NURSING SKILLS MIDTERM EXAM
QUESTIONS WITH VERIFIED
ANSWERS
Identify all of the following that meet the definition of a health care-associated
infection (HAI).
A. An infected bedsore on a patient admitted directly from a doctor's office
B. A urinary tract infection that develops after a Foley catheter insertion
C. A human immunodeficiency virus-positive patient
D. An incisional wound that develops purulent drainage - Answer-A urinary tract
infection that develops after a Foley catheter insertion
An incisional wound that develops purulent drainage
Notes: When an invasive procedure performed in a health care setting, such as
insertion of a Foley catheter or creation of an incisional wound during surgery,
results in infection, we can assume that a breakdown in aseptic practice has resulted
in an HAI. (REF: p. 181)
A restless, confused patient needs to have the sterile packing in his hip wound
replaced. Which approach by the nurse would be best for maintaining sterile
technique?
A. Position the patient using as many pillows as needed.
B. Use nursing assistive personnel to help position the patient.
C. Give the patient pain medication so he doesn't move.
D. Wear a mask and sterile gown while changing the dressing. - Answer-Use nursing
assistive personnel to help position the patient.
Notes: It is appropriate to ask help from other staff members to help maintain a
patient in position during a dressing change. (REF: 186)
The nurse is setting up an over-bed table with supplies to clean a wound and to
replace a sterile dressing. The nurse would need to consider that contamination
exists if which situation is present?
A. The sterile gloves are kept above waist level.
B. The over-bed table is positioned before any of the supplies are opened.
C. The nurse pours the bottle of cleaning solution with the palm facing the label.
D. The sterile glove package is dry and intact with a water stain. - Answer-The sterile
glove package is dry and intact with a water stain.
Notes: If a package has a water stain, it is considered contaminated, even if the
package looks intact and is currently dry. (REF: p. 192)
Which of the following is not a principle of surgical asepsis?
,A. All items used within a sterile field must be sterile.
B. If an item's sterility is in doubt, the nurse can check its expiration date.
C. Table drapes are part of a sterile field only at table level.
D. Moisture on the sterile field contaminates the field. - Answer-If an item's sterility is
in doubt, the nurse can check its expiration date.
Notes: When sterility is in doubt, assume that the item is not sterile. (REF: p. 186)
Positioning a hemiplegic patient in Fowler's position will increase the patient's:
(Select all that apply.)
A. Ventilatory capacity.
B. Cardiac output.
C. Ability to swallow.
D. Risk of aspiration. - Answer-A. Ventilatory capacity.
B. Cardiac output.
C. Ability to swallow.
Notes: Fowler's position increases ventilation and cardiac output and improves the
patient's ability to swallow. Answer "D" is incorrect; Fowler's position helps to prevent
aspiration of food, liquids, and gastric secretions. (REF: p. 213)
Two assistive personnel ask the nurse for assistance to transfer a patient from the
bed to a stretcher using the three-person lift technique. What is the most appropriate
response from the nurse?
A. "As long as we use proper body mechanics, no one will get hurt."
B. "Since the patient weighs only 100 pounds, you can handle the transfer
yourselves."
C. "Please find the slide board for us to use."
D. "Which one of you wants to be at the patient's head?" - Answer-"Please find the
slide board for us to use."
Notes: The three-person lift for horizontal transfer from the bed to the stretcher is no
longer recommended. Physical stress can be decreased significantly by the use of a
slide board. (REF: p. 200)
A patient with a proprioceptive disorder is being assessed for his ability to walk from
bed to chair. You notice that the patient is bent forward and is leaning toward the
right. Which nursing diagnosis would be the primary one on which to base his care?
A. Activity intolerance
B. Risk for injury
C. Chronic pain
D. Nutrition: less than body requirements - Answer-Risk for injury
Notes: A problem with proprioceptive function interferes with a person's awareness
of his posture and changes in balance. Safety issues would be of primary concern
during this patient's assessment and care. (REF: p. 200)
, The patient is being log-rolled onto his right side. The patient's position would be
correct if what assessment was observed?
A. The patient is left in Sims' position.
B. The patient is moved in a smooth, continuous motion.
C. Two pillows are placed behind the patient's back while on his side.
D. A straight line is evident from the shoulder to the hip. - Answer-A straight line is
evident from the shoulder to the hip.
Notes: This answer focuses on the patient's position, which requires the vertebral
column to be straight. No specified number of pillows are needed behind the
patient's back. (REF: p. 217)
The nurse teaches a patient ROM exercises for the shoulder. For abduction, how
high is the patient taught to raise the arm?
A. 120 degrees
B. 140 degrees
C. 180 degrees
D. 220 degrees - Answer-180 degrees
Notes: Raising the arm above the head achieves 180-degree abduction. (REF: p.
224, Table 10-2)
A child with cerebral palsy can experience difficulty with movement, loss of balance,
and lack of muscle control. Which gait does the nurse instruct the parents to use for
crutch walking?
A. Four-point
B. Three-point
C. Two-point
D. Swing-to - Answer-Four-point
Notes: The four-point gait provides the most support and improves balance. (REF: p.
242)
Which situation is a contraindication for the use of elastic stockings?
A. Use of stockings within the previous 3 months
B. Recent skin graft to the lower leg
C. Increased circulation in lower extremities
D. Immobility for longer than 1 week - Answer-Recent skin graft to the lower leg
Notes: The success of a skin graft could be compromised by the application of
elastic stockings to the site. (REF: p. 234)
A patient is recovering from bilateral knee replacements and is prescribed bilateral
partial weight bearing. You are asked to reinforce crutch walking and know that the
following crutch gait would be most appropriate for this patient.
