1. A student nurse is demonstrating the proper procedure for maintaining a sterile field.

Which of
the following guidelines should be followed? (Select all that apply.)
1. Never reach across a sterile field.
2. Objects below the waist are considered unsterile.
3. A dry area is micro-organism free.
4. A sterile object is still sterile if touched by a nonsterile object.
5. One inch around the edges is considered contaminated.
Correct Answers: 1,2,5
Rationale: Sterile fields must remain microorganism-free in order to prevent infection. The
nurse must understand and utilize the guidelines for a sterile procedure.
2.The client has a large, deep abdominal incision that requires a dressing. The incision is packed
with sterile half-inch packing and covered with a dry 4 x 4 inch gauze. When changing the
dressing, the nurse accidentally drops the packing onto the clients abdomen. The nurse should:
1.
2.
3.
4.

Add alcohol to the packing and insert it into the incision

Throw the packing away, and prepare a new one
Pick up the packing with sterile forceps, and gently place it into the incision
Rinse the packing with sterile water, and put the packing into the incision with sterile
gloves
Correct Answer: B
Explanation: A sterile object (the packing) remains sterile only when touched by another
sterile object. The clients abdomen is not sterile; therefore the nurse should throw the
packing away and prepare a new one.
A. The nurse should not add alcohol to the packing and insert it into the incision.
C. The packing is considered contaminated, as it touched a nonsterile surface, and
therefore should be discarded.
D. The nurse should not rinse the packing with sterile water and put the packing into the
incision, as it is considered contaminated. It touched a nonsterile surface. The nurse should
throw the packing away and prepare a new one.

3.The nurse has a prescription to obtain a sputum culture from a client admitted to the hospital
with a diagnosis of pneumonia. Which actions should the nurse take when obtaining the
specimen? Select all that apply.
1.
2.
3.
4.
5.

Explain the procedure to the client.

Obtain the specimen early in the morning.
Have the client brush his teeth before expectoration.
Instruct the client to take deep breaths before coughing.
Place the lid of the culture container face down on the bedside table.

Rationale: 1,2,3,4
The nurse always explains a procedure to a client. The specimen is obtained early in the
morning whenever possible because increased amounts of sputum collect in the airways
during sleep. The client should rinse the mouth or brush the teeth before specimen
collection to avoid contaminating the specimen. The client should take deep breaths before
expectoration for best sputum production. Placing the lid face down on the bedside table
contaminates the lid and could result in inaccurate findings.

4.A registered nurse (RN) is orienting an unlicensed assistive personnel (UAP) to the clinical
nursing unit. The RN determines that the UAP needs further teaching if which procedure is
performed by the UAP during a routine hand washing procedure?
1.
2.
3.
4.

Keeps hands lower than elbows

Dries from forearm down to fingers
Washes continuously for 10 to 15 seconds
Uses 3 to 5 mL of soap from the dispenser

Rationale: 2
Proper hand washing procedure involves wetting the hands and wrists and keeping the
hands lower than the forearms so that water flows toward the fingertips. The nurse uses 3
to 5 mL of soap and scrubs for 10 to 15 seconds, using rubbing and circular motions. The
hands are rinsed and then dried, moving from the fingers to the forearms. The paper towel
is then discarded, and a second one is used to turn off the faucet to avoid hand
contamination.
5.Which are accurate principles of sterile technique?Select all that apply.
1. The edge of a sterile field and 1 inch inward is unsterile.
2. If a package is not labeled as sterile, it should be considered an unsterile item.
3. Sterile objects that come in contact with unsterile objects are considered
contaminated.
4. Any part of a sterile field that hangs below the top of the table is sterile as long as it is
not touched.
5. When a sterile field becomes wet, it remains sterile as long as the items on the field
are not contaminated.
6. Items in a sterile package must be used immediately as soon as it has been opened;
otherwise, it is considered contaminated.
Rationale: 1,2,3,6
Sterile means the absence of all microorganisms. To maintain sterile technique, the nurse
must follow several principles, including the edge of a sterile field and 1 inch inward is
unsterile; sterile packages are labeled as sterile, and, if the package is not so labeled, it is

considered unsterile; sterile objects that come in contact with unsterile objects are
considered contaminated; items in a sterile package must be used immediately as soon as
the package has been opened, or it is considered contaminated; any part of a sterile field
that falls or hangs below the top of the table is unsterile; and a sterile field that becomes
wet will draw microorganisms from the surface underneath (strike-through) and
contaminate the field.
6.The nurse is teaching a client to perform peritoneal dialysis in preparation for discharge to
home. Which items should the nurse tell the client to use to prevent infection when connecting
and disconnecting the peritoneal dialysis system?
1.
2.
3.
4.

