NUR 155 EXAM 3 | ACTUAL EXAM QUESTIONS AND ANSWERS PLUS
RATIONALES | 2025/2026 UPDATE | 100% CORRECT- GALEN
Question 1
A nurse is assessing a client's surgical wound and notes clear, watery plasma-like drainage. How
should the nurse document this finding?
A) Purulent drainage
B) Sanguineous drainage
C) Serosanguineous drainage
D) Serous drainage
E) Purosanguineous drainage
Correct Answer: D) Serous drainage
Rationale: Serous drainage is composed primarily of the clear, serous portion of the blood
and from serous membranes. It is clear and watery. Purulent drainage is milky and
contains pus. Sanguineous is bloody, and serosanguineous is a mix of bloody and serous
drainage.
Question 2
A client has a deep wound from a dog bite that is left open to heal from the inside out. The nurse
recognizes this as which type of wound healing?
A) Primary intention
B) Secondary intention
C) Tertiary intention
D) Quaternary intention
E) Regeneration
Correct Answer: B) Secondary intention
Rationale: Secondary intention healing occurs in wounds with extensive tissue loss where
the edges cannot be approximated (closed). The wound is left open and heals by filling in
with granulation tissue from the bottom up. This process is slower and results in more
scarring and a higher risk of infection compared to primary intention.
Question 3
A client is admitted with a severe infection, has a fever, and an elevated white blood cell (WBC)
count. The nurse observes that the wound drainage is thick, milky, and has a foul odor. This type
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of drainage is best described as:
A) Serous
B) Sanguineous
C) Serosanguineous
D) Purulent
E) Hemorrhagic
Correct Answer: D) Purulent
Rationale: Purulent drainage is a sign of infection. It is made up of white blood cells,
liquefied dead tissue debris, and both dead and live bacteria. It is typically thick, opaque,
and can be tan, yellow, green, or brown. The text describes it as containing pus and being
milky-like.
Question 4
A nurse is caring for a client with a Stage I pressure ulcer on their coccyx. Which assessment
finding is characteristic of this stage?
A) An open, shallow crater with a red-pink wound bed.
B) Full-thickness skin loss with visible subcutaneous fat.
C) A localized area of intact skin with non-blanchable redness.
D) A partial-thickness loss of dermis presenting as a blister.
E) Purple or maroon discoloration of intact skin.
Correct Answer: C) A localized area of intact skin with non-blanchable redness.
Rationale: The defining characteristic of a Stage I pressure ulcer is an area of intact skin
with non-blanchable erythema (redness). This means that when pressure is applied to the
reddened area, it does not turn white, indicating underlying tissue damage has begun.
Question 5
When applying an abdominal binder to a postoperative client, where should the nurse begin
fastening the binder?
A) Start at the top (near the xiphoid process) and fasten downwards.
B) Start in the middle and fasten outwards in both directions.
C) The starting point does not matter as long as it is secure.
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D) Start at the bottom and fasten upwards.
E) Apply the top and bottom fasteners first, then the middle.
Correct Answer: D) Start at the bottom and fasten upwards.
Rationale: The correct procedure for applying an abdominal binder is to start at the
bottom and work up. This helps to provide adequate support and ensures the binder
conforms properly to the client's body, preventing it from riding up and keeping dressings
intact.
Question 6
Which of the following clients is at the highest risk for developing a pressure ulcer?
A) A 30-year-old client who is ambulating after an appendectomy.
B) A 50-year-old client admitted for observation with normal mobility.
C) A 75-year-old client with a hip fracture who is immobile and has urinary incontinence.
D) A 45-year-old client with a well-controlled chronic condition.
E) A 25-year-old athlete with a minor sports injury.
Correct Answer: C) A 75-year-old client with a hip fracture who is immobile and has
urinary incontinence.
Rationale: This client possesses multiple significant risk factors: advanced age, immobility
(which causes prolonged pressure), and incontinence (which exposes the skin to moisture,
leading to maceration and breakdown). This combination places the client at the highest
risk according to the listed risk factors.
Question 7
A nurse assesses a client's wound and notes that it appears to be healing by primary intention.
Which of the following is an example of a wound that heals by primary intention?
A) A large, open pressure ulcer.
B) A clean surgical incision closed with sutures.
C) A severe burn left open to heal.
D) A wound left open for several days to allow an infection to resolve.
E) A jagged laceration from an accident.
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Correct Answer: B) A clean surgical incision closed with sutures.
Rationale: Primary intention healing occurs when the tissue surfaces have been
approximated (closed) with minimal tissue loss. This is characteristic of clean surgical
wounds that are closed with sutures, staples, or adhesive, resulting in minimal scarring.
Question 8
A client with joint stiffness due to chronic arthritis would most likely benefit from which type of
therapy to increase blood flow and relax muscles?
A) Cold therapy
B) Heat therapy
C) Compression therapy
D) Elevation
E) Immobilization
Correct Answer: B) Heat therapy
Rationale: Heat therapy causes vasodilation, which increases blood flow, oxygen, and
nutrients to the area. It also increases cellular metabolism and inflammation, which can
help with chronic conditions. It is specifically indicated for musculoskeletal problems like
joint stiffness and arthritis to promote relaxation and reduce pain.
Question 9
A client presents to the emergency department with an acutely sprained ankle that is swollen and
painful. The nurse should anticipate applying which type of therapy?
A) Heat therapy
B) Cold therapy
C) A warm whirlpool bath.
D) A heating pad set on high.
E) Alternating hot and cold packs.
Correct Answer: B) Cold therapy
Rationale: Cold therapy causes vasoconstriction, which decreases blood flow to the area.
This is beneficial for acute injuries like sprains because it reduces swelling (edema),
inflammation, and pain. It works by decreasing capillary permeability and cellular
metabolism.
