NU 155 EXAM 3: MEDICAL-SURGICAL NURSING I 2026 |
Galen College of Nursing | Verified Questions & Detailed
Rationales | Pass Guaranteed - A+ Graded
Section 1: Wound Care & Pressure Injuries (20 Questions)
Q1: A nurse is assessing a patient who has been bedridden for 5 days following hip
surgery. Upon skin inspection, the nurse observes an area on the sacrum with
non-blanchable erythema of intact skin. Which pressure injury stage should the nurse
document?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Suspected deep tissue injury
D. Unstageable pressure injury
Correct Answer: A [CORRECT]
Rationale: Stage 1 pressure injury is characterized by intact skin with non-blanchable
erythema, usually over a bony prominence. The skin may be painful, firm, soft, or
warmer/cooler than adjacent tissue. This matches the presentation described. Stage 2
involves partial-thickness skin loss with exposed dermis (shallow open ulcer or
intact/popped serum-filled blister), which is not present here. Suspected deep tissue
injury presents as a purple or maroon localized area of discolored intact skin or
blood-filled blister due to damage to underlying soft tissue from pressure or shear.
Unstageable pressure injury involves full-thickness tissue loss in which the base of the
ulcer is covered by slough or eschar, making true depth unobservable. Early recognition
of Stage 1 is critical because the skin is still intact and immediate intervention can
prevent progression to deeper tissue damage.
,Q2: A patient presents with a full-thickness wound on the right heel with visible
subcutaneous fat, but no exposure of muscle, tendon, or bone. Slough is present but
does not obscure wound depth. Which stage should the nurse assign?
A. Stage 2 pressure injury
B. Stage 3 pressure injury
C. Stage 4 pressure injury
D. Unstageable pressure injury
Correct Answer: B [CORRECT]
Rationale: Stage 3 pressure injury involves full-thickness skin loss in which
subcutaneous fat is visible in the ulcer, but muscle, tendon, or bone are not exposed.
Slough may be present but does not obscure depth. This differentiates it from Stage 2
(partial-thickness loss of skin with exposed dermis) and Stage 4 (full-thickness skin and
tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage,
or bone). The wound is not unstageable because the depth can be determined despite
the presence of slough. Stage 3 injuries often require advanced wound care
interventions and may take weeks to months to heal depending on patient
comorbidities.
Q3: Which of the following wound drainage types would the nurse expect to document
when observing thin, watery, clear or slightly yellow fluid draining from a surgical
incision on postoperative day 2?
A. Sanguineous drainage
B. Serosanguineous drainage
C. Serous drainage
D. Purulent drainage
Correct Answer: C [CORRECT]
,Rationale: Serous drainage is thin, watery, clear or slightly yellow plasma that is normal
during the inflammatory and proliferative phases of wound healing. Sanguineous
drainage is bright red and indicates fresh bleeding. Serosanguineous drainage is thin,
watery, pale red to pink (mixture of serum and blood) and is common in early
postoperative periods but contains more blood than described. Purulent drainage is
thick, opaque, yellow, green, or tan and indicates infection. The description of thin,
watery, clear/slightly yellow fluid without blood is classic for serous drainage, which is
expected and normal in healing wounds.
Q4: A nurse is caring for a patient with a pressure injury that presents as a localized
area of purple or maroon discolored intact skin on the coccyx following a prolonged
surgical procedure. Which documentation is most accurate?
A. Stage 1 pressure injury with deep tissue involvement
B. Suspected deep tissue injury (sDTI)
C. Stage 2 pressure injury with hematoma formation
D. Unstageable pressure injury due to eschar
Correct Answer: B [CORRECT]
Rationale: Suspected deep tissue injury (sDTI) is characterized by a localized area of
persistent non-blanchable deep red, maroon, or purple discoloration of intact skin or a
blood-filled blister due to damage to underlying soft tissue from pressure and/or shear.
