TEST BANK
Taylor's Clinical Nursing Skills
Pamela B. Lynn EdD MSN RN
6th Edition
,Table of Contents
Chapter 01 Asepsis and Infection Control 1
Chapter 02 Vital Signs 13
Chapter 03 Health Assessment 25
Chapter 04 Safety 36
Chapter 05 Medications 48
Chapter 06 Perioperative Nursing 60
Chapter 07 Hygiene 72
Chapter 08 Skin Integrity and Wound Care 83
Chapter 09 Activity 94
Chapter 10 Comfort and Pain Management 105
Chapter 11 Nutrition 117
Chapter 12 Urinary Elimination 129
Chapter 13 Bowel Elimination 141
Chapter 14 Oxygenation 153
Chapter 15 Perfusion and Cardiovascular Care 165
Chapter 16 Fluid, Electrolyte, and Acid–Base Balance 177
Chapter 17 Neurologic Care 189
Chapter 18 Laboratory Specimen Collection 201
,______________________________________________________________________________________________
Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
Chapter 01, Asepsis and Infection Control
1. The nurse is caring for a postoperative client in contact isolation. Which action(s) will the
nurse employ to limit the spread of microorganisms to other clients? Select all that apply.
A) Wash hands after removing gloves prior to leaving the client’s room.
B) Apply clean gloves when performing a sterile dressing change.
C) Place used syringes and uncapped needles in a puncture-resistant container after
use.
D) Remove personal protective equipment (PPE) prior to exiting the client’s room.
E) Remove the respirator after exiting the client’s room and closing the door.
F) Replace the sealed items from the client’s room in stock to use for other client use.
ANS: A, C, D, E
Feedback:
Limiting the spread of disease when a client is in contact isolation includes using gloves
and washing hands before leaving the client’s private room. The nurse should wear sterile
gloves when performing a sterile dressing. The nurse follows standard precautions by
placing used syringes and uncapped needles into a puncture-resistant container. It is
important for the nurse to remove PPE prior to exiting the room to avoid spreading
organisms from the PPE outside of the room. The respirator is not to be removed until
after exiting the room and the door is closed. The nurse cannot use items from the client’s
room, including sealed items, because of the risk of spreading the infection through
contact.
PTS: 1 REF: Pages 4, 7, Fundamentals Review 1-1, Fundamentals Review 1-4
OBJ: 1, 3
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
2. A nurse is implementing practices with the goal of reducing the number and transfer of
pathogens. Which action(s) is consistent with this goal? Select all that apply.
A) Carry soiled items close to the body to prevent transfer of pathogens into the
environment.
B) Place soiled bed linen or any other items on the floor, instead of on the bed or
furniture.
C) Move equipment close to the body when brushing, dusting, or scrubbing articles.
D) Clean the least soiled areas first and then move to the more soiled ones.
E) Use personal grooming habits, such as shampooing hair often, to prevent spreading
microorganisms.
F) Shake out linens before placing them back on the bed to remove lint or debris.
ANS: D, E
Feedback:
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Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
The nurse will carry soiled items, including linens, equipment, and other used articles,
away from the body to prevent them from touching the clothing. The nurse does not place
soiled bed linens or any other item on the floor, which is grossly contaminated; it will
increase contamination of both the bed linens and the floor. The nurse will move
equipment away from the body when brushing, dusting, or scrubbing articles. The nurse
will clean the least soiled areas first and then move to the more soiled ones. The nurse will
use personal grooming habits that help prevent spreading microorganisms, such as
shampooing their hair regularly. The nurse does not shake linens; dust and lint particles
constitute a vehicle by which organisms may be transported from one area to another.
PTS: 1 REF: Page 4, Fundamentals Review 1-1 OBJ: 1, 3
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
3. The nurse is educating a client’s caregiver about hand hygiene prior to performing
dressing changes for a client that will be discharged the next day. Which statement made
by the caregiver indicates that the education is effective?
