NU 155 Exam 3 Medical-Surgical Nursing I (2026) PDF
| Galen College of Nursing
PART 1 — QUESTIONS 1–50
Question 1. A nurse on a surgical unit notices a rise in post-op wound infections and
begins to wonder if using chlorhexidine for pre-op skin cleansing is more effective than
povidone-iodine. She decides to research the best practice for preventing surgical site
infections. Which step of the Evidence-Based Practice (EBP) process is the nurse
demonstrating?
A. Searching for the most relevant evidence
B. Cultivating a spirit of inquiry
C. Integrating evidence with patient preferences
D. Evaluating outcomes of practice changes
Correct Answer: B
Rationale: The spirit of inquiry is the first step in EBP, where a clinician questions current
practices and wonders if there is a better approach. By noticing the rise in infections and
questioning the effectiveness of current practices, this nurse is demonstrating a spirit of
inquiry. This step precedes searching for evidence, integrating findings with patient
preferences, or evaluating outcomes .
Question 2. 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. Apply warm compresses to the lower extremities regularly
D. Clean the wound with hydrogen peroxide and apply antibiotic ointment
Correct Answer: B
,Rationale: This presentation is consistent with wound dehiscence, a complication where
the surgical wound separates. It is crucial to cover the area with a sterile saline-soaked
dressing to keep tissues moist and prevent contamination while minimizing trauma. Dry
dressings cause tissue desiccation, and hydrogen peroxide can damage granulation
tissue. Warm compresses and massage are contraindicated .
Question 3. The nurse is assessing a postoperative client who has advanced cognitive
impairment. Which action by the nurse 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
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. Vital signs
alone are not reliable indicators, and assuming no pain without complaint is unsafe .
Question 4. 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
Rationale: Neuropathic pain results from nerve damage often associated with diabetes
mellitus (diabetic neuropathy). It is characterized by sharp, burning sensations typically
,in a "stocking-glove" distribution in the lower extremities. Nociceptive pain arises from
tissue damage, referred pain is perceived at a site distant from the source, and phantom
pain occurs after limb amputation .
Question 5. 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
Rationale: A family history of malignant hyperthermia (high fever during surgery)
requires immediate notification because this is a potentially fatal condition triggered by
anesthesia. The PHCP needs to be aware so appropriate precautions (such as using non-
triggering anesthesia agents) can be taken .
Question 6. 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
Rationale: Numbness could indicate compromised circulation or nerve injury following
femoral artery catheterization. This requires immediate assessment to prevent serious
complications such as limb ischemia. Mild pain and fatigue are expected in
postoperative clients, and stable vital signs after transfusion are reassuring .
, Question 7. 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
Rationale: High calcium intake is not a recognized risk factor for DVT. DVT risk factors
include oral contraceptive use (increases clotting risk), prolonged immobility (venous
stasis), and smoking (damages blood vessels). This indicates the client needs additional
teaching on DVT risk factors .
Question 8. A patient has been admitted to the ED after experiencing a fall while rock
climbing. He appears to have several facial fractures. Which observed assessment
finding is most serious?
A. Malaligned nasal bridge
B. Clear fluid draining from one of the nares, testing positive for glucose
C. Blood draining from one of the nares
D. Crackling of the skin (crepitus) upon palpation
Correct Answer: B
Rationale: Clear fluid draining from the nares that tests positive for glucose indicates
cerebrospinal fluid (CSF) drainage, which is a sign of a skull fracture. This is a serious
complication that requires immediate intervention. Blood drainage and crepitus may be
observed with facial fractures but are not as immediately life-threatening as CSF leak,
which can lead to meningitis .
| Galen College of Nursing
PART 1 — QUESTIONS 1–50
Question 1. A nurse on a surgical unit notices a rise in post-op wound infections and
begins to wonder if using chlorhexidine for pre-op skin cleansing is more effective than
povidone-iodine. She decides to research the best practice for preventing surgical site
infections. Which step of the Evidence-Based Practice (EBP) process is the nurse
demonstrating?
A. Searching for the most relevant evidence
B. Cultivating a spirit of inquiry
C. Integrating evidence with patient preferences
D. Evaluating outcomes of practice changes
Correct Answer: B
Rationale: The spirit of inquiry is the first step in EBP, where a clinician questions current
practices and wonders if there is a better approach. By noticing the rise in infections and
questioning the effectiveness of current practices, this nurse is demonstrating a spirit of
inquiry. This step precedes searching for evidence, integrating findings with patient
preferences, or evaluating outcomes .
Question 2. 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. Apply warm compresses to the lower extremities regularly
D. Clean the wound with hydrogen peroxide and apply antibiotic ointment
Correct Answer: B
,Rationale: This presentation is consistent with wound dehiscence, a complication where
the surgical wound separates. It is crucial to cover the area with a sterile saline-soaked
dressing to keep tissues moist and prevent contamination while minimizing trauma. Dry
dressings cause tissue desiccation, and hydrogen peroxide can damage granulation
tissue. Warm compresses and massage are contraindicated .
Question 3. The nurse is assessing a postoperative client who has advanced cognitive
impairment. Which action by the nurse 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
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. Vital signs
alone are not reliable indicators, and assuming no pain without complaint is unsafe .
Question 4. 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
Rationale: Neuropathic pain results from nerve damage often associated with diabetes
mellitus (diabetic neuropathy). It is characterized by sharp, burning sensations typically
,in a "stocking-glove" distribution in the lower extremities. Nociceptive pain arises from
tissue damage, referred pain is perceived at a site distant from the source, and phantom
pain occurs after limb amputation .
Question 5. 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
Rationale: A family history of malignant hyperthermia (high fever during surgery)
requires immediate notification because this is a potentially fatal condition triggered by
anesthesia. The PHCP needs to be aware so appropriate precautions (such as using non-
triggering anesthesia agents) can be taken .
Question 6. 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
Rationale: Numbness could indicate compromised circulation or nerve injury following
femoral artery catheterization. This requires immediate assessment to prevent serious
complications such as limb ischemia. Mild pain and fatigue are expected in
postoperative clients, and stable vital signs after transfusion are reassuring .
, Question 7. 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
Rationale: High calcium intake is not a recognized risk factor for DVT. DVT risk factors
include oral contraceptive use (increases clotting risk), prolonged immobility (venous
stasis), and smoking (damages blood vessels). This indicates the client needs additional
teaching on DVT risk factors .
Question 8. A patient has been admitted to the ED after experiencing a fall while rock
climbing. He appears to have several facial fractures. Which observed assessment
finding is most serious?
A. Malaligned nasal bridge
B. Clear fluid draining from one of the nares, testing positive for glucose
C. Blood draining from one of the nares
D. Crackling of the skin (crepitus) upon palpation
Correct Answer: B
Rationale: Clear fluid draining from the nares that tests positive for glucose indicates
cerebrospinal fluid (CSF) drainage, which is a sign of a skull fracture. This is a serious
complication that requires immediate intervention. Blood drainage and crepitus may be
observed with facial fractures but are not as immediately life-threatening as CSF leak,
which can lead to meningitis .
