NURS 101L | Sterile Technique & Wound Care Comprehensive Exam
(2026 Update) WCU
1. When preparing a sterile field, which action by the nurse represents a break
in surgical asepsis?
A. Opening the outermost flap of the sterile kit away from the body.
B. Keeping the sterile field above waist level at all times.
C. Reaching across the sterile field to pick up a discarded wrapper.
D. Dropping a sterile item onto the field from a height of 6 inches.
Answer: C
Rationale: Reaching over a sterile field contaminates it. Sterile objects must be kept in
view, and movement over the field must be avoided.
2. The nurse is assessing a pressure injury that presents as a shallow, open ulcer
with a red-pink wound bed without slough. How should this be staged?
A. Stage I
B. Stage II
C. Stage III
D. Deep Tissue Pressure Injury
Answer: B
Rationale: Stage II involves partial-thickness loss of dermis presenting as a shallow open
ulcer with a red-pink wound bed.
,3. What is the primary purpose of ‘lipping’ a sterile solution before pouring it
into a sterile container?
A. To ensure the solution is at the correct temperature.
B. To wash away any microorganisms from the lip of the bottle.
C. To prevent the solution from dripping down the label.
D. To verify the expiration date and integrity of the seal.
Answer: B
Rationale: Pouring a small amount of liquid out (lipping) cleans the rim of the bottle of
potential contaminants before the solution is used for the procedure.
4. A patient’s surgical wound has thick, yellow drainage with a foul odor. The
nurse documents this exudate as:
A. Serosanguineous
B. Purulent
C. Sanguineous
D. Serous
Answer: B
Rationale: Purulent drainage is thick, often yellow, green, or brown, and typically indicates
infection.
5. Which border of a sterile drape is considered contaminated and safe to touch
with unsterile hands during setup?
A. The outer 1-inch border
B. The inner 2-inch border
C. Only the corners
D. The entire back side of the drape
Answer: A
Rationale: A 1-inch (2.5 cm) border around the edges of a sterile field is considered
contaminated.
, 6. A nurse is performing a sterile dressing change. If a sterile gauze pad falls on
the 1-inch border of the sterile field, what is the priority action?
A. Pick it up with sterile forceps and move it to the center.
B. Use it only for cleaning the peri-wound area.
C. Consider the gauze contaminated and discard it.
D. Continue the procedure as long as the center is clean.
Answer: C
Rationale: The 1-inch border is unsterile. Any item touching it is contaminated and must
be discarded.
7. Which phase of wound healing is characterized by the formation of
granulation tissue and wound contraction?
A. Proliferation phase
B. Inflammatory phase
C. Hemostasis phase
D. Maturation phase
Answer: A
Rationale: The proliferation phase involves building new tissue (granulation) to fill the
wound space.
8. The nurse observes a wound with full-thickness tissue loss where the base is
completely covered by yellow slough. What is the correct staging?
A. Unstageable
B. Stage IV
C. Stage III
D. Deep Tissue Pressure Injury
Answer: A
Rationale: If the base of the wound is obscured by slough or eschar, the depth cannot be
determined, making it unstageable until debrided.
(2026 Update) WCU
1. When preparing a sterile field, which action by the nurse represents a break
in surgical asepsis?
A. Opening the outermost flap of the sterile kit away from the body.
B. Keeping the sterile field above waist level at all times.
C. Reaching across the sterile field to pick up a discarded wrapper.
D. Dropping a sterile item onto the field from a height of 6 inches.
Answer: C
Rationale: Reaching over a sterile field contaminates it. Sterile objects must be kept in
view, and movement over the field must be avoided.
2. The nurse is assessing a pressure injury that presents as a shallow, open ulcer
with a red-pink wound bed without slough. How should this be staged?
A. Stage I
B. Stage II
C. Stage III
D. Deep Tissue Pressure Injury
Answer: B
Rationale: Stage II involves partial-thickness loss of dermis presenting as a shallow open
ulcer with a red-pink wound bed.
,3. What is the primary purpose of ‘lipping’ a sterile solution before pouring it
into a sterile container?
A. To ensure the solution is at the correct temperature.
B. To wash away any microorganisms from the lip of the bottle.
C. To prevent the solution from dripping down the label.
D. To verify the expiration date and integrity of the seal.
Answer: B
Rationale: Pouring a small amount of liquid out (lipping) cleans the rim of the bottle of
potential contaminants before the solution is used for the procedure.
4. A patient’s surgical wound has thick, yellow drainage with a foul odor. The
nurse documents this exudate as:
A. Serosanguineous
B. Purulent
C. Sanguineous
D. Serous
Answer: B
Rationale: Purulent drainage is thick, often yellow, green, or brown, and typically indicates
infection.
5. Which border of a sterile drape is considered contaminated and safe to touch
with unsterile hands during setup?
A. The outer 1-inch border
B. The inner 2-inch border
C. Only the corners
D. The entire back side of the drape
Answer: A
Rationale: A 1-inch (2.5 cm) border around the edges of a sterile field is considered
contaminated.
, 6. A nurse is performing a sterile dressing change. If a sterile gauze pad falls on
the 1-inch border of the sterile field, what is the priority action?
A. Pick it up with sterile forceps and move it to the center.
B. Use it only for cleaning the peri-wound area.
C. Consider the gauze contaminated and discard it.
D. Continue the procedure as long as the center is clean.
Answer: C
Rationale: The 1-inch border is unsterile. Any item touching it is contaminated and must
be discarded.
7. Which phase of wound healing is characterized by the formation of
granulation tissue and wound contraction?
A. Proliferation phase
B. Inflammatory phase
C. Hemostasis phase
D. Maturation phase
Answer: A
Rationale: The proliferation phase involves building new tissue (granulation) to fill the
wound space.
8. The nurse observes a wound with full-thickness tissue loss where the base is
completely covered by yellow slough. What is the correct staging?
A. Unstageable
B. Stage IV
C. Stage III
D. Deep Tissue Pressure Injury
Answer: A
Rationale: If the base of the wound is obscured by slough or eschar, the depth cannot be
determined, making it unstageable until debrided.
