Question Set A: Sequence, Sterility, and the Number You Trust

Six items. No time limit. Before you read the options on any item, write in the FIRST margin the single action you believe comes first. That is the mechanism of this page.

Item 1 · Ordered response A nurse is beginning the abdominal portion of an assessment on an adult admitted with nausea and abdominal distention. Place the four techniques in the order the nurse performs them.

1. Percuss all four quadrants for tympany and dullness.
2. Auscultate all four quadrants, beginning at the right lower quadrant.
3. Palpate lightly, leaving any tender area for last.
4. Inspect the contour, symmetry, skin, and visible movement.

Item 2 · Multiple choice A nurse reviewing a blood pressure recorded by another staff member learns that the patient's arm was hanging unsupported below heart level during the measurement, and the recorded value is higher than the patient's usual readings. What does the nurse do before charting anything?

1. Chart the value as obtained and add a note describing the arm position.
2. Reposition the patient with the back supported and the arm supported at heart level, allow a brief rest, and repeat the measurement.
3. Chart the value and plan to recheck the blood pressure in one hour.
4. Report the elevated value to the provider before repeating it.

Item 3 · Select all that apply A nurse is inserting an indwelling urinary catheter. Which statements about the sterile field are correct? Select all that apply.

1. The outer one inch of the drape is not sterile.
2. Anything that falls below waist or table level is contaminated.
3. A field the nurse has turned away from is treated as contaminated.
4. A field that has become wet is treated as contaminated.
5. A gloved hand may rest at the nurse's side between steps and return to the field.
6. Reaching across the field is acceptable as long as nothing is touched.

Item 4 · Multiple choice A blindly inserted nasogastric tube has been placed for feeding on an adult. What must exist before the first feeding is delivered through it?

1. Documentation that two nurses injected an air bolus and auscultated over the epigastrium.
2. Aspirate from the tube whose appearance is consistent with gastric contents.
3. A radiograph read by the provider confirming the position of the tube tip.
4. An exposed tube length that matches the length recorded at insertion.

Item 5 · Multiple choice A sacral wound shows full-thickness skin loss with adipose tissue visible in the wound bed. The edges are rolled and there is tunneling at the three o'clock position. No fascia, muscle, tendon, or bone is visible or palpable, and no part of the base is obscured by slough or eschar. How does the nurse stage this pressure injury?

1. Stage 2
2. Stage 3
3. Stage 4
4. Unstageable

Item 6 · Select all that apply An abdominal incision separates and a loop of bowel protrudes through the wound. Which actions does the nurse take? Select all that apply.

1. Cover the wound with sterile gauze moistened with sterile normal saline.
2. Position the patient in low Fowler's with the knees bent.
3. Keep the patient nothing by mouth.
4. Notify the surgeon immediately.
5. Gently replace the protruding tissue inside the abdominal wall.
6. Apply a dry pressure dressing and secure it firmly with tape.

Margin notewrite what comes first before you read the options.

TakeawayDeciding the first action before reading the options changes which option looks correct.

Rationales → BOOK 15 · P13.