NU 155 Exam 3 Medical-Surgical Nursing I 2026
Comprehensive Questions And Answers With Detailed
Rationales
QUESTION 1
The nurse is monitoring a client's surgical incision and notes an increase in the amount of drainage, a
separation of the incision line, and the appearance of underlying tissue. Which of the following is an
appropriate action for the nurse to take?
A. Cover the wound loosely with a sterile dry dressing
B. Apply a sterile, normal-saline soaked dressing to the wound
C. Clean the wound with hydrogen peroxide and apply antibiotic ointment
D. Massage the wound edges to promote healing
Correct Answer: B. Apply a sterile, normal-saline soaked dressing to the wound
Expert Rationale: This presentation is consistent with wound dehiscence, a serious postoperative
complication where the surgical wound separates. The priority action is to cover the area with a sterile
saline-soaked dressing to keep the tissues moist and prevent contamination while minimizing trauma. Dry
dressings can cause tissue desiccation, and hydrogen peroxide can damage new granulation tissue.
Massaging the wound edges is contraindicated and could worsen the separation .
QUESTION 2
The nurse is assessing a postoperative client with advanced cognitive impairment. Which action is most
effective when assessing the client's level of pain?
A. Ask the client to rate pain on a scale from 0 to 10
B. Monitor the client's body language, facial expressions, emotional status, and consolability
C. Assume no pain if there is no verbal complaint
D. Measure vital signs only
,Correct Answer: B. Monitor the client's body language, facial expressions, emotional status, and
consolability
Expert Rationale: Clients with advanced cognitive impairment have limited ability to self-report pain.
Observational pain assessment tools that include behavioral and emotional cues are considered the most
reliable strategies to identify pain in this population. Self-report tools are often ineffective when the client
cannot comprehend or communicate effectively. Vital signs alone are unreliable indicators of pain and
should not be the sole assessment method .
QUESTION 3
The nurse is caring for a client who has diabetes mellitus and reports sharp, burning pain in bilateral
lower extremities. The nurse understands that the client may be experiencing:
A. Nociceptive pain
B. Referred pain
C. Neuropathic pain
D. Phantom limb pain
Correct Answer: C. Neuropathic pain
Expert Rationale: Neuropathic pain results from nerve damage often associated with diabetes mellitus,
characterized by sharp, burning sensations typically in a "stocking-glove" distribution in the lower
extremities. Nociceptive pain results from tissue damage and is typically described as aching or
throbbing. Referred pain is perceived at a location other than the site of the painful stimulus. Phantom
limb pain occurs after amputation .
QUESTION 4
The nurse is caring for a client who is scheduled to have surgery the following day. It requires notification
to the primary health care provider (PHCP) if the client:
A. Has a history of smoking
B. Reports a family history of high fever during a surgical procedure
,C. Is allergic to latex
D. Has a recent upper respiratory infection
Correct Answer: B. Reports a family history of high fever during a surgical procedure
Expert Rationale: A family history of high fever during a surgical procedure suggests the possibility of
malignant hyperthermia, a life-threatening genetic condition triggered by certain anesthetic agents. This
requires immediate notification of the healthcare provider and anesthesiologist. A history of smoking,
latex allergy, and recent upper respiratory infection are also important to document, but a family history
of malignant hyperthermia is the most critical finding requiring immediate notification .
QUESTION 5
The nurse is caring for a group of assigned clients. Which of the following clients requires immediate
follow-up by the nurse?
A. Client with a healing surgical wound reporting mild pain
B. The client who had a cardiac catheterization via the right femoral artery 1 hour ago who is reporting
numbness in the right leg
C. Client scheduled for discharge in 2 days reporting fatigue
D. Client with stable vital signs after a blood transfusion
Correct Answer: B. The client who had a cardiac catheterization via the right femoral artery 1 hour ago
who is reporting numbness in the right leg
Expert Rationale: Numbness in the right leg following femoral artery catheterization could indicate
compromised circulation or nerve injury, requiring immediate assessment to prevent serious
complications such as limb ischemia. This finding represents a potential complication that must be
evaluated promptly. Mild pain in a healing wound, fatigue before discharge, and stable vital signs after
transfusion are not emergencies .
QUESTION 6
The nurse has reinforced teaching with a client about risk factors for deep vein thrombosis (DVT). Which
of the following risk factors identified by the client indicates a need for further teaching?
, A. Oral contraceptive use
B. Prolonged immobility
C. Intake of foods high in calcium
D. Smoking
Correct Answer: C. Intake of foods high in calcium
Expert Rationale: High calcium intake is not a recognized risk factor for DVT. Known risk factors include
oral contraceptive use, prolonged immobility, smoking, obesity, surgery, trauma, and hypercoagulable
states. The client's identification of a non-risk factor indicates a need for additional teaching .
QUESTION 7
The nurse is caring for a client who is postoperative. Which action should the nurse take to minimize the
client's risk of developing deep vein thrombosis (DVT)?
A. Apply warm compresses to the lower extremities regularly
B. Give bed rest for at least 48 hours after surgery
C. Assist the client to ambulate frequently as early as tolerated
D. Limit fluid intake to reduce workload on the heart
Correct Answer: C. Assist the client to ambulate frequently as early as tolerated
Expert Rationale: Early ambulation stimulates venous return and reduces venous stasis, which is critical
in preventing DVT formation postoperatively. Bed rest increases DVT risk. Warm compresses do not
prevent DVT, and fluid restriction is not indicated for DVT prevention .
QUESTION 8
The nurse is caring for a client who has left-sided heart failure (HF) and has developed a cough, crackles,
and weak peripheral pulses. Which of the following additional findings should the nurse expect to
observe?
