PNR 104/PNR104 Exam 4 V3 | Basic Skills,
Quality & Safety in Nursing Practice Q&A
with Rationale | Fortis College
1. A nurse is preparing to perform a sterile procedure. Which action would violate the
principles of surgical asepsis?
A. Keeping the sterile field within the line of vision at all times.
B. Reaching over the sterile field to pick up a specimen container.
C. Holding sterile objects above the level of the waist.
D. Discarding any sterile package that has become moist or damp.
Correct Answer: B
Expert Explanation: Reaching over a sterile field contaminates it because microorganisms
can drop from the nurse’s sleeves or skin onto the field. A sterile object or field becomes
contaminated by any contact with unsterile objects or by crossing the ‘sterile air zone.’
Nurses must maintain a one-inch border around the edge of the sterile field which is
considered contaminated.
2. When repositioning a patient in bed to prevent pressure injuries, which action should the
nurse take to reduce friction and shear?
A. Using a friction-reducing drawsheet or slide board.
B. Pulling the patient up in bed using the underarms.
,C. Dragging the patient across the linens to the head of the bed.
D. Increasing the head of the bed to 90 degrees before moving.
Correct Answer: A
Expert Explanation: Using a friction-reducing device like a drawsheet prevents the
patient’s skin from rubbing directly against the bed linens. Friction and shear are primary
mechanical causes of skin breakdown and pressure ulcer development. Proper body
mechanics and assistive devices protect both the patient’s skin integrity and the nurse’s
musculoskeletal health.
3. A nurse is caring for a patient who has a Stage 2 pressure injury on the sacrum. How should
the nurse document the appearance of this wound?
A. Non-blanchable erythema of intact skin.
B. Full-thickness tissue loss with exposed bone or muscle.
C. Full-thickness tissue loss with visible subcutaneous fat.
D. Partial-thickness skin loss involving the epidermis and/or dermis.
Correct Answer: D
Expert Explanation: A Stage 2 pressure injury is characterized by partial-thickness loss of
dermis presenting as a shallow open ulcer with a red-pink wound bed. It may also present
as an intact or open/ruptured serum-filled blister. This stage does not involve the slough or
necrotic tissue typically found in deeper stages.
, 4. Which intervention is most effective in preventing post-operative atelectasis in a patient
who just had abdominal surgery?
A. Administering prophylactic antibiotics as ordered.
B. Restricting oral fluid intake to 1000 mL per day.
C. Encouraging the use of an incentive spirometer 10 times every hour.
D. Applying sequential compression devices to the lower extremities.
Correct Answer: C
Expert Explanation: Incentive spirometry promotes deep breathing and lung expansion,
which helps prevent the collapse of alveoli (atelectasis). Patients undergoing abdominal
surgery are at high risk due to shallow breathing caused by pain. Splinting the incision with
a pillow while coughing further enhances the effectiveness of these respiratory exercises.
5. A patient is on contact precautions for MRSA. Which personal protective equipment (PPE)
must the nurse don before entering the room?
A. Gown and gloves.
B. N95 respirator and gloves.
C. Surgical mask and goggles.
D. Gloves only.
Correct Answer: A
Quality & Safety in Nursing Practice Q&A
with Rationale | Fortis College
1. A nurse is preparing to perform a sterile procedure. Which action would violate the
principles of surgical asepsis?
A. Keeping the sterile field within the line of vision at all times.
B. Reaching over the sterile field to pick up a specimen container.
C. Holding sterile objects above the level of the waist.
D. Discarding any sterile package that has become moist or damp.
Correct Answer: B
Expert Explanation: Reaching over a sterile field contaminates it because microorganisms
can drop from the nurse’s sleeves or skin onto the field. A sterile object or field becomes
contaminated by any contact with unsterile objects or by crossing the ‘sterile air zone.’
Nurses must maintain a one-inch border around the edge of the sterile field which is
considered contaminated.
2. When repositioning a patient in bed to prevent pressure injuries, which action should the
nurse take to reduce friction and shear?
A. Using a friction-reducing drawsheet or slide board.
B. Pulling the patient up in bed using the underarms.
,C. Dragging the patient across the linens to the head of the bed.
D. Increasing the head of the bed to 90 degrees before moving.
Correct Answer: A
Expert Explanation: Using a friction-reducing device like a drawsheet prevents the
patient’s skin from rubbing directly against the bed linens. Friction and shear are primary
mechanical causes of skin breakdown and pressure ulcer development. Proper body
mechanics and assistive devices protect both the patient’s skin integrity and the nurse’s
musculoskeletal health.
3. A nurse is caring for a patient who has a Stage 2 pressure injury on the sacrum. How should
the nurse document the appearance of this wound?
A. Non-blanchable erythema of intact skin.
B. Full-thickness tissue loss with exposed bone or muscle.
C. Full-thickness tissue loss with visible subcutaneous fat.
D. Partial-thickness skin loss involving the epidermis and/or dermis.
Correct Answer: D
Expert Explanation: A Stage 2 pressure injury is characterized by partial-thickness loss of
dermis presenting as a shallow open ulcer with a red-pink wound bed. It may also present
as an intact or open/ruptured serum-filled blister. This stage does not involve the slough or
necrotic tissue typically found in deeper stages.
, 4. Which intervention is most effective in preventing post-operative atelectasis in a patient
who just had abdominal surgery?
A. Administering prophylactic antibiotics as ordered.
B. Restricting oral fluid intake to 1000 mL per day.
C. Encouraging the use of an incentive spirometer 10 times every hour.
D. Applying sequential compression devices to the lower extremities.
Correct Answer: C
Expert Explanation: Incentive spirometry promotes deep breathing and lung expansion,
which helps prevent the collapse of alveoli (atelectasis). Patients undergoing abdominal
surgery are at high risk due to shallow breathing caused by pain. Splinting the incision with
a pillow while coughing further enhances the effectiveness of these respiratory exercises.
5. A patient is on contact precautions for MRSA. Which personal protective equipment (PPE)
must the nurse don before entering the room?
A. Gown and gloves.
B. N95 respirator and gloves.
C. Surgical mask and goggles.
D. Gloves only.
Correct Answer: A