A) “Because gloves will be used, I do not have to use hand hygiene.”
B) “I will wash my hands prior to removing all personal protective equipment (PPE).”
C) “Hand hygiene is needed after I am in contact with objects near the client.”
D) “I will avoid the use of hand lotion after performing hand hygiene.”
ANS: C
Feedback:
Hand hygiene must be performed when moving from a contaminated body site to a clean
body site during client care and after contact with inanimate objects near the client. Using
gloves does not eliminate the need for hand hygiene and, in some cases, gloves must still
be used after hand hygiene. Lotions may be used to prevent irritation. Hands should be
washed after removing all PPE.
PTS: 1 REF: Page 5, Fundamentals Review 1-3 OBJ: 1
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Apply NOT: Multiple Choice
4. The nurse is caring for a group of clients and is using an alcohol-based handrub between
the care of each client. In which situation will the nurse perform a soap and water
cleansing rather than using an alcohol-based handrub?
A) The nurse's hands are visibly soiled.
B) The nurse anticipates contact with the client's skin during care.
C) When the nurse leaves the room of an immunocompromised client.
D) When the nurse is caring for a client with an active infection.
ANS: A
Feedback:
Alcohol-based handrubs may be used if hands are not visibly soiled or have not come in
contact with blood or body fluids. They should be used before and after each client
contact, or when in contact with surfaces in the client's environment to decrease the spread
of pathogens. Handwashing is required if hands are visibly soiled, before eating, and after
using the restroom.
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2|Page
,______________________________________________________________________________________________
Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
PTS: 1 REF: Page 8, Skill 1-1 OBJ: 1, 2
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
5. A nurse has been exposed to urine while caring for an incontinent client. Which guideline
will be followed by the nurse for performing hand hygiene?
A) Use an alcohol-based handrub to decontaminate the hands.
B) Remove all jewelry prior to washing the hands.
C) Keep hands lower than elbows to allow water to flow toward fingertips.
D) Pat dry with a paper towel, beginning with the forearms and moving to fingertips.
ANS: C
Feedback:
Handwashing, as opposed to hand hygiene with an alcohol-based handrub, is required
when hands are exposed to body fluids. Jewelry should be removed, if possible, and
secured in a safe place, but a plain wedding band may remain in place. To wash hands, wet
the hands and wrist area, keep hands lower than elbows to allow water to flow toward
fingertips and pat hands dry with a paper towel, beginning with the fingers and moving
upward toward forearms.
PTS: 1 REF: Page 12, Skill 1-2 OBJ: 1, 2
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
6. A nurse is implementing the principles of surgical asepsis while inserting a client's
indwelling urinary catheter. Which action will the nurse perform?
A) Hold sterile objects above waist level to prevent accidental contamination.
B) Consider the outside of the sterile package to be partially sterile.
C) Consider the outer 3-inch (7.5-cm) edge of a sterile field to be contaminated.
D) Open sterile packages so that the first edge of the wrapper is directed toward
oneself.
ANS: A
Feedback:
Holding a sterile object above waist level ensures the object is kept in sight and prevents
accidental contamination. The outside of the sterile package and the outer 1 inch (2.5 cm)
of a sterile field are contaminated. Sterile packages should be opened so that the first edge
of the wrapper is directed away from the nurse.
PTS: 1 REF: Page 5, Fundamentals Review 1-2 OBJ: 4
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
7. The nurse is performing a sterile change of a client's central-line catheter dressing. The
client receives a telephone call and stretches the phone cord across the open sterile
dressing kit. What is the next action the nurse needs to take?
A) Determine which item was touched and replace it.
B) Obtain and use another sterile central-line dressing kit.
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Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
C) Remove the old central-line dressing and discard.
D) Place surgical masks on the nurse and the client.
ANS: B
Feedback:
The phone cord touches the sterile field in such a way that there is no way to determine
what item or items are touched, and those items need replacement. The next action for the
nurse to take is to gather another sterile kit and start over. After opening the new kit, the
nurse may place mask on themselves and the client and remove the old central-line
dressing.
