NURS 104L Fundamentals of Nursing Skills Lab - Week 13 Quiz 2026
|WCU
1. When preparing a sterile field, which part of the sterile drape is considered
contaminated?
A. The center of the drape
B. The 1-inch (2.5 cm) border around the edge
C. The top surface of the drape
D. Anything touched by sterile forceps
Answer: B
Rationale: In nursing practice, the outer 1-inch border of a sterile field is considered
contaminated because it comes into contact with non-sterile surfaces.
2. A nurse is inserting an indwelling urinary catheter for a female patient. After
seeing urine flash in the tubing, what is the next appropriate step?
A. Immediately inflate the balloon
B. Advance the catheter another 1 to 2 inches
C. Ask the patient to cough to ensure placement
D. Withdraw the catheter slightly and then inflate
Answer: B
Rationale: Advancing the catheter 1-2 inches after urine return ensures the balloon is fully
inside the bladder before inflation, preventing urethral trauma.
,3. During the administration of a large-volume enema, the patient complains of
abdominal cramping. What should the nurse do first?
A. Stop the procedure and notify the provider
B. Advance the rectal tube further
C. Lower the enema container to slow the flow
D. Instruct the patient to hold their breath
Answer: C
Rationale: Lowering the container slows the rate of flow, which usually relieves cramping
while still allowing the procedure to continue.
4. What is the best time to change an ostomy appliance to avoid excessive
drainage during the process?
A. First thing in the morning or 2-4 hours after meals
B. Right before bedtime
C. Immediately after a meal
D. Whenever the patient feels the urge to defecate
Answer: A
Rationale: Changing the appliance when the bowel is least active, such as before breakfast,
minimizes output during the procedure.
5. A nurse is assessing a surgical wound and observes thick, yellow-green
drainage. How should this be documented?
A. Serous drainage
B. Sanguineous drainage
C. Serosanguineous drainage
D. Purulent drainage
Answer: D
Rationale: Purulent drainage is thick and indicates infection; it can be yellow, green, or
brown.
, 6. When removing an indwelling catheter, what is the nurse’s priority action?
A. Pull the catheter quickly to minimize discomfort
B. Cut the inflation port with scissors to drain the water
C. Ensure the balloon is fully deflated by drawing back on the syringe
D. Ask the patient to strain as the catheter is removed
Answer: C
Rationale: The balloon must be fully deflated to prevent urethral damage; the nurse
should allow the syringe to fill by gravity or active aspiration.
7. Which position is most appropriate for a patient receiving a cleansing enema?
A. Left lateral Sims’ position
B. High-Fowler’s position
C. Supine with legs abducted
D. Prone position
Answer: A
Rationale: The Sims’ position allows the enema solution to flow by gravity into the sigmoid
colon and rectum.
8. A nurse observes a sterile field and sees a bottle of sterile saline that was
opened 48 hours ago. What action should the nurse take?
A. Discard the bottle and obtain a new one
B. Use the saline but ‘lip’ the bottle first
C. Check if the cap was tightly sealed and use it
D. Use the saline if it appears clear and has no odor
Answer: A
Rationale: Sterile solutions are typically only considered sterile for 24 hours after opening,
depending on facility policy; 48 hours is too long.
|WCU
1. When preparing a sterile field, which part of the sterile drape is considered
contaminated?
A. The center of the drape
B. The 1-inch (2.5 cm) border around the edge
C. The top surface of the drape
D. Anything touched by sterile forceps
Answer: B
Rationale: In nursing practice, the outer 1-inch border of a sterile field is considered
contaminated because it comes into contact with non-sterile surfaces.
2. A nurse is inserting an indwelling urinary catheter for a female patient. After
seeing urine flash in the tubing, what is the next appropriate step?
A. Immediately inflate the balloon
B. Advance the catheter another 1 to 2 inches
C. Ask the patient to cough to ensure placement
D. Withdraw the catheter slightly and then inflate
Answer: B
Rationale: Advancing the catheter 1-2 inches after urine return ensures the balloon is fully
inside the bladder before inflation, preventing urethral trauma.
,3. During the administration of a large-volume enema, the patient complains of
abdominal cramping. What should the nurse do first?
A. Stop the procedure and notify the provider
B. Advance the rectal tube further
C. Lower the enema container to slow the flow
D. Instruct the patient to hold their breath
Answer: C
Rationale: Lowering the container slows the rate of flow, which usually relieves cramping
while still allowing the procedure to continue.
4. What is the best time to change an ostomy appliance to avoid excessive
drainage during the process?
A. First thing in the morning or 2-4 hours after meals
B. Right before bedtime
C. Immediately after a meal
D. Whenever the patient feels the urge to defecate
Answer: A
Rationale: Changing the appliance when the bowel is least active, such as before breakfast,
minimizes output during the procedure.
5. A nurse is assessing a surgical wound and observes thick, yellow-green
drainage. How should this be documented?
A. Serous drainage
B. Sanguineous drainage
C. Serosanguineous drainage
D. Purulent drainage
Answer: D
Rationale: Purulent drainage is thick and indicates infection; it can be yellow, green, or
brown.
, 6. When removing an indwelling catheter, what is the nurse’s priority action?
A. Pull the catheter quickly to minimize discomfort
B. Cut the inflation port with scissors to drain the water
C. Ensure the balloon is fully deflated by drawing back on the syringe
D. Ask the patient to strain as the catheter is removed
Answer: C
Rationale: The balloon must be fully deflated to prevent urethral damage; the nurse
should allow the syringe to fill by gravity or active aspiration.
7. Which position is most appropriate for a patient receiving a cleansing enema?
A. Left lateral Sims’ position
B. High-Fowler’s position
C. Supine with legs abducted
D. Prone position
Answer: A
Rationale: The Sims’ position allows the enema solution to flow by gravity into the sigmoid
colon and rectum.
8. A nurse observes a sterile field and sees a bottle of sterile saline that was
opened 48 hours ago. What action should the nurse take?
A. Discard the bottle and obtain a new one
B. Use the saline but ‘lip’ the bottle first
C. Check if the cap was tightly sealed and use it
D. Use the saline if it appears clear and has no odor
Answer: A
Rationale: Sterile solutions are typically only considered sterile for 24 hours after opening,
depending on facility policy; 48 hours is too long.