Comprehensive Questions And Answers With Detailed
Rationales
QUESTION 1
The nurse is monitoring a client's surgical incision and notes an increase in the amount of drainage, a
separation of the incision line, and the appearance of underlying tissue. Which of the following is an
appropriate action for the nurse to take?
A. Cover the wound loosely with a sterile dry dressing
B. Apply a sterile, normal-saline soaked dressing to the wound
C. Clean the wound with hydrogen peroxide and apply antibiotic ointment
D. Massage the wound edges to promote healing
Correct Answer: B. Apply a sterile, normal-saline soaked dressing to the wound
Expert Rationale: This presentation is consistent with wound dehiscence, a serious postoperative
complication where the surgical wound separates. The priority action is to cover the area with a sterile
saline-soaked dressing to keep the tissues moist and prevent contamination while minimizing trauma. Dry
dressings can cause tissue desiccation, and hydrogen peroxide can damage new granulation tissue.
Massaging the wound edges is contraindicated and could worsen the separation .
QUESTION 2
The nurse is assessing a postoperative client with advanced cognitive impairment. Which action is most
effective when assessing the client's level of pain?
A. Ask the client to rate pain on a scale from 0 to 10
B. Monitor the client's body language, facial expressions, emotional status, and consolability
C. Assume no pain if there is no verbal complaint
D. Measure vital signs only
,Correct Answer: B. Monitor the client's body language, facial expressions, emotional status, and
consolability
Expert Rationale: Clients with advanced cognitive impairment have limited ability to self-report pain.
Observational pain assessment tools that include behavioral and emotional cues are considered the most
reliable strategies to identify pain in this population. Self-report tools are often ineffective when the client
cannot comprehend or communicate effectively. Vital signs alone are unreliable indicators of pain and
should not be the sole assessment method .
QUESTION 3
The nurse is caring for a client who has diabetes mellitus and reports sharp, burning pain in bilateral
lower extremities. The nurse understands that the client may be experiencing:
A. Nociceptive pain
B. Referred pain
C. Neuropathic pain
D. Phantom limb pain
Correct Answer: C. Neuropathic pain
Expert Rationale: Neuropathic pain results from nerve damage often associated with diabetes mellitus,
characterized by sharp, burning sensations typically in a "stocking-glove" distribution in the lower
extremities. Nociceptive pain results from tissue damage and is typically described as aching or
throbbing. Referred pain is perceived at a location other than the site of the painful stimulus. Phantom
limb pain occurs after amputation .
QUESTION 4
The nurse is caring for a client who is scheduled to have surgery the following day. It requires notification
to the primary health care provider (PHCP) if the client:
A. Has a history of smoking
B. Reports a family history of high fever during a surgical procedure
,C. Is allergic to latex
D. Has a recent upper respiratory infection
Correct Answer: B. Reports a family history of high fever during a surgical procedure
Expert Rationale: A family history of high fever during a surgical procedure suggests the possibility of
malignant hyperthermia, a life-threatening genetic condition triggered by certain anesthetic agents. This
requires immediate notification of the healthcare provider and anesthesiologist. A history of smoking,
latex allergy, and recent upper respiratory infection are also important to document, but a family history
of malignant hyperthermia is the most critical finding requiring immediate notification .
QUESTION 5
The nurse is caring for a group of assigned clients. Which of the following clients requires immediate
follow-up by the nurse?
A. Client with a healing surgical wound reporting mild pain
B. The client who had a cardiac catheterization via the right femoral artery 1 hour ago who is reporting
numbness in the right leg
C. Client scheduled for discharge in 2 days reporting fatigue
D. Client with stable vital signs after a blood transfusion
Correct Answer: B. The client who had a cardiac catheterization via the right femoral artery 1 hour ago
who is reporting numbness in the right leg
Expert Rationale: Numbness in the right leg following femoral artery catheterization could indicate
compromised circulation or nerve injury, requiring immediate assessment to prevent serious
complications such as limb ischemia. This finding represents a potential complication that must be
evaluated promptly. Mild pain in a healing wound, fatigue before discharge, and stable vital signs after
transfusion are not emergencies .
QUESTION 6
The nurse has reinforced teaching with a client about risk factors for deep vein thrombosis (DVT). Which
of the following risk factors identified by the client indicates a need for further teaching?
, A. Oral contraceptive use
B. Prolonged immobility
C. Intake of foods high in calcium
D. Smoking
Correct Answer: C. Intake of foods high in calcium
Expert Rationale: High calcium intake is not a recognized risk factor for DVT. Known risk factors include
oral contraceptive use, prolonged immobility, smoking, obesity, surgery, trauma, and hypercoagulable
states. The client's identification of a non-risk factor indicates a need for additional teaching .
QUESTION 7
The nurse is caring for a client who is postoperative. Which action should the nurse take to minimize the
client's risk of developing deep vein thrombosis (DVT)?
A. Apply warm compresses to the lower extremities regularly
B. Give bed rest for at least 48 hours after surgery
C. Assist the client to ambulate frequently as early as tolerated
D. Limit fluid intake to reduce workload on the heart
Correct Answer: C. Assist the client to ambulate frequently as early as tolerated
Expert Rationale: Early ambulation stimulates venous return and reduces venous stasis, which is critical
in preventing DVT formation postoperatively. Bed rest increases DVT risk. Warm compresses do not
prevent DVT, and fluid restriction is not indicated for DVT prevention .
QUESTION 8
The nurse is caring for a client who has left-sided heart failure (HF) and has developed a cough, crackles,
and weak peripheral pulses. Which of the following additional findings should the nurse expect to
observe?