PTS: 1 REF: Page 28, Skill 1-5 OBJ: 4, 5
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
8. A nurse is adding a sterile solution to a sterile field and has just opened the bottle
according to manufacturer's directions. Which step will the nurse take?
A) Touch the tip of the bottle to the sterile container to start the flow of the solution
and pour it into the container directly from the top of the container edge.
B) Hold the bottle outside the edge of the sterile field with the label side facing the
palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm).
C) Pour a small amount of solution out of the bottle prior to pouring the full amount
into the container while holding the solution bottle with the label facing out.
D) Hold the bottle inside the 1-inch (2.5-cm) edges of the sterile field with the label
side facing the palm of the hand and pour from a height of 2 to 4 inches (5 to 10
cm).
ANS: B
Feedback:
Holding the bottle outside the edge of the sterile field with the label side facing the palm of
the hand and preparing to pour from a height of 4 to 6 inches (10 to 15 cm) is the correct
step for adding a sterile solution. The tip of the solutions should never touch the container
or dressing, and the label should face the palm when pouring the solution. Only a used
bottle of solution needs to be lipped. The bottle should be held outside the edge of the
sterile field.
PTS: 1 REF: Page 32, Skill 1-6 OBJ: 4, 5
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
9. Place in order the steps the nurse performs for putting the first hand into a sterile glove.
Use all options.
A) Carefully open the inner package. Fold open the top flap, then the bottom and
sides.
B) Place the inner package on the work surface with the side labeled of the cuff
closest to the body.
C) With the thumb and forefinger of the nondominant hand, grasp the folded cuff
of the glove for the dominant hand, touching only the exposed inside of the
glove.
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Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
D) Keeping the hands above the waistline, lift and hold the glove up and off the
inner package with fingers down.
E) Place the sterile glove package on a clean, dry surface at or above your waist.
F) Carefully insert dominant hand palm up into the glove and pull it on.
G) Open the outside wrapper by carefully peeling the top layer back and remove
inner package, handling only the outside of it.
ANS:
E, G, B, A, C, D, F
Feedback:
The expected outcome to achieve when putting on and removing sterile gloves is that the
gloves are applied and removed without contamination. The nurse performs this procedure
using the steps in the order listed.
PTS: 1 REF: Page 35, Skill 1-7 OBJ: 6
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Ordered Response
10. The nurse is providing care for a client with a Staphylococcus aureus infection in a
surgical wound that requires the use of personal protective equipment (PPE). Place in
order the actions the nurse will perform. Use all options.
A) Put on goggles and place over eyes and adjust to fit.
B) Put on the mask or respirator over your nose, mouth, and chin.
C) Put on the gown, with the opening in the back. Tie gown securely at neck and
waist.
D) Perform hand hygiene.
E) Put on clean, disposable gloves and extend gloves to cover the cuffs of the
gown.
F) Provide instruction about precautions to client, family members, and visitors.
ANS:
D, F, C, B, A, E
Feedback:
The expected outcome to achieve when using PPE according to the steps listed is that the
transmission of microorganisms is prevented. Other outcomes that may be appropriate
include that the client and staff remain free of exposure to potentially infectious
microorganisms and the client verbalizes information about the rationale for use of PPE.
Prior to performing any contact intervention, the nurse performs hand hygiene, then dons
gloves. Next, the nurse puts on the gown, followed by facial protection including mask or
respirator and goggles. Finally, the nurse dons clean disposable gloves that extend to cover
the cuff of the gown.
PTS: 1 REF: Page 17, Skill 1-3 OBJ: 6
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Ordered Response
11. A nurse's gloves get soiled while providing morning care for a client. Which action
demonstrates applied principles of infection control during glove removal?
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Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
A) Use the nondominant hand to grasp the opposite glove near the cuffed end on the
outside exposed area.