QUESTIONS WITH VERIFIED
ANSWERS
Identify all of the following that meet the definition of a health care-associated
infection (HAI).
A. An infected bedsore on a patient admitted directly from a doctor's office
B. A urinary tract infection that develops after a Foley catheter insertion
C. A human immunodeficiency virus-positive patient
D. An incisional wound that develops purulent drainage - Answer-A urinary tract
infection that develops after a Foley catheter insertion
An incisional wound that develops purulent drainage
Notes: When an invasive procedure performed in a health care setting, such as
insertion of a Foley catheter or creation of an incisional wound during surgery,
results in infection, we can assume that a breakdown in aseptic practice has resulted
in an HAI. (REF: p. 181)
A restless, confused patient needs to have the sterile packing in his hip wound
replaced. Which approach by the nurse would be best for maintaining sterile
technique?
A. Position the patient using as many pillows as needed.
B. Use nursing assistive personnel to help position the patient.
C. Give the patient pain medication so he doesn't move.
D. Wear a mask and sterile gown while changing the dressing. - Answer-Use nursing
assistive personnel to help position the patient.
Notes: It is appropriate to ask help from other staff members to help maintain a
patient in position during a dressing change. (REF: 186)
The nurse is setting up an over-bed table with supplies to clean a wound and to
replace a sterile dressing. The nurse would need to consider that contamination
exists if which situation is present?
A. The sterile gloves are kept above waist level.
B. The over-bed table is positioned before any of the supplies are opened.
C. The nurse pours the bottle of cleaning solution with the palm facing the label.
D. The sterile glove package is dry and intact with a water stain. - Answer-The sterile
glove package is dry and intact with a water stain.
Notes: If a package has a water stain, it is considered contaminated, even if the
package looks intact and is currently dry. (REF: p. 192)
Which of the following is not a principle of surgical asepsis?
,A. All items used within a sterile field must be sterile.
B. If an item's sterility is in doubt, the nurse can check its expiration date.
C. Table drapes are part of a sterile field only at table level.
D. Moisture on the sterile field contaminates the field. - Answer-If an item's sterility is
in doubt, the nurse can check its expiration date.
Notes: When sterility is in doubt, assume that the item is not sterile. (REF: p. 186)
Positioning a hemiplegic patient in Fowler's position will increase the patient's:
(Select all that apply.)
A. Ventilatory capacity.
B. Cardiac output.
C. Ability to swallow.
D. Risk of aspiration. - Answer-A. Ventilatory capacity.
B. Cardiac output.
C. Ability to swallow.
Notes: Fowler's position increases ventilation and cardiac output and improves the
patient's ability to swallow. Answer "D" is incorrect; Fowler's position helps to prevent
aspiration of food, liquids, and gastric secretions. (REF: p. 213)
Two assistive personnel ask the nurse for assistance to transfer a patient from the
bed to a stretcher using the three-person lift technique. What is the most appropriate
response from the nurse?
A. "As long as we use proper body mechanics, no one will get hurt."
B. "Since the patient weighs only 100 pounds, you can handle the transfer
yourselves."
C. "Please find the slide board for us to use."
D. "Which one of you wants to be at the patient's head?" - Answer-"Please find the
slide board for us to use."
Notes: The three-person lift for horizontal transfer from the bed to the stretcher is no
longer recommended. Physical stress can be decreased significantly by the use of a
slide board. (REF: p. 200)
A patient with a proprioceptive disorder is being assessed for his ability to walk from
bed to chair. You notice that the patient is bent forward and is leaning toward the
right. Which nursing diagnosis would be the primary one on which to base his care?
A. Activity intolerance
B. Risk for injury
C. Chronic pain
D. Nutrition: less than body requirements - Answer-Risk for injury
Notes: A problem with proprioceptive function interferes with a person's awareness
of his posture and changes in balance. Safety issues would be of primary concern
during this patient's assessment and care. (REF: p. 200)
, The patient is being log-rolled onto his right side. The patient's position would be
correct if what assessment was observed?
A. The patient is left in Sims' position.
B. The patient is moved in a smooth, continuous motion.
C. Two pillows are placed behind the patient's back while on his side.
D. A straight line is evident from the shoulder to the hip. - Answer-A straight line is
evident from the shoulder to the hip.
Notes: This answer focuses on the patient's position, which requires the vertebral
column to be straight. No specified number of pillows are needed behind the
patient's back. (REF: p. 217)
The nurse teaches a patient ROM exercises for the shoulder. For abduction, how
high is the patient taught to raise the arm?
A. 120 degrees
B. 140 degrees
C. 180 degrees
D. 220 degrees - Answer-180 degrees
Notes: Raising the arm above the head achieves 180-degree abduction. (REF: p.
224, Table 10-2)
A child with cerebral palsy can experience difficulty with movement, loss of balance,
and lack of muscle control. Which gait does the nurse instruct the parents to use for
crutch walking?
A. Four-point
B. Three-point
C. Two-point
D. Swing-to - Answer-Four-point
Notes: The four-point gait provides the most support and improves balance. (REF: p.
242)
Which situation is a contraindication for the use of elastic stockings?
A. Use of stockings within the previous 3 months
B. Recent skin graft to the lower leg
C. Increased circulation in lower extremities
D. Immobility for longer than 1 week - Answer-Recent skin graft to the lower leg
Notes: The success of a skin graft could be compromised by the application of
elastic stockings to the site. (REF: p. 234)
A patient is recovering from bilateral knee replacements and is prescribed bilateral
partial weight bearing. You are asked to reinforce crutch walking and know that the
following crutch gait would be most appropriate for this patient.