Gloves only
Gloves and mask
Gloves, mask, and apron
Gloves, mask, and goggles

Rationale: 2
Gloves and a mask should be worn during connection and disconnection of peritoneal
dialysis circuits. This prevents transmission of microorganisms by contact and via the
airborne route. Goggles are unnecessary to prevent client infection in this situation, as is an
apron.
7.The nurse is determining a family member's ability to use sterile gloves to perform a dressing
change. Which statement would indicate to the nurse that the family member needs further
instruction?
1. "Whichever glove I decide to put on first is up to me."
2. "I know that I can use the inner wrapper as a sterile field."
3. "If I touch the counter with my gloved hand, I need to open another pair and start over."
4. "I don't have to worry about washing my hands because I will be wearing sterile gloves."
Rationale: 4
Hands must always be washed (even though sterile gloves are used) to keep germs from
spreading. The sequence for donning gloves is up to the individual as long as sterile
technique is maintained. The inside wrapper makes an excellent area for usage because it is
sterile. If the gloves touch anything unsterile, they must be considered contaminated, and a
new package must be used.
8.The nurse is observing an unlicensed assistive personnel (UAP) performing indwelling urinary
catheter care on a client. The nurse intervenes and determines the UAP needs more teaching if
which action is done by the UAP?
1. Cleaning the area with mild soap and water
2. Cleaning the tube in an up-and-down motion
3. Cleaning the labia minora and majora before cleaning the tube

4. Cleaning from the urethral meatus down the tube approximately 4 inches
Rationale: 2
When performing indwelling urinary catheter care, the labia minora and majora should be
cleaned before cleaning the tube. The area should be cleaned with mild soap and water. The
tube should be cleaned from the urethral meatus down approximately 4 inches. The tube
should be cleaned in a circular motion, not an up-and-down motion. All of these actions
prevent the introduction of bacteria into the urethra.
9.The nursing instructor is teaching a group of nursing students about culture and sensitivity
testing for sputum. Which statement, if made by a student, indicates a need for further
instruction?
1.
2.
3.
4.

"A single sputum specimen is collected in a sterile container."

"This test assists in determining which antibiotic should be used."
"The purpose of this test is to differentiate between a viral and bacterial infection."
"If the client cannot produce a good specimen, suctioning or bronchoscopy may be
necessary."

Rationale: 3
This test does not allow for differentiation between viral and bacterial infection. A single
sputum specimen can be tested for culture and sensitivity. This allows for the determination
of the type of bacterial infection and therefore assists in determining which antibiotic
should be used to treat it. If the client cannot produce a good specimen, suctioning or
bronchoscopy may be used.
10.The nurse plans to change the dressing of the client who has had arterial bypass surgery.
Which technique is important for the nurse to follow?
1. Clean technique
2. Aseptic technique
3. Standard precautions
4. Reverse isolation technique
Rationale: 2
Aseptic technique is important to reduce risk of infection. Clean technique would place the
client at risk for infection. Standard precautions are important but are not specific to this
procedure. Reverse isolation is not necessary.
The nurse prepares to suction a client through a tracheostomy tube. What should the nurse wear
to perform this procedure?
1. Mask, gown, and a cap
2. Mask, sterile gloves, and a cap
3. Gown, mask, and sterile gloves
4. Goggles, mask, and sterile gloves

Rationale: 4
The nurse should wear a mask and goggles when suctioning the client. Sterile gloves are
also worn. A mask offers full protection of the nurse's nose and mouth, and goggles protect
the nurse's eyes from getting splashed with sputum. A gown protects the nurse's uniform,
and a cap protects the nurse's hair, but these items are not required for suctioning a client.