NURS 104L Sterile Technique and Wound Care Comprehensive
Examination 2026 |WCU
1. While preparing a sterile field, the nurse notes that the sterile drape has a
small moisture droplet that has seeped through the packaging. What is the most
appropriate action?
A. Assume the moisture is sterile water from the sterilization process.
B. Continue using the drape as long as the moisture is on the corner.
C. Wipe the moisture off with a sterile gauze pad.
D. Discard the drape and obtain a new sterile kit.
Answer: D
Rationale: The principle of surgical asepsis states that a sterile object becomes
contaminated by capillary action when it comes into contact with a wet, contaminated
surface.
2. A nurse is assessing a patient’s pressure injury and observes full-thickness
skin loss with visible subcutaneous fat, but no bone, tendon, or muscle is
exposed. How should this be staged?
A. Stage 3
B. Stage 2
C. Stage 1
D. Stage 4
Answer: A
Rationale: Stage 3 pressure injuries involve full-thickness tissue loss where subcutaneous
fat may be visible, but bone, tendon, or muscle are not exposed.
,3. During a dressing change, the nurse notes clear, watery drainage on the old
gauze. This type of drainage is documented as:
A. Serous
B. Purulent
C. Sanguineous
D. Serosanguineous
Answer: A
Rationale: Serous drainage is clear, watery plasma. Sanguineous is bright red;
serosanguineous is pale pink/watery; purulent is thick yellow/green/tan.
4. The nurse is performing a sterile procedure and accidentally touches the
outer one-inch border of the sterile field with a sterile gloved hand. What is the
next step?
A. Change the sterile gloves and continue the procedure.
B. Continue the procedure as the border is considered sterile.
C. Only use the center of the sterile field for the rest of the procedure.
D. Consider the field contaminated and start over.
Answer: D
Rationale: The outer one-inch border of a sterile field is considered contaminated. Once
touched, the sterile glove is no longer sterile, and the field is compromised.
5. A patient’s surgical wound has opened, and internal organs are protruding
through the incision. Which term best describes this complication?
A. Dehiscence
B. Evisceration
C. Fistula
D. Adhesion
Answer: B
, Rationale: Evisceration is the total separation of wound layers and protrusion of visceral
organs through the wound opening.
6. Which phase of wound healing is characterized by the formation of
granulation tissue and the resurfacing of the wound by epithelialization?
A. Inflammatory phase
B. Proliferative phase
C. Hemostasis phase
D. Maturation phase
Answer: B
Rationale: The proliferative phase involves the filling of the wound with granulation
tissue, wound contraction, and resurfacing via epithelialization.
7. A nurse is using the Braden Scale to assess a patient’s risk for pressure
injuries. Which score would indicate the highest risk?
A. 23
B. 9
C. 14
D. 18
Answer: B
Rationale: In the Braden Scale, a lower score indicates a higher risk for pressure injury
development. A score of 9 represents a very high risk.
8. When removing sterile gloves, which action is performed first to prevent
contamination?
A. Slide the fingers of the gloved hand under the cuff of the other glove.
B. Grasp the outside of the cuff of the other glove with the gloved hand.
C. Pull the glove off from the fingertips.
D. Wash the gloved hands before removal.
Answer: B
Examination 2026 |WCU
1. While preparing a sterile field, the nurse notes that the sterile drape has a
small moisture droplet that has seeped through the packaging. What is the most
appropriate action?
A. Assume the moisture is sterile water from the sterilization process.
B. Continue using the drape as long as the moisture is on the corner.
C. Wipe the moisture off with a sterile gauze pad.
D. Discard the drape and obtain a new sterile kit.
Answer: D
Rationale: The principle of surgical asepsis states that a sterile object becomes
contaminated by capillary action when it comes into contact with a wet, contaminated
surface.
2. A nurse is assessing a patient’s pressure injury and observes full-thickness
skin loss with visible subcutaneous fat, but no bone, tendon, or muscle is
exposed. How should this be staged?
A. Stage 3
B. Stage 2
C. Stage 1
D. Stage 4
Answer: A
Rationale: Stage 3 pressure injuries involve full-thickness tissue loss where subcutaneous
fat may be visible, but bone, tendon, or muscle are not exposed.
,3. During a dressing change, the nurse notes clear, watery drainage on the old
gauze. This type of drainage is documented as:
A. Serous
B. Purulent
C. Sanguineous
D. Serosanguineous
Answer: A
Rationale: Serous drainage is clear, watery plasma. Sanguineous is bright red;
serosanguineous is pale pink/watery; purulent is thick yellow/green/tan.
4. The nurse is performing a sterile procedure and accidentally touches the
outer one-inch border of the sterile field with a sterile gloved hand. What is the
next step?
A. Change the sterile gloves and continue the procedure.
B. Continue the procedure as the border is considered sterile.
C. Only use the center of the sterile field for the rest of the procedure.
D. Consider the field contaminated and start over.
Answer: D
Rationale: The outer one-inch border of a sterile field is considered contaminated. Once
touched, the sterile glove is no longer sterile, and the field is compromised.
5. A patient’s surgical wound has opened, and internal organs are protruding
through the incision. Which term best describes this complication?
A. Dehiscence
B. Evisceration
C. Fistula
D. Adhesion
Answer: B
, Rationale: Evisceration is the total separation of wound layers and protrusion of visceral
organs through the wound opening.
6. Which phase of wound healing is characterized by the formation of
granulation tissue and the resurfacing of the wound by epithelialization?
A. Inflammatory phase
B. Proliferative phase
C. Hemostasis phase
D. Maturation phase
Answer: B
Rationale: The proliferative phase involves the filling of the wound with granulation
tissue, wound contraction, and resurfacing via epithelialization.
7. A nurse is using the Braden Scale to assess a patient’s risk for pressure
injuries. Which score would indicate the highest risk?
A. 23
B. 9
C. 14
D. 18
Answer: B
Rationale: In the Braden Scale, a lower score indicates a higher risk for pressure injury
development. A score of 9 represents a very high risk.
8. When removing sterile gloves, which action is performed first to prevent
contamination?
A. Slide the fingers of the gloved hand under the cuff of the other glove.
B. Grasp the outside of the cuff of the other glove with the gloved hand.
C. Pull the glove off from the fingertips.
D. Wash the gloved hands before removal.
Answer: B
