CLINICAL NURSING SKILLS AND TECHNIQUES
COMPREHENSIVE TEST PAPER QUESTIONS
AND SOLUTIONS GRADED A+
◉ The nurse assists a new nurse to add items to a sterile field.
Which action by the new nurse requires further instruction?
The nurse drops the item from the wrapper into the side of the
sterile field.
The nurse keeps hands and wrists on the outside of the wrapped
sterile item.
The nurse grasps the remaining flap of the wrapper and pulls back
toward wrist.
The nurse holds wrapped item in dominant hand to open, opening
top flap away from body.
Answer: The nurse drops the item from the wrapper into the side of
the sterile field.
Rationale: The outer edges of the sterile field are considered
nonsterile. Dropping items into the outer edges of the field causes
those items to be considered contaminated. Items are dropped
toward the center of the field from approximately six inches above
the surface of the field. The nurse opens the package outward over
the hands, maintaining the sterility of the item inside the package.
,Items are typically held in the non-dominant hand while the
dominant hand pulls the package open.
◉ Which should be documented by the nurse?
The specific items that the nurse transferred into a sterile field.
The fact that the nurse washed her hands before a procedure.
The fact that the nurse donned gloves two different times during a
procedure.
The fact that sterile technique was used for a given procedure.
Answer: The fact that sterile technique was used for a given
procedure.
Rationale: The fact that sterile technique was used for a given
procedure should be documented, but the other items listed do not
need to be documented, as they are standard procedure.
◉ The nurse prepares for a sterile procedure. What action does the
nurse perform first?
Perform hand hygiene with alcohol-based handrub.
Place all the necessary supplies in the room.
Identify the client the procedure is prescribed for.
Put on personal protective equipment, if required.
Answer: Perform hand hygiene with alcohol-based handrub.
,Rationale: Hand hygiene is done prior to donning any personal
protective equipment, before entering the room, and before
interacting directly with the client, such as checking the name on the
armband.
◉ The nurse needs to place gauze from a wrapped item into the
sterile field. Which action does the nurse take?
Remove the gauze from the package with one sterile hand.
Drop the item from 6 in (15 cm) above the sterile field.
Lay the item in an open package on the 1-in (2.5-cm) border.
Extend the sterile field by laying the open package beside it.
Answer: Drop the item from 6 in (15 cm) above the sterile field.
Rationale: Dropping the item from roughly 6 in (15 cm) above the
surface prevents contamination of the field or dropping the item too
close to the 1-in (2.5-cm), nonsterile border. Removing the gauze
with one sterile hand risks contamination of that hand. It does not
extend the sterile field to lay an unsterile package to the outside of
the 1-in (2.5-cm) border.
◉ The nurse is preparing to administer a bolus of IV pain medication
through a drug-infusion lock. Before flushing the lock with saline,
there is no blood return with aspiration. What would be the initial
recommended nursing intervention in this situation?
, Check the patency of the tubing by injecting 3 mL sterile water.
Reassess the IV site for any infiltration or inflammation.
Forcefully attempt to flush the drug-infusion lock with saline,
observing the site for changes.
Remove the device to another part of the arm.
Answer: Reassess the IV site for any infiltration or inflammation.
Rationale: When there is no blood return upon aspiration of a drug-
infusion lock, the nurse should first reassess the IV site for any
infiltration or inflammation. Blood return does not always occur
even though the IV lock is patent. If the lock is patent, the nurse
should slowly and gently attempt to flush it with saline and observe
the site for changes. If signs of infiltration are present, the nurse
would remove the device and restart in another location.
◉ The nurse is preparing to give an IV medication to a client through
a drug-infusion lock. Which action would the nurse perform to
ensure the right client receives the medication?
Ask the client's family to identify the client.
State the client's name and ask if this is correct.
If the client cannot identify self, ask the client's roommate to identify
the client.
Ask the client to state his or her name and birth date.