RATIONALES | 2025/2026 UPDATE | 100% CORRECT- GALEN
Question 1
A nurse is assessing a client's surgical wound and notes clear, watery plasma-like drainage. How
should the nurse document this finding?
A) Purulent drainage
B) Sanguineous drainage
C) Serosanguineous drainage
D) Serous drainage
E) Purosanguineous drainage
Correct Answer: D) Serous drainage
Rationale: Serous drainage is composed primarily of the clear, serous portion of the blood
and from serous membranes. It is clear and watery. Purulent drainage is milky and
contains pus. Sanguineous is bloody, and serosanguineous is a mix of bloody and serous
drainage.
Question 2
A client has a deep wound from a dog bite that is left open to heal from the inside out. The nurse
recognizes this as which type of wound healing?
A) Primary intention
B) Secondary intention
C) Tertiary intention
D) Quaternary intention
E) Regeneration
Correct Answer: B) Secondary intention
Rationale: Secondary intention healing occurs in wounds with extensive tissue loss where
the edges cannot be approximated (closed). The wound is left open and heals by filling in
with granulation tissue from the bottom up. This process is slower and results in more
scarring and a higher risk of infection compared to primary intention.
Question 3
A client is admitted with a severe infection, has a fever, and an elevated white blood cell (WBC)
count. The nurse observes that the wound drainage is thick, milky, and has a foul odor. This type
,[Type here]
of drainage is best described as:
A) Serous
B) Sanguineous
C) Serosanguineous
D) Purulent
E) Hemorrhagic
Correct Answer: D) Purulent
Rationale: Purulent drainage is a sign of infection. It is made up of white blood cells,
liquefied dead tissue debris, and both dead and live bacteria. It is typically thick, opaque,
and can be tan, yellow, green, or brown. The text describes it as containing pus and being
milky-like.
Question 4
A nurse is caring for a client with a Stage I pressure ulcer on their coccyx. Which assessment
finding is characteristic of this stage?
A) An open, shallow crater with a red-pink wound bed.
B) Full-thickness skin loss with visible subcutaneous fat.
C) A localized area of intact skin with non-blanchable redness.
D) A partial-thickness loss of dermis presenting as a blister.
E) Purple or maroon discoloration of intact skin.
Correct Answer: C) A localized area of intact skin with non-blanchable redness.
Rationale: The defining characteristic of a Stage I pressure ulcer is an area of intact skin
with non-blanchable erythema (redness). This means that when pressure is applied to the
reddened area, it does not turn white, indicating underlying tissue damage has begun.
Question 5
When applying an abdominal binder to a postoperative client, where should the nurse begin
fastening the binder?
A) Start at the top (near the xiphoid process) and fasten downwards.
B) Start in the middle and fasten outwards in both directions.
C) The starting point does not matter as long as it is secure.
,[Type here]
D) Start at the bottom and fasten upwards.
E) Apply the top and bottom fasteners first, then the middle.
Correct Answer: D) Start at the bottom and fasten upwards.
Rationale: The correct procedure for applying an abdominal binder is to start at the
bottom and work up. This helps to provide adequate support and ensures the binder
conforms properly to the client's body, preventing it from riding up and keeping dressings
intact.
Question 6
Which of the following clients is at the highest risk for developing a pressure ulcer?
A) A 30-year-old client who is ambulating after an appendectomy.
B) A 50-year-old client admitted for observation with normal mobility.
C) A 75-year-old client with a hip fracture who is immobile and has urinary incontinence.
D) A 45-year-old client with a well-controlled chronic condition.
E) A 25-year-old athlete with a minor sports injury.
Correct Answer: C) A 75-year-old client with a hip fracture who is immobile and has
urinary incontinence.
Rationale: This client possesses multiple significant risk factors: advanced age, immobility
(which causes prolonged pressure), and incontinence (which exposes the skin to moisture,
leading to maceration and breakdown). This combination places the client at the highest
risk according to the listed risk factors.
Question 7
A nurse assesses a client's wound and notes that it appears to be healing by primary intention.
Which of the following is an example of a wound that heals by primary intention?
A) A large, open pressure ulcer.
B) A clean surgical incision closed with sutures.
C) A severe burn left open to heal.
D) A wound left open for several days to allow an infection to resolve.
E) A jagged laceration from an accident.
, [Type here]
Correct Answer: B) A clean surgical incision closed with sutures.
Rationale: Primary intention healing occurs when the tissue surfaces have been
approximated (closed) with minimal tissue loss. This is characteristic of clean surgical
wounds that are closed with sutures, staples, or adhesive, resulting in minimal scarring.
Question 8
A client with joint stiffness due to chronic arthritis would most likely benefit from which type of
therapy to increase blood flow and relax muscles?
A) Cold therapy
B) Heat therapy
C) Compression therapy
D) Elevation
E) Immobilization
Correct Answer: B) Heat therapy
Rationale: Heat therapy causes vasodilation, which increases blood flow, oxygen, and
nutrients to the area. It also increases cellular metabolism and inflammation, which can
help with chronic conditions. It is specifically indicated for musculoskeletal problems like
joint stiffness and arthritis to promote relaxation and reduce pain.
Question 9
A client presents to the emergency department with an acutely sprained ankle that is swollen and
painful. The nurse should anticipate applying which type of therapy?
A) Heat therapy
B) Cold therapy
C) A warm whirlpool bath.
D) A heating pad set on high.
E) Alternating hot and cold packs.
Correct Answer: B) Cold therapy
Rationale: Cold therapy causes vasoconstriction, which decreases blood flow to the area.
This is beneficial for acute injuries like sprains because it reduces swelling (edema),
inflammation, and pain. It works by decreasing capillary permeability and cellular
metabolism.