This contrasts with Stage 1 (non-blanchable erythema of intact skin without the deep
purple/maroon color). The deep color indicates damage to underlying soft tissue
structures. sDTI may rapidly evolve and become open, exposing the depth of tissue
destruction. These injuries are often preceded by skin that is painful, firm, mushy, boggy,
warmer, or cooler than adjacent tissue. The area should be protected from additional
pressure and monitored closely for deterioration.
, Q5: According to the Braden Scale for Predicting Pressure Sore Risk, which combination
of subscale scores places a patient at highest risk for pressure injury development?
A. Sensory perception: 3, Moisture: 3, Activity: 3, Mobility: 3, Nutrition: 3, Friction/Shear:
2
B. Sensory perception: 2, Moisture: 2, Activity: 2, Mobility: 2, Nutrition: 2, Friction/Shear:
1
C. Sensory perception: 4, Moisture: 4, Activity: 4, Mobility: 4, Nutrition: 4, Friction/Shear:
3
D. Sensory perception: 1, Moisture: 1, Activity: 1, Mobility: 1, Nutrition: 1, Friction/Shear:
1
Correct Answer: D [CORRECT]
Rationale: The Braden Scale scores range from 6-23, with lower scores indicating higher
risk. Scores of 15-18 = mild risk, 13-14 = moderate risk, 10-12 = high risk, and 9 or less =
very high risk. Option D yields a total score of 6 (1+1+1+1+1+1), indicating the highest
possible risk category. Option A totals 17 (mild risk), Option B totals 11 (high risk), and
Option C totals 23 (no risk). The subscales assess: sensory perception (ability to
respond meaningfully to pressure-related discomfort), moisture (degree to which skin is
exposed to moisture), activity (degree of physical activity), mobility (ability to change
and control body position), nutrition (usual food intake pattern), and friction/shear
(amount of assistance needed to move and degree of sliding against sheets).
Q6: A nurse is applying a wet-to-damp dressing to a patient's wound with yellow slough
and minimal exudate. The nurse should use which type of solution for moistening the
dressing?
A. Sterile normal saline
B. Hydrogen peroxide
C. Acetic acid
Galen College of Nursing | Verified Questions & Detailed
Rationales | Pass Guaranteed - A+ Graded
Section 1: Wound Care & Pressure Injuries (20 Questions)
Q1: A nurse is assessing a patient who has been bedridden for 5 days following hip
surgery. Upon skin inspection, the nurse observes an area on the sacrum with
non-blanchable erythema of intact skin. Which pressure injury stage should the nurse
document?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Suspected deep tissue injury
D. Unstageable pressure injury
Correct Answer: A [CORRECT]
Rationale: Stage 1 pressure injury is characterized by intact skin with non-blanchable
erythema, usually over a bony prominence. The skin may be painful, firm, soft, or
warmer/cooler than adjacent tissue. This matches the presentation described. Stage 2
involves partial-thickness skin loss with exposed dermis (shallow open ulcer or
intact/popped serum-filled blister), which is not present here. Suspected deep tissue
injury presents as a purple or maroon localized area of discolored intact skin or
blood-filled blister due to damage to underlying soft tissue from pressure or shear.
Unstageable pressure injury involves full-thickness tissue loss in which the base of the
ulcer is covered by slough or eschar, making true depth unobservable. Early recognition
of Stage 1 is critical because the skin is still intact and immediate intervention can
prevent progression to deeper tissue damage.
,Q2: A patient presents with a full-thickness wound on the right heel with visible
subcutaneous fat, but no exposure of muscle, tendon, or bone. Slough is present but
does not obscure wound depth. Which stage should the nurse assign?
A. Stage 2 pressure injury
B. Stage 3 pressure injury
C. Stage 4 pressure injury
D. Unstageable pressure injury
Correct Answer: B [CORRECT]
Rationale: Stage 3 pressure injury involves full-thickness skin loss in which
subcutaneous fat is visible in the ulcer, but muscle, tendon, or bone are not exposed.