B) Remove the glove on the nondominant hand by pulling it straight off, keeping the
contaminated area on the outside.
C) After removing the glove on the nondominant hand, hold the removed glove in the
remaining gloved hand.
D) After removing the first glove, slide the fingers of the ungloved hand between the
remaining glove and the wrist and pull the glove straight off with the contaminated
area on the outside.
ANS: C
Feedback:
When removing gloves, the dominant hand is used to grasp the opposite glove near the
cuff end on the outside exposed area. It is pulled off and inverted, with the contaminated
area on the inside. The removed glove is held in the remaining gloved hand. Then, the
fingers of the ungloved hand are slid between the remaining glove and the wrist and the
glove is pulled off and inverted.
PTS: 1 REF: Page 17, Skill 1-3 OBJ: 3
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
12. A nurse finishes providing care to a client with a communicable respiratory infection.
Place in order the nurse’s steps to remove the personal protective equipment (PPE). Use all
options.
A) Gloves
B) Respirator
C) Gown
D) Goggles
ANS:
A, D, C, B
Feedback:
There are a variety of ways to remove PPE to ensure safe removal without contaminating
clothing, skin, or mucous membranes. One method for removal of PPE is the removal of
gloves, goggles, gown, and respirator.
PTS: 1 REF: Page 17, Skill 1-3 OBJ: 3
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Ordered Response
13. A nurse is inserting a urinary catheter into a client and observes a hole in one of the sterile
gloves. Which is the appropriate action for the nurse to take?
A) Finish the procedure and perform handwashing immediately afterward.
B) Finish the procedure, remove damaged glove, and open new sterile gloves.
C) Stop the procedure, remove damaged glove, and open new sterile gloves.
D) Stop the procedure, remove damaged glove, perform handwashing, and open new
sterile gloves.
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6|Page
Taylor's Clinical Nursing Skills
Pamela B. Lynn EdD MSN RN
6th Edition
,Table of Contents
Chapter 01 Asepsis and Infection Control 1
Chapter 02 Vital Signs 13
Chapter 03 Health Assessment 25
Chapter 04 Safety 36
Chapter 05 Medications 48
Chapter 06 Perioperative Nursing 60
Chapter 07 Hygiene 72
Chapter 08 Skin Integrity and Wound Care 83
Chapter 09 Activity 94
Chapter 10 Comfort and Pain Management 105
Chapter 11 Nutrition 117
Chapter 12 Urinary Elimination 129
Chapter 13 Bowel Elimination 141
Chapter 14 Oxygenation 153
Chapter 15 Perfusion and Cardiovascular Care 165
Chapter 16 Fluid, Electrolyte, and Acid–Base Balance 177
Chapter 17 Neurologic Care 189
Chapter 18 Laboratory Specimen Collection 201
,______________________________________________________________________________________________
Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
Chapter 01, Asepsis and Infection Control
1. The nurse is caring for a postoperative client in contact isolation. Which action(s) will the
nurse employ to limit the spread of microorganisms to other clients? Select all that apply.
A) Wash hands after removing gloves prior to leaving the client’s room.
B) Apply clean gloves when performing a sterile dressing change.
C) Place used syringes and uncapped needles in a puncture-resistant container after
use.
D) Remove personal protective equipment (PPE) prior to exiting the client’s room.
E) Remove the respirator after exiting the client’s room and closing the door.
F) Replace the sealed items from the client’s room in stock to use for other client use.
ANS: A, C, D, E
Feedback:
Limiting the spread of disease when a client is in contact isolation includes using gloves
and washing hands before leaving the client’s private room. The nurse should wear sterile
gloves when performing a sterile dressing. The nurse follows standard precautions by
placing used syringes and uncapped needles into a puncture-resistant container. It is
important for the nurse to remove PPE prior to exiting the room to avoid spreading
organisms from the PPE outside of the room. The respirator is not to be removed until
after exiting the room and the door is closed. The nurse cannot use items from the client’s
room, including sealed items, because of the risk of spreading the infection through
contact.
