NUR 155 Exam 3 Galen College Newest Actual Exam Preparation With Complete
Questions And Correct Answers With Rationales | Already Graded A+||Brand
New Version!!
Question 1
A nurse is preparing a patient for a scheduled surgical procedure. The incision that will be made
by the surgeon is classified as which type of wound?
A) Unintentional wound
B) Intentional wound
C) Chronic wound
D) Open contaminated wound
E) Penetrating accidental wound
Correct Answer: B) Intentional wound
Rationale: An intentional wound occurs during therapy, such as a surgical incision or a
venipuncture. These are created under sterile conditions with a specific therapeutic
purpose. Unintentional wounds, conversely, are accidental (such as a fracture from a car
accident) and occur under non-sterile conditions, increasing the risk of infection.
Question 2
When assessing a wound that is confined specifically to the skin layers (the dermis and
epidermis) and is expected to heal by the replacement of destroyed tissue with the same kind of
cells, the nurse identifies this as:
A) Full thickness wound
B) Complex wound
C) Partial thickness wound
D) Tertiary intention wound
E) Deