Q&A | Nursing
1. Which of the following best describes the primary difference between
medical asepsis and surgical asepsis?
A) Medical asepsis destroys all microorganisms, while surgical asepsis
reduces their number
B) Medical asepsis reduces the number of microorganisms, while surgical
asepsis destroys all microorganisms and spores
C) Medical asepsis is used only for wound care, while surgical asepsis is used
for all procedures
D) There is no significant difference between the two practices
Correct Answer: Medical asepsis reduces the number of microorganisms,
while surgical asepsis destroys all microorganisms and spores
Rationale: Medical asepsis (clean technique) involves reducing the number of
microorganisms through hand hygiene and cleaning . Surgical asepsis (sterile
technique) completely destroys all microorganisms and their spores using
heat or chemical processes . This distinction is fundamental to infection
prevention in nursing practice.
2. A nurse is preparing to perform a sterile dressing change. Which action
indicates correct understanding of surgical asepsis?
A) Opening sterile supplies while wearing clean gloves
B) Keeping sterile items within the 1-inch border of the sterile field
C) Placing sterile items outside the 1-inch border of the sterile field
D) Reaching over the sterile field to retrieve additional supplies
Correct Answer: Keeping sterile items within the 1-inch border of the sterile
field
,Rationale: The 1-inch border around a sterile field is considered
contaminated . All sterile items must be placed within this border. Reaching
over the sterile field and opening supplies with non-sterile gloves would
contaminate the field.
3. A client requires an indwelling urinary catheter. Before inserting the
catheter, what is the most important nursing action?
A) Placing the client in a supine position
B) Assessing the client for allergies to latex or iodine
C) Opening the sterile catheterization kit
D) Donning sterile gloves
Correct Answer: Assessing the client for allergies to latex or iodine
Rationale: Before any procedure, the nurse must identify issues that may
impact client safety, including verifying allergies . Latex allergies are
common, and many catheter kits contain latex. Identifying allergies is a
critical pre-procedure safety step.
4. A nurse is inserting a female indwelling urinary catheter. After inserting
the catheter into the urethra, urine begins to flow. What should the nurse do
next?
A) Inflate the balloon immediately
B) Advance the catheter an additional 1 to 2 inches
C) Secure the catheter to the client's thigh
D) Remove the catheter and start over
Correct Answer: Advance the catheter an additional 1 to 2 inches
,Rationale: After urine begins to flow, the catheter must be advanced an
additional 1 to 2 inches to ensure the balloon is fully inside the bladder
before inflation . Inflating the balloon prematurely could cause urethral
trauma.
5. A nurse is performing a sterile wound irrigation and packing procedure.
The nurse should administer pain medication:
A) Immediately before starting the procedure
B) At least 20 minutes before the procedure
C) Only if the client requests it during the procedure
D) After the procedure is completed
Correct Answer: At least 20 minutes before the procedure
Rationale: Pain medication should be administered at least 20 minutes before
a painful procedure such as wound irrigation and packing to allow it to take
effect . This promotes client comfort and cooperation during the procedure.
6. A client has a pressure ulcer that requires packing. Which action
demonstrates correct wound packing technique?
A) Packing the wound tightly to fill all dead space
B) Packing the wound loosely with ordered packing material
C) Leaving the packing material outside the wound
D) Using dry gauze to pack the wound without moisture
Correct Answer: Packing the wound loosely with ordered packing material
Rationale: Wounds should be packed gently and loosely with the ordered
packing material to allow for drainage and prevent further tissue damage .
, Tight packing can cause ischemia and delay healing. The packing should fill
the wound space without being compressed.
7. A nurse is assessing a wound during a dressing change. Which finding
should be reported to the provider immediately?
A) Serosanguineous drainage
B) Granulation tissue in the wound bed
C) Foul odor and purulent drainage
D) Wound edges that are well-approximated
Correct Answer: Foul odor and purulent drainage
Rationale: Foul odor and purulent (yellow/green) drainage are signs of
infection that require immediate provider notification. Serosanguineous
drainage and granulation tissue are normal healing findings. Well-
approximated edges indicate healing.
8. A client is at risk for developing a pressure ulcer. Which nursing
intervention is most effective for prevention?
A) Massaging bony prominences to improve circulation
B) Repositioning the client at least every 2 hours
C) Keeping the client in a supine position at all times
D) Using a donut-shaped cushion for the sacrum
Correct Answer: Repositioning the client at least every 2 hours
Rationale: Frequent repositioning (at least every 2 hours) is the most
effective intervention for preventing pressure ulcers by relieving pressure on
bony prominences . Massaging bony prominences can cause tissue damage,
and donut cushions can impair circulation.