PTS: 1 REF: Pages 4, 7, Fundamentals Review 1-1, Fundamentals Review 1-4
OBJ: 1, 3
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
2. A nurse is implementing practices with the goal of reducing the number and transfer of
pathogens. Which action(s) is consistent with this goal? Select all that apply.
A) Carry soiled items close to the body to prevent transfer of pathogens into the
environment.
B) Place soiled bed linen or any other items on the floor, instead of on the bed or
furniture.
C) Move equipment close to the body when brushing, dusting, or scrubbing articles.
D) Clean the least soiled areas first and then move to the more soiled ones.
E) Use personal grooming habits, such as shampooing hair often, to prevent spreading
microorganisms.
F) Shake out linens before placing them back on the bed to remove lint or debris.
ANS: D, E
Feedback:
______________________________________________________________________________________________
1|Page
,______________________________________________________________________________________________
Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
The nurse will carry soiled items, including linens, equipment, and other used articles,
away from the body to prevent them from touching the clothing. The nurse does not place
soiled bed linens or any other item on the floor, which is grossly contaminated; it will
increase contamination of both the bed linens and the floor. The nurse will move
equipment away from the body when brushing, dusting, or scrubbing articles. The nurse
will clean the least soiled areas first and then move to the more soiled ones. The nurse will
use personal grooming habits that help prevent spreading microorganisms, such as
shampooing their hair regularly. The nurse does not shake linens; dust and lint particles
constitute a vehicle by which organisms may be transported from one area to another.
PTS: 1 REF: Page 4, Fundamentals Review 1-1 OBJ: 1, 3
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
3. The nurse is educating a client’s caregiver about hand hygiene prior to performing
dressing changes for a client that will be discharged the next day. Which statement made
by the caregiver indicates that the education is effective?
A) “Because gloves will be used, I do not have to use hand hygiene.”
B) “I will wash my hands prior to removing all personal protective equipment (PPE).”
C) “Hand hygiene is needed after I am in contact with objects near the client.”
D) “I will avoid the use of hand lotion after performing hand hygiene.”
ANS: C
Feedback:
Hand hygiene must be performed when moving from a contaminated body site to a clean
body site during client care and after contact with inanimate objects near the client. Using
gloves does not eliminate the need for hand hygiene and, in some cases, gloves must still
be used after hand hygiene. Lotions may be used to prevent irritation. Hands should be
washed after removing all PPE.
PTS: 1 REF: Page 5, Fundamentals Review 1-3 OBJ: 1
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Apply NOT: Multiple Choice
4. The nurse is caring for a group of clients and is using an alcohol-based handrub between
the care of each client. In which situation will the nurse perform a soap and water
cleansing rather than using an alcohol-based handrub?
A) The nurse's hands are visibly soiled.
B) The nurse anticipates contact with the client's skin during care.
C) When the nurse leaves the room of an immunocompromised client.
D) When the nurse is caring for a client with an active infection.
ANS: A
Feedback:
Alcohol-based handrubs may be used if hands are not visibly soiled or have not come in
contact with blood or body fluids. They should be used before and after each client
contact, or when in contact with surfaces in the client's environment to decrease the spread
of pathogens. Handwashing is required if hands are visibly soiled, before eating, and after
using the restroom.
______________________________________________________________________________________________
2|Page
,______________________________________________________________________________________________
Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
PTS: 1 REF: Page 8, Skill 1-1 OBJ: 1, 2
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
5. A nurse has been exposed to urine while caring for an incontinent client. Which guideline
will be followed by the nurse for performing hand hygiene?
A) Use an alcohol-based handrub to decontaminate the hands.
B) Remove all jewelry prior to washing the hands.
C) Keep hands lower than elbows to allow water to flow toward fingertips.
D) Pat dry with a paper towel, beginning with the forearms and moving to fingertips.
