CLINICAL NURSING SKILLS AND
TECHNIQUES ADVANCED TEST BANK
QUESTIONS AND CORRECT ANSWERS
LATEST UPDATE
1. A nurse is measuring a patient’s blood pressure and uses a cuff that is too narrow for the
patient’s arm circumference. Which result should the nurse expect?
A. A falsely elevated blood pressure reading
B. A falsely low blood pressure reading
C. An accurate reading if the patient is supine
D. An inability to detect Korotkoff sounds
Answer: A
Conceptual Explanation: A blood pressure cuff that is too small or narrow will result in a
falsely high reading because the cuff must be over-inflated to occlude the artery.
Conversely, a cuff that is too wide will result in a falsely low reading.
2. While setting up a sterile field, the nurse realizes that a 1-inch (2.5 cm) border around the
edge of the sterile drape is considered:
A. Sterile as long as it remains dry
B. Sterile if handled only with sterile gloves
,C. Part of the sterile field for 30 minutes
D. Contaminated and should not be used for sterile items
Answer: D
Conceptual Explanation: In aseptic technique, the 1-inch (2.5 cm) border at the edge of a
sterile field is considered contaminated because it is in contact with non-sterile surfaces.
3. What is the maximum duration a nurse should apply suction during tracheal suctioning?
A. 5 seconds
B. 10 to 15 seconds
C. 20 seconds
D. 30 seconds
Answer: B
Conceptual Explanation: Suctioning should be limited to 10 to 15 seconds to prevent
hypoxia and vagal stimulation, which can lead to bradycardia.
4. When administering a large-volume enema, the nurse should place the patient in which
position?
A. Right-sided Sims position
B. Dorsal recumbent position
C. Left-sided Sims position
, D. High-Fowler’s position
Answer: C
Conceptual Explanation: The left Sims position allows the enema solution to flow by
gravity along the natural curve of the sigmoid colon and rectum, improving retention and
effectiveness.
5. The nurse observes coolness, pallor, and swelling at a peripheral IV site. Which
complication should the nurse document?
A. Extravasation
B. Phlebitis
C. Infiltration
D. Thrombosis
Answer: C
Conceptual Explanation: Infiltration is characterized by coolness, pallor, and edema at the
site due to the IV fluid entering the subcutaneous tissue. Phlebitis would present with
warmth and redness.
6. A patient has an IV site that is red, warm, and has a visible red streak along the vein. What
is the nurse’s priority action?
A. Apply a cold compress
B. Discontinue the IV and remove the catheter
TECHNIQUES ADVANCED TEST BANK
QUESTIONS AND CORRECT ANSWERS
LATEST UPDATE
1. A nurse is measuring a patient’s blood pressure and uses a cuff that is too narrow for the
patient’s arm circumference. Which result should the nurse expect?
A. A falsely elevated blood pressure reading
B. A falsely low blood pressure reading
C. An accurate reading if the patient is supine
D. An inability to detect Korotkoff sounds
Answer: A
Conceptual Explanation: A blood pressure cuff that is too small or narrow will result in a
falsely high reading because the cuff must be over-inflated to occlude the artery.
Conversely, a cuff that is too wide will result in a falsely low reading.
2. While setting up a sterile field, the nurse realizes that a 1-inch (2.5 cm) border around the
edge of the sterile drape is considered:
A. Sterile as long as it remains dry
B. Sterile if handled only with sterile gloves
,C. Part of the sterile field for 30 minutes
D. Contaminated and should not be used for sterile items
Answer: D
Conceptual Explanation: In aseptic technique, the 1-inch (2.5 cm) border at the edge of a
sterile field is considered contaminated because it is in contact with non-sterile surfaces.
3. What is the maximum duration a nurse should apply suction during tracheal suctioning?
A. 5 seconds
B. 10 to 15 seconds
C. 20 seconds
D. 30 seconds
Answer: B
Conceptual Explanation: Suctioning should be limited to 10 to 15 seconds to prevent
hypoxia and vagal stimulation, which can lead to bradycardia.
4. When administering a large-volume enema, the nurse should place the patient in which
position?
A. Right-sided Sims position
B. Dorsal recumbent position
C. Left-sided Sims position
, D. High-Fowler’s position
Answer: C
Conceptual Explanation: The left Sims position allows the enema solution to flow by
gravity along the natural curve of the sigmoid colon and rectum, improving retention and
effectiveness.
5. The nurse observes coolness, pallor, and swelling at a peripheral IV site. Which
complication should the nurse document?
A. Extravasation
B. Phlebitis
C. Infiltration
D. Thrombosis
Answer: C
Conceptual Explanation: Infiltration is characterized by coolness, pallor, and edema at the
site due to the IV fluid entering the subcutaneous tissue. Phlebitis would present with
warmth and redness.
6. A patient has an IV site that is red, warm, and has a visible red streak along the vein. What
is the nurse’s priority action?
A. Apply a cold compress
B. Discontinue the IV and remove the catheter
