NUR 170 Exam 1 Med Surg | 100 Actual study
Questions and Answers + Expert Rationales |
2026 Updated | 100% correct
1. A nurse is preparing a sterile field. The nurse should identify which of the following actions
contaminated the sterile field? (Select all that apply.)
A. A cotton ball dampened with sterile normal saline is placed on the field.
B. A contaminated instrument touches the outer edge of the sterile field.
C. A sterile instrument is dropped onto the near side of the sterile field.
D. The nurse turns to address the client's question concerning the procedure.
E. The procedure is postponed for 30 minutes to accommodate the client.
F. A liquid is poured into a sterile container from a distance of 25 cm.
Correct Answer: A, D, E, F
Expert Rationale: A sterile field becomes contaminated when any non-sterile item or action
introduces microorganisms. A cotton ball dampened with sterile saline (A) contaminates the
field because moisture wicks microorganisms from the non-sterile outer wrapper through
capillary action. When the nurse turns away (D), the sterile field is no longer in direct view, and
the nurse's back is considered unsterile. A 30-minute postponement (E) leaves the field
uncovered and exposed to airborne contaminants. Pouring liquid from 25 cm (F) is incorrect
because the recommended distance is 4-6 inches (10-15 cm); pouring from too high splashes
and breaks sterility. A contaminated instrument touching the outer edge (B) does NOT
contaminate the field because the outer 1-inch border is considered unsterile. A sterile
instrument dropped onto the near side (C) remains sterile as long as it stays within the sterile
field boundaries.
2. A nurse should identify that which of the following is the goal of surgical asepsis?
A. To create and maintain a micro-organism-free environment.
B. To kill all micro-organisms on all instruments involved in a procedure.
C. To reduce the presence of pathogenic organisms in the environment.
,D. To minimize exposure to the client's blood during an invasive procedure.
Correct Answer: A
Expert Rationale: Surgical asepsis, also known as sterile technique, aims to eliminate ALL
microorganisms—pathogenic and non-pathogenic—from the environment. This is achieved
through sterilization processes. Option B is incorrect because sterilization applies to instruments
but is not the comprehensive goal. Option C describes medical asepsis (clean technique), which
only reduces pathogens. Option D describes standard precautions, not surgical asepsis.
3. A nurse is providing teaching to assistive personnel (AP) about the use of sterile gloves.
Which instruction regarding the open-gloving method should the nurse give?
A. "Ask another team member to assist with donning gloves."
B. "Choose a pair of gloves at least one size smaller than usual."
C. "Grasp only the underside of the cuff with your ungloved hand."
D. "Grasp only the inside of the glove with your ungloved hand."
Correct Answer: D
Expert Rationale: During open-gloving, the nurse should grasp only the inside (cuff) of the glove
with the ungloved hand because this surface will touch the skin and is not required to remain
sterile. The outside of the glove must remain sterile. Option A is incorrect because open-gloving
is performed independently. Option B is wrong because gloves should fit properly, not be
smaller. Option C is incorrect because the underside/cuff exterior must remain sterile.
4. While waiting for a sterile procedure to begin, how should a nurse position their hands and
arms?
A. With hands clasped together in front of the body above the waist.
B. At the sides of the body, with hands pointing downward.
C. Folded across the chest with hands on the shoulders.
D. With hands clasped together at the back of the body at waist level.
Correct Answer: A
Expert Rationale: Hands must be kept in front of the body above waist level and below shoulder
level—the "sterile zone." This keeps hands in view and prevents accidental contact with
,unsterile surfaces. Option B allows hands to fall below waist level (unsterile zone). Option C
brings hands to shoulder level and may contaminate gloves. Option D places hands behind the
body where they cannot be visualized.
5. Prior to entering the surgical-scrub area, which personal protective equipment (PPE) items
should a nurse don? (Select all that apply.)
A. Gown
B. Protective eyewear
C. Hair cover
D. Mask
E. Shoe covers
Correct Answer: B, C, D, E
Expert Rationale: Before entering the surgical scrub area, the nurse should don protective
eyewear, hair cover, mask, and shoe covers to prevent contamination of the sterile
environment. The surgical gown (A) is donned AFTER the surgical hand scrub, not before. This
sequence ensures that the gown remains sterile and the scrubbed hands do not contaminate
the gown.
