CORRECT ANSWERS |FALL 2025/2026 UPDATE
Question 1
A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following
actions by the newly licensed nurse requires intervention by the charge nurse?
A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.
B. The newly licensed nurse places sterile objects 2.5 cm (1 inch) within the border of the field.
C. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring.
D. The sterile field is positioned at the level of the newly licensed nurse's waist.
Correct Answer
A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.
The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are
unsterile and will contaminate the sterile field.
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,Question 2
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of
the following actions should the nurse plan to take?
A. Use a resuscitation bag with 80% oxygen prior to the procedure.
B. Select a suction catheter that is half the size of the lumen.
C. Place the end of the suction catheter in water-soluble lubricant.
D. Adjust the wall suction apparatus to a pressure of 170 mm Hg.
Correct Answer
B. Select a suction catheter that is half the size of the lumen.
The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the
mucosa.
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,Question 3
A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse
after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the
cuff when obtaining the blood pressure?
A
B
C
D
Correct Answer
D
To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at
which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be
the correct pressure to which the nurse should inflate the cuff.
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, Question 4
A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for
the client's procedure, which of the following precautions should the nurse take?
A. Ensure sterilization of nondisposable items with ethylene oxide.
B. Wrap monitoring cords with stockinette and tape them in place.
C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
D. Wear hypoallergenic latex gloves that contain powder.
Correct Answer
B. Wrap monitoring cords with stockinette and tape them in place.
Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with
the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure
them.
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