& Skills I (2026) Actual Q&A PDF
1. A nurse is preparing to insert a condom catheter for a male patient.
Which assessment finding would indicate the device is contraindicated?
A) The patient has a history of urinary retention
B) The patient has phimosis or scrotal edema
C) The patient is uncircumcised
D) The patient has a reclining bed
Correct Answer: The patient has phimosis or scrotal edema
Rationale: Condom catheters are contraindicated in patients with
phimosis, paraphimosis, or scrotal edema because application can cause
severe tissue injury or compromise blood flow. Urinary retention, being
uncircumcised, or bed position are not contraindications for this device.
2. Which type of urinary incontinence is characterized by an involuntary
loss of urine associated with a sudden, strong urge to void?
A) Stress incontinence
B) Overflow incontinence
C) Urge incontinence
D) Functional incontinence
Correct Answer: Urge incontinence
Rationale: Urge incontinence is characterized by a sudden, intense urge
to void followed by an involuntary loss of urine, often caused by an
overactive bladder detrusor muscle. Stress incontinence involves leakage
with physical exertion, and overflow incontinence results from bladder
overdistention.
,3. What is the primary purpose of maintaining a closed drainage system
for a patient with an indwelling urinary catheter?
A) To prevent the patient from removing the catheter
B) To reduce the risk of catheter-associated urinary tract infection (CAUTI)
C) To allow for accurate measurement of urinary specific gravity
D) To prevent kinking of the catheter tubing
Correct Answer: To reduce the risk of catheter-associated urinary tract
infection (CAUTI)
Rationale: A closed drainage system prevents bacteria from entering the
urinary tract, which is the primary intervention for preventing CAUTI.
While it may help with other aspects of care, infection prevention is the
main purpose.
4. A nurse is assessing the stoma of a patient with a descending
colostomy. What is the expected appearance and consistency of the
effluent?
A) Liquid, greenish, and containing enzymes
B) Formed, brown, and resembling normal stool
C) Paste-like, yellowish-green, and odorous
D) Thin, watery, and clear
Correct Answer: Formed, brown, and resembling normal stool
Rationale: A descending colostomy is located in the distal large intestine
where most water has been absorbed, resulting in formed, brown stool
similar to normal feces. Liquid or paste-like effluent would be expected
with more proximal ostomies.
5. Which type of wound drainage is composed of clear, watery plasma and
does not contain red blood cells?
A) Sanguineous
,B) Serosanguineous
C) Purulent
D) Serous
Correct Answer: Serous
Rationale: Serous drainage is a clear, thin, and watery fluid that is
essentially plasma, indicating normal wound healing without infection or
significant bleeding. Sanguineous drainage contains blood, and purulent
drainage indicates infection.
6. According to the principles of surgical asepsis, what is the correct action
when a sterile object touches the 1-inch border of a sterile field?
A) The object is considered sterile because the border is part of the field
B) The object is considered contaminated and must be discarded
C) The object can be used if the nurse wipes it with an antiseptic wipe
D) The object can be used if the contact was less than three seconds
Correct Answer: The object is considered contaminated and must be
discarded
Rationale: The 1-inch border around a sterile field is considered
contaminated. Any sterile object touching this border is immediately
contaminated and cannot be used. Wiping or brief contact does not
restore sterility.
7. Which phase of wound healing is characterized by the formation of
granulation tissue and angiogenesis?
A) Hemostasis
B) Inflammatory
C) Proliferative
D) Maturation
, Correct Answer: Proliferative
Rationale: The proliferative phase involves the formation of granulation
tissue, angiogenesis (new blood vessel growth), and epithelialization.
Hemostasis is the initial clotting phase, the inflammatory phase involves
cleaning the wound, and maturation is the final remodeling phase.
8. A nurse is assessing a patient's wound and notes beefy red granulation
tissue. What is the most appropriate nursing intervention?
A) Debride the red tissue with a sterile scalpel
B) Apply a wet-to-dry dressing to remove exudate
C) Maintain a moist wound environment with a foam dressing
D) Pack the wound tightly with gauze to absorb drainage
Correct Answer: Maintain a moist wound environment with a foam
dressing
Rationale: Beefy red granulation tissue indicates healthy healing. A moist
environment with a foam dressing promotes healing and absorbs
moderate exudate without damaging new tissue【17†L5-L7】.
Debridement is not needed for healthy tissue, and wet-to-dry dressings
can be traumatic.
9. A patient has an order for a 24-hour urine specimen collection. Which
measure is most important for the nurse to implement?
A) Instruct the client to empty his bladder and save this voiding to start
the collection
B) Instruct the client to use sterile individual containers to collect the urine
C) Post a sign stating "Save All Urine" in the bathroom
D) Keep the urine specimen in the refrigerator
Correct Answer: Post a sign stating "Save All Urine" in the bathroom