6. A nurse should identify that which area of the hands requires special attention during the
prescribed wash?
A. The area between each finger
B. The area under each fingernail
C. The palm of each hand
D. The back of the hands
Correct Answer: B
Expert Rationale: The subungual area (under the fingernails) harbors the highest concentration
of microorganisms, including pathogens. Studies show this area is most frequently missed
during hand hygiene. Special attention with a nail cleaner is required during surgical hand
scrubs. While other areas (A, C, D) need cleaning, they do not require the "special attention"
that subungual areas demand.
, 7. A nurse is preparing to wash their hands prior to surgery. For which reason should the
nurse keep their hands above their elbows?
A. To prevent them from coming into contact with a contaminated object.
B. To facilitate the application of sufficient friction to the hands.
C. To provide good visualization of the hands as they are scrubbed.
D. To encourage water and soap to flow away from the clean hands.
Correct Answer: D
Expert Rationale: Keeping hands above elbows during surgical hand scrub allows water and
microorganisms to flow from the cleanest area (hands) to the less clean area (elbows),
preventing recontamination. Gravity directs water downward and away from the hands. Option
A is incorrect because hand positioning doesn't prevent contact with objects. Option B and C do
not address the primary rationale.
8. When opening a sterile pack, which action would compromise the sterility of the
instruments and supplies inside?
A. Allowing movement of team members around the field.
B. Holding the sterile pack below waist or table level.
C. Keeping sterile items away from the edge of the table.
D. Opening the sterile pack just prior to the procedure.
Correct Answer: B
Expert Rationale: Any sterile item held below waist level is considered contaminated because
this area is outside the sterile visual field and more likely to contact unsterile surfaces. The
waist-to-shoulder area defines the "sterile zone." Option A is acceptable if team members
maintain distance. Option C is a correct sterile technique (1-inch border from edge). Option D is
correct practice to minimize contamination risk.
9. A nurse is preparing to flush and change the dressing on a client's central venous catheter.
What is the primary purpose for performing this intervention using surgical asepsis?
A. To promote the catheter's patency
Questions and Answers + Expert Rationales |
2026 Updated | 100% correct
1. A nurse is preparing a sterile field. The nurse should identify which of the following actions
contaminated the sterile field? (Select all that apply.)
A. A cotton ball dampened with sterile normal saline is placed on the field.
B. A contaminated instrument touches the outer edge of the sterile field.
C. A sterile instrument is dropped onto the near side of the sterile field.
D. The nurse turns to address the client's question concerning the procedure.
E. The procedure is postponed for 30 minutes to accommodate the client.
F. A liquid is poured into a sterile container from a distance of 25 cm.
Correct Answer: A, D, E, F
Expert Rationale: A sterile field becomes contaminated when any non-sterile item or action
introduces microorganisms. A cotton ball dampened with sterile saline (A) contaminates the
field because moisture wicks microorganisms from the non-sterile outer wrapper through
capillary action. When the nurse turns away (D), the sterile field is no longer in direct view, and
the nurse's back is considered unsterile. A 30-minute postponement (E) leaves the field
uncovered and exposed to airborne contaminants. Pouring liquid from 25 cm (F) is incorrect
because the recommended distance is 4-6 inches (10-15 cm); pouring from too high splashes
and breaks sterility. A contaminated instrument touching the outer edge (B) does NOT
contaminate the field because the outer 1-inch border is considered unsterile. A sterile
instrument dropped onto the near side (C) remains sterile as long as it stays within the sterile
field boundaries.
2. A nurse should identify that which of the following is the goal of surgical asepsis?
A. To create and maintain a micro-organism-free environment.
B. To kill all micro-organisms on all instruments involved in a procedure.
C. To reduce the presence of pathogenic organisms in the environment.
,D. To minimize exposure to the client's blood during an invasive procedure.
Correct Answer: A
Expert Rationale: Surgical asepsis, also known as sterile technique, aims to eliminate ALL
microorganisms—pathogenic and non-pathogenic—from the environment. This is achieved
through sterilization processes. Option B is incorrect because sterilization applies to instruments
but is not the comprehensive goal. Option C describes medical asepsis (clean technique), which
only reduces pathogens. Option D describes standard precautions, not surgical asepsis.