Slough may be present but does not obscure depth. This differentiates it from Stage 2
(partial-thickness loss of skin with exposed dermis) and Stage 4 (full-thickness skin and
tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage,
or bone). The wound is not unstageable because the depth can be determined despite
the presence of slough. Stage 3 injuries often require advanced wound care
interventions and may take weeks to months to heal depending on patient
comorbidities.
Q3: Which of the following wound drainage types would the nurse expect to document
when observing thin, watery, clear or slightly yellow fluid draining from a surgical
incision on postoperative day 2?
A. Sanguineous drainage
B. Serosanguineous drainage
C. Serous drainage
D. Purulent drainage
Correct Answer: C [CORRECT]
,Rationale: Serous drainage is thin, watery, clear or slightly yellow plasma that is normal
during the inflammatory and proliferative phases of wound healing. Sanguineous
drainage is bright red and indicates fresh bleeding. Serosanguineous drainage is thin,
watery, pale red to pink (mixture of serum and blood) and is common in early
postoperative periods but contains more blood than described. Purulent drainage is
thick, opaque, yellow, green, or tan and indicates infection. The description of thin,
watery, clear/slightly yellow fluid without blood is classic for serous drainage, which is
expected and normal in healing wounds.
Q4: A nurse is caring for a patient with a pressure injury that presents as a localized
area of purple or maroon discolored intact skin on the coccyx following a prolonged
surgical procedure. Which documentation is most accurate?
A. Stage 1 pressure injury with deep tissue involvement
B. Suspected deep tissue injury (sDTI)
C. Stage 2 pressure injury with hematoma formation
D. Unstageable pressure injury due to eschar
Correct Answer: B [CORRECT]
Rationale: Suspected deep tissue injury (sDTI) is characterized by a localized area of
persistent non-blanchable deep red, maroon, or purple discoloration of intact skin or a
blood-filled blister due to damage to underlying soft tissue from pressure and/or shear.
This contrasts with Stage 1 (non-blanchable erythema of intact skin without the deep
purple/maroon color). The deep color indicates damage to underlying soft tissue
structures. sDTI may rapidly evolve and become open, exposing the depth of tissue
destruction. These injuries are often preceded by skin that is painful, firm, mushy, boggy,
warmer, or cooler than adjacent tissue. The area should be protected from additional
pressure and monitored closely for deterioration.
, Q5: According to the Braden Scale for Predicting Pressure Sore Risk, which combination
of subscale scores places a patient at highest risk for pressure injury development?
A. Sensory perception: 3, Moisture: 3, Activity: 3, Mobility: 3, Nutrition: 3, Friction/Shear:
2
B. Sensory perception: 2, Moisture: 2, Activity: 2, Mobility: 2, Nutrition: 2, Friction/Shear:
1
C. Sensory perception: 4, Moisture: 4, Activity: 4, Mobility: 4, Nutrition: 4, Friction/Shear:
3
D. Sensory perception: 1, Moisture: 1, Activity: 1, Mobility: 1, Nutrition: 1, Friction/Shear:
1
Correct Answer: D [CORRECT]
Rationale: The Braden Scale scores range from 6-23, with lower scores indicating higher
risk. Scores of 15-18 = mild risk, 13-14 = moderate risk, 10-12 = high risk, and 9 or less =
very high risk. Option D yields a total score of 6 (1+1+1+1+1+1), indicating the highest
possible risk category. Option A totals 17 (mild risk), Option B totals 11 (high risk), and
Option C totals 23 (no risk). The subscales assess: sensory perception (ability to
respond meaningfully to pressure-related discomfort), moisture (degree to which skin is
exposed to moisture), activity (degree of physical activity), mobility (ability to change
and control body position), nutrition (usual food intake pattern), and friction/shear
(amount of assistance needed to move and degree of sliding against sheets).
Q6: A nurse is applying a wet-to-damp dressing to a patient's wound with yellow slough
and minimal exudate. The nurse should use which type of solution for moistening the
dressing?
A. Sterile normal saline
B. Hydrogen peroxide
C. Acetic acid