ANS: C
Feedback:
Handwashing, as opposed to hand hygiene with an alcohol-based handrub, is required
when hands are exposed to body fluids. Jewelry should be removed, if possible, and
secured in a safe place, but a plain wedding band may remain in place. To wash hands, wet
the hands and wrist area, keep hands lower than elbows to allow water to flow toward
fingertips and pat hands dry with a paper towel, beginning with the fingers and moving
upward toward forearms.
PTS: 1 REF: Page 12, Skill 1-2 OBJ: 1, 2
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
6. A nurse is implementing the principles of surgical asepsis while inserting a client's
indwelling urinary catheter. Which action will the nurse perform?
A) Hold sterile objects above waist level to prevent accidental contamination.
B) Consider the outside of the sterile package to be partially sterile.
C) Consider the outer 3-inch (7.5-cm) edge of a sterile field to be contaminated.
D) Open sterile packages so that the first edge of the wrapper is directed toward
oneself.
ANS: A
Feedback:
Holding a sterile object above waist level ensures the object is kept in sight and prevents
accidental contamination. The outside of the sterile package and the outer 1 inch (2.5 cm)
of a sterile field are contaminated. Sterile packages should be opened so that the first edge
of the wrapper is directed away from the nurse.
PTS: 1 REF: Page 5, Fundamentals Review 1-2 OBJ: 4
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
7. The nurse is performing a sterile change of a client's central-line catheter dressing. The
client receives a telephone call and stretches the phone cord across the open sterile
dressing kit. What is the next action the nurse needs to take?
A) Determine which item was touched and replace it.
B) Obtain and use another sterile central-line dressing kit.
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Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
C) Remove the old central-line dressing and discard.
D) Place surgical masks on the nurse and the client.
ANS: B
Feedback:
The phone cord touches the sterile field in such a way that there is no way to determine
what item or items are touched, and those items need replacement. The next action for the
nurse to take is to gather another sterile kit and start over. After opening the new kit, the
nurse may place mask on themselves and the client and remove the old central-line
dressing.
PTS: 1 REF: Page 28, Skill 1-5 OBJ: 4, 5
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
8. A nurse is adding a sterile solution to a sterile field and has just opened the bottle
according to manufacturer's directions. Which step will the nurse take?
A) Touch the tip of the bottle to the sterile container to start the flow of the solution
and pour it into the container directly from the top of the container edge.
B) Hold the bottle outside the edge of the sterile field with the label side facing the
palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm).
C) Pour a small amount of solution out of the bottle prior to pouring the full amount
into the container while holding the solution bottle with the label facing out.
D) Hold the bottle inside the 1-inch (2.5-cm) edges of the sterile field with the label
side facing the palm of the hand and pour from a height of 2 to 4 inches (5 to 10
cm).
ANS: B
Feedback:
Holding the bottle outside the edge of the sterile field with the label side facing the palm of
the hand and preparing to pour from a height of 4 to 6 inches (10 to 15 cm) is the correct
step for adding a sterile solution. The tip of the solutions should never touch the container
or dressing, and the label should face the palm when pouring the solution. Only a used
bottle of solution needs to be lipped. The bottle should be held outside the edge of the
sterile field.
PTS: 1 REF: Page 32, Skill 1-6 OBJ: 4, 5
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
9. Place in order the steps the nurse performs for putting the first hand into a sterile glove.
Use all options.
A) Carefully open the inner package. Fold open the top flap, then the bottom and
sides.
B) Place the inner package on the work surface with the side labeled of the cuff
closest to the body.
C) With the thumb and forefinger of the nondominant hand, grasp the folded cuff
of the glove for the dominant hand, touching only the exposed inside of the
glove.
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4|Page
,______________________________________________________________________________________________
Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
D) Keeping the hands above the waistline, lift and hold the glove up and off the
inner package with fingers down.
E) Place the sterile glove package on a clean, dry surface at or above your waist.
F) Carefully insert dominant hand palm up into the glove and pull it on.