Answer: Ask the client to state his or her name and birth date.
COMPREHENSIVE TEST PAPER QUESTIONS
AND SOLUTIONS GRADED A+
◉ The nurse assists a new nurse to add items to a sterile field.
Which action by the new nurse requires further instruction?
The nurse drops the item from the wrapper into the side of the
sterile field.
The nurse keeps hands and wrists on the outside of the wrapped
sterile item.
The nurse grasps the remaining flap of the wrapper and pulls back
toward wrist.
The nurse holds wrapped item in dominant hand to open, opening
top flap away from body.
Answer: The nurse drops the item from the wrapper into the side of
the sterile field.
Rationale: The outer edges of the sterile field are considered
nonsterile. Dropping items into the outer edges of the field causes
those items to be considered contaminated. Items are dropped
toward the center of the field from approximately six inches above
the surface of the field. The nurse opens the package outward over
the hands, maintaining the sterility of the item inside the package.
,Items are typically held in the non-dominant hand while the
dominant hand pulls the package open.
◉ Which should be documented by the nurse?
The specific items that the nurse transferred into a sterile field.
The fact that the nurse washed her hands before a procedure.
The fact that the nurse donned gloves two different times during a
procedure.
The fact that sterile technique was used for a given procedure.
Answer: The fact that sterile technique was used for a given
procedure.
Rationale: The fact that sterile technique was used for a given
procedure should be documented, but the other items listed do not
need to be documented, as they are standard procedure.
◉ The nurse prepares for a sterile procedure. What action does the
nurse perform first?
Perform hand hygiene with alcohol-based handrub.
Place all the necessary supplies in the room.
Identify the client the procedure is prescribed for.
Put on personal protective equipment, if required.
Answer: Perform hand hygiene with alcohol-based handrub.
,Rationale: Hand hygiene is done prior to donning any personal
protective equipment, before entering the room, and before
interacting directly with the client, such as checking the name on the
armband.
◉ The nurse needs to place gauze from a wrapped item into the
sterile field. Which action does the nurse take?
Remove the gauze from the package with one sterile hand.
Drop the item from 6 in (15 cm) above the sterile field.
Lay the item in an open package on the 1-in (2.5-cm) border.
Extend the sterile field by laying the open package beside it.
Answer: Drop the item from 6 in (15 cm) above the sterile field.
Rationale: Dropping the item from roughly 6 in (15 cm) above the
surface prevents contamination of the field or dropping the item too
close to the 1-in (2.5-cm), nonsterile border. Removing the gauze
with one sterile hand risks contamination of that hand. It does not
extend the sterile field to lay an unsterile package to the outside of
the 1-in (2.5-cm) border.
◉ The nurse is preparing to administer a bolus of IV pain medication
through a drug-infusion lock. Before flushing the lock with saline,
there is no blood return with aspiration. What would be the initial
recommended nursing intervention in this situation?
, Check the patency of the tubing by injecting 3 mL sterile water.
Reassess the IV site for any infiltration or inflammation.
Forcefully attempt to flush the drug-infusion lock with saline,
observing the site for changes.
Remove the device to another part of the arm.
Answer: Reassess the IV site for any infiltration or inflammation.
Rationale: When there is no blood return upon aspiration of a drug-
infusion lock, the nurse should first reassess the IV site for any
infiltration or inflammation. Blood return does not always occur
even though the IV lock is patent. If the lock is patent, the nurse
should slowly and gently attempt to flush it with saline and observe
the site for changes. If signs of infiltration are present, the nurse
would remove the device and restart in another location.
◉ The nurse is preparing to give an IV medication to a client through
a drug-infusion lock. Which action would the nurse perform to
ensure the right client receives the medication?
Ask the client's family to identify the client.
State the client's name and ask if this is correct.
If the client cannot identify self, ask the client's roommate to identify
the client.
Ask the client to state his or her name and birth date.
Answer: Ask the client to state his or her name and birth date.