3. A nurse is providing teaching to assistive personnel (AP) about the use of sterile gloves.
Which instruction regarding the open-gloving method should the nurse give?
A. "Ask another team member to assist with donning gloves."
B. "Choose a pair of gloves at least one size smaller than usual."
C. "Grasp only the underside of the cuff with your ungloved hand."
D. "Grasp only the inside of the glove with your ungloved hand."
Correct Answer: D
Expert Rationale: During open-gloving, the nurse should grasp only the inside (cuff) of the glove
with the ungloved hand because this surface will touch the skin and is not required to remain
sterile. The outside of the glove must remain sterile. Option A is incorrect because open-gloving
is performed independently. Option B is wrong because gloves should fit properly, not be
smaller. Option C is incorrect because the underside/cuff exterior must remain sterile.
4. While waiting for a sterile procedure to begin, how should a nurse position their hands and
arms?
A. With hands clasped together in front of the body above the waist.
B. At the sides of the body, with hands pointing downward.
C. Folded across the chest with hands on the shoulders.
D. With hands clasped together at the back of the body at waist level.
Correct Answer: A
Expert Rationale: Hands must be kept in front of the body above waist level and below shoulder
level—the "sterile zone." This keeps hands in view and prevents accidental contact with
,unsterile surfaces. Option B allows hands to fall below waist level (unsterile zone). Option C
brings hands to shoulder level and may contaminate gloves. Option D places hands behind the
body where they cannot be visualized.
5. Prior to entering the surgical-scrub area, which personal protective equipment (PPE) items
should a nurse don? (Select all that apply.)
A. Gown
B. Protective eyewear
C. Hair cover
D. Mask
E. Shoe covers
Correct Answer: B, C, D, E
Expert Rationale: Before entering the surgical scrub area, the nurse should don protective
eyewear, hair cover, mask, and shoe covers to prevent contamination of the sterile
environment. The surgical gown (A) is donned AFTER the surgical hand scrub, not before. This
sequence ensures that the gown remains sterile and the scrubbed hands do not contaminate
the gown.
6. A nurse should identify that which area of the hands requires special attention during the
prescribed wash?
A. The area between each finger
B. The area under each fingernail
C. The palm of each hand
D. The back of the hands
Correct Answer: B
Expert Rationale: The subungual area (under the fingernails) harbors the highest concentration
of microorganisms, including pathogens. Studies show this area is most frequently missed
during hand hygiene. Special attention with a nail cleaner is required during surgical hand
scrubs. While other areas (A, C, D) need cleaning, they do not require the "special attention"
that subungual areas demand.
, 7. A nurse is preparing to wash their hands prior to surgery. For which reason should the
nurse keep their hands above their elbows?
A. To prevent them from coming into contact with a contaminated object.
B. To facilitate the application of sufficient friction to the hands.
C. To provide good visualization of the hands as they are scrubbed.
D. To encourage water and soap to flow away from the clean hands.
Correct Answer: D
Expert Rationale: Keeping hands above elbows during surgical hand scrub allows water and
microorganisms to flow from the cleanest area (hands) to the less clean area (elbows),
preventing recontamination. Gravity directs water downward and away from the hands. Option
A is incorrect because hand positioning doesn't prevent contact with objects. Option B and C do
not address the primary rationale.
8. When opening a sterile pack, which action would compromise the sterility of the
instruments and supplies inside?
A. Allowing movement of team members around the field.
B. Holding the sterile pack below waist or table level.
C. Keeping sterile items away from the edge of the table.
D. Opening the sterile pack just prior to the procedure.
Correct Answer: B
Expert Rationale: Any sterile item held below waist level is considered contaminated because
this area is outside the sterile visual field and more likely to contact unsterile surfaces. The
waist-to-shoulder area defines the "sterile zone." Option A is acceptable if team members
maintain distance. Option C is a correct sterile technique (1-inch border from edge). Option D is
correct practice to minimize contamination risk.
9. A nurse is preparing to flush and change the dressing on a client's central venous catheter.
What is the primary purpose for performing this intervention using surgical asepsis?
A. To promote the catheter's patency
