous intravenous infusion of 0.9% Normal Saline. The nurse
notes the site is cool to the touch, swollen, and the patient complains of pain. What is the
nurse’s priority action?
A. Apply a warm compress to the site immediately.
,B. Slow the infusion rate to a KVO (keep vein open) rate.
C. Stop the infusion and discontinue the IV catheter.
D. Elevate the extremity and notify the physician.
Answer: C
Conceptual Explanation: These are classic signs of infiltration. The priority action is to
stop the infusion and remove the catheter to prevent further tissue damage before
implementing other comfort measures.
3. When administering a pre-filled Lovenox (enoxaparin) injection, which action should the
nurse take?
A. Administer the injection in the lateral abdominal wall (love handles).
B. Massage the injection site after withdrawing the needle to promote absorption.
C. Expel the nitrogen air bubble from the syringe before administration.
D. Aspirate for blood return before injecting the medication.
Answer: A
Conceptual Explanation: Enoxaparin should be injected into the subcutaneous tissue of
the abdomen, specifically the anterolateral or posterolateral walls. The air bubble should
not be expelled, the site should not be massaged, and aspiration is not recommended for
heparin/Lovenox.
, 4. The nurse is performing tracheal suctioning on a patient with a tracheostomy. What is the
maximum duration for each suction pass?
A. 5 seconds
B. 30 seconds
C. 20 to 25 seconds
D. 10 to 15 seconds
Answer: D
Conceptual Explanation: Suctioning should be limited to 10-15 seconds to prevent
hypoxia and vagal stimulation. Longer durations can cause significant oxygen desaturation.
5. Which assessment finding indicates that a patient’s chest tube is functioning correctly and
the lung has not yet fully re-expanded?
A. Continuous bubbling in the water-seal chamber.
B. Constant vigorous bubbling in the suction control chamber.
C. The drainage in the collection chamber has stopped completely.
D. Intermittent tidaling in the water-seal chamber with respirations.
Answer: D
Conceptual Explanation: Tidaling (the rise and fall of water with breathing) indicates the
system is patent and the lung is still expanding. Continuous bubbling in the water-seal
chamber suggests an air leak.
TECHNIQUES 15TH EDITION
COMPREHENSIVE EXAM QUESTIONS
AND CORRECT ANSWERS LATEST
UPDATE
1. While preparing a sterile field, the nurse realizes that a sterile bowl is needed. Which
action by the nurse maintains the integrity of the sterile field?
A. Reaching across the sterile field to pick up the bowl from the supply cart.
B. Asking a colleague to drop the sterile bowl onto the field from the side.
C. Leaving the sterile field unattended to retrieve the bowl from the storage room.
D. Placing the sterile bowl on the 1-inch border of the sterile drape.
Answer: B
Conceptual Explanation: Items must be introduced to a sterile field from the side to avoid
reaching over it. Reaching over contaminates the field. The 1-inch border is considered
non-sterile, and a sterile field should never be left unattended.
2. A patient is receiving a continuous intravenous infusion of 0.9% Normal Saline. The nurse
notes the site is cool to the touch, swollen, and the patient complains of pain. What is the
nurse’s priority action?
A. Apply a warm compress to the site immediately.
,B. Slow the infusion rate to a KVO (keep vein open) rate.
C. Stop the infusion and discontinue the IV catheter.
D. Elevate the extremity and notify the physician.
Answer: C
Conceptual Explanation: These are classic signs of infiltration. The priority action is to
stop the infusion and remove the catheter to prevent further tissue damage before
implementing other comfort measures.
3. When administering a pre-filled Lovenox (enoxaparin) injection, which action should the
nurse take?
A. Administer the injection in the lateral abdominal wall (love handles).
B. Massage the injection site after withdrawing the needle to promote absorption.
C. Expel the nitrogen air bubble from the syringe before administration.
D. Aspirate for blood return before injecting the medication.
Answer: A
Conceptual Explanation: Enoxaparin should be injected into the subcutaneous tissue of
the abdomen, specifically the anterolateral or posterolateral walls. The air bubble should
not be expelled, the site should not be massaged, and aspiration is not recommended for
heparin/Lovenox.
, 4. The nurse is performing tracheal suctioning on a patient with a tracheostomy. What is the
maximum duration for each suction pass?
A. 5 seconds
B. 30 seconds
C. 20 to 25 seconds
D. 10 to 15 seconds
Answer: D
Conceptual Explanation: Suctioning should be limited to 10-15 seconds to prevent
hypoxia and vagal stimulation. Longer durations can cause significant oxygen desaturation.
5. Which assessment finding indicates that a patient’s chest tube is functioning correctly and
the lung has not yet fully re-expanded?
A. Continuous bubbling in the water-seal chamber.
B. Constant vigorous bubbling in the suction control chamber.
C. The drainage in the collection chamber has stopped completely.
D. Intermittent tidaling in the water-seal chamber with respirations.
Answer: D
Conceptual Explanation: Tidaling (the rise and fall of water with breathing) indicates the
system is patent and the lung is still expanding. Continuous bubbling in the water-seal
chamber suggests an air leak.