G) Open the outside wrapper by carefully peeling the top layer back and remove
inner package, handling only the outside of it.
ANS:
E, G, B, A, C, D, F
Feedback:
The expected outcome to achieve when putting on and removing sterile gloves is that the
gloves are applied and removed without contamination. The nurse performs this procedure
using the steps in the order listed.
PTS: 1 REF: Page 35, Skill 1-7 OBJ: 6
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Ordered Response
10. The nurse is providing care for a client with a Staphylococcus aureus infection in a
surgical wound that requires the use of personal protective equipment (PPE). Place in
order the actions the nurse will perform. Use all options.
A) Put on goggles and place over eyes and adjust to fit.
B) Put on the mask or respirator over your nose, mouth, and chin.
C) Put on the gown, with the opening in the back. Tie gown securely at neck and
waist.
D) Perform hand hygiene.
E) Put on clean, disposable gloves and extend gloves to cover the cuffs of the
gown.
F) Provide instruction about precautions to client, family members, and visitors.
ANS:
D, F, C, B, A, E
Feedback:
The expected outcome to achieve when using PPE according to the steps listed is that the
transmission of microorganisms is prevented. Other outcomes that may be appropriate
include that the client and staff remain free of exposure to potentially infectious
microorganisms and the client verbalizes information about the rationale for use of PPE.
Prior to performing any contact intervention, the nurse performs hand hygiene, then dons
gloves. Next, the nurse puts on the gown, followed by facial protection including mask or
respirator and goggles. Finally, the nurse dons clean disposable gloves that extend to cover
the cuff of the gown.
PTS: 1 REF: Page 17, Skill 1-3 OBJ: 6
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Ordered Response
11. A nurse's gloves get soiled while providing morning care for a client. Which action
demonstrates applied principles of infection control during glove removal?
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Test Bank - Taylor's Clinical Nursing Skills, 6th Edition (Lynn, 2023)
A) Use the nondominant hand to grasp the opposite glove near the cuffed end on the
outside exposed area.
B) Remove the glove on the nondominant hand by pulling it straight off, keeping the
contaminated area on the outside.
C) After removing the glove on the nondominant hand, hold the removed glove in the
remaining gloved hand.
D) After removing the first glove, slide the fingers of the ungloved hand between the
remaining glove and the wrist and pull the glove straight off with the contaminated
area on the outside.
ANS: C
Feedback:
When removing gloves, the dominant hand is used to grasp the opposite glove near the
cuff end on the outside exposed area. It is pulled off and inverted, with the contaminated
area on the inside. The removed glove is held in the remaining gloved hand. Then, the
fingers of the ungloved hand are slid between the remaining glove and the wrist and the
glove is pulled off and inverted.
PTS: 1 REF: Page 17, Skill 1-3 OBJ: 3
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
12. A nurse finishes providing care to a client with a communicable respiratory infection.
Place in order the nurse’s steps to remove the personal protective equipment (PPE). Use all
options.
A) Gloves
B) Respirator
C) Gown
D) Goggles
ANS:
A, D, C, B
Feedback:
There are a variety of ways to remove PPE to ensure safe removal without contaminating
clothing, skin, or mucous membranes. One method for removal of PPE is the removal of
gloves, goggles, gown, and respirator.
PTS: 1 REF: Page 17, Skill 1-3 OBJ: 3
NAT: Client Needs: Safe and Effective Care Environment: Safety and Infection Control
TOP: Chapter Number: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Ordered Response
13. A nurse is inserting a urinary catheter into a client and observes a hole in one of the sterile
gloves. Which is the appropriate action for the nurse to take?
A) Finish the procedure and perform handwashing immediately afterward.
B) Finish the procedure, remove damaged glove, and open new sterile gloves.
C) Stop the procedure, remove damaged glove, and open new sterile gloves.
D) Stop the procedure, remove damaged glove, perform handwashing, and open new
sterile gloves.
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