NUR 155 Exam 3: 81 Questions & Answers: Updated A+ Score Solution
Question 1
A nurse assesses a postoperative patient's surgical incision. Which finding
indicates normal wound healing?
A. Thick green drainage with odor
B. Well-approximated wound edges with slight redness
C. Separation of wound edges
D. Large amount of bloody drainage
Correct Answer: B
Rationale: Slight redness and well-approximated edges are expected during the
inflammatory phase of healing.
Question 2
Which patient is at greatest risk for developing a pressure injury?
A. Ambulates independently twice daily
B. Bedridden with poor nutrition
C. Walks with a cane
D. Young athlete recovering from surgery
Correct Answer: B
Rationale: Immobility and poor nutrition greatly increase pressure injury risk.
,Question 3
Which intervention best prevents pressure injuries?
A. Massage reddened areas
B. Reposition every 2 hours
C. Apply heat continuously
D. Restrict fluids
Correct Answer: B
Rationale: Frequent repositioning reduces prolonged pressure on tissues.
Question 4
Which oxygen delivery device provides the highest oxygen concentration?
A. Nasal cannula
B. Simple face mask
C. Venturi mask
D. Non-rebreather mask
Correct Answer: D
Rationale: A non-rebreather mask can deliver approximately 60–100% oxygen.
Question 5
A patient using a nasal cannula reports nasal dryness. What is the nurse's best
action?
,A. Remove oxygen therapy
B. Add humidification if appropriate
C. Increase oxygen flow to 10 L/min
D. Encourage mouth breathing
Correct Answer: B
Rationale: Humidification helps reduce drying of the nasal mucosa.
Question 6
Which assessment finding requires immediate nursing intervention?
A. Respiratory rate 18/min
B. Oxygen saturation 86% on room air
C. Heart rate 82/min
D. Blood pressure 126/74 mmHg
Correct Answer: B
Rationale: Oxygen saturation below 90% indicates significant hypoxemia.
Question 7
Proper body mechanics require the nurse to:
A. Bend at the waist
B. Keep the object away from the body
, C. Lift with the legs while keeping the back straight
D. Twist while lifting
Correct Answer: C
Rationale: Using the leg muscles protects the back and reduces injury.
Question 8
Which complication is most likely in an immobile patient?
A. Improved circulation
B. Pressure injuries
C. Increased muscle strength
D. Lower risk of DVT
Correct Answer: B
Rationale: Immobility increases the risk of skin breakdown.
Question 9
Which pain scale is appropriate for an alert adult?
A. FLACC Scale
B. Numeric Rating Scale (0–10)
C. Apgar Score
D. Braden Scale
Correct Answer: B
Question 1
A nurse assesses a postoperative patient's surgical incision. Which finding
indicates normal wound healing?
A. Thick green drainage with odor
B. Well-approximated wound edges with slight redness
C. Separation of wound edges
D. Large amount of bloody drainage
Correct Answer: B
Rationale: Slight redness and well-approximated edges are expected during the
inflammatory phase of healing.
Question 2
Which patient is at greatest risk for developing a pressure injury?
A. Ambulates independently twice daily
B. Bedridden with poor nutrition
C. Walks with a cane
D. Young athlete recovering from surgery
Correct Answer: B
Rationale: Immobility and poor nutrition greatly increase pressure injury risk.
,Question 3
Which intervention best prevents pressure injuries?
A. Massage reddened areas
B. Reposition every 2 hours
C. Apply heat continuously
D. Restrict fluids
Correct Answer: B
Rationale: Frequent repositioning reduces prolonged pressure on tissues.
Question 4
Which oxygen delivery device provides the highest oxygen concentration?
A. Nasal cannula
B. Simple face mask
C. Venturi mask
D. Non-rebreather mask
Correct Answer: D
Rationale: A non-rebreather mask can deliver approximately 60–100% oxygen.
Question 5
A patient using a nasal cannula reports nasal dryness. What is the nurse's best
action?
,A. Remove oxygen therapy
B. Add humidification if appropriate
C. Increase oxygen flow to 10 L/min
D. Encourage mouth breathing
Correct Answer: B
Rationale: Humidification helps reduce drying of the nasal mucosa.
Question 6
Which assessment finding requires immediate nursing intervention?
A. Respiratory rate 18/min
B. Oxygen saturation 86% on room air
C. Heart rate 82/min
D. Blood pressure 126/74 mmHg
Correct Answer: B
Rationale: Oxygen saturation below 90% indicates significant hypoxemia.
Question 7
Proper body mechanics require the nurse to:
A. Bend at the waist
B. Keep the object away from the body
, C. Lift with the legs while keeping the back straight
D. Twist while lifting
Correct Answer: C
Rationale: Using the leg muscles protects the back and reduces injury.
Question 8
Which complication is most likely in an immobile patient?
A. Improved circulation
B. Pressure injuries
C. Increased muscle strength
D. Lower risk of DVT
Correct Answer: B
Rationale: Immobility increases the risk of skin breakdown.
Question 9
Which pain scale is appropriate for an alert adult?
A. FLACC Scale
B. Numeric Rating Scale (0–10)
C. Apgar Score
D. Braden Scale
Correct Answer: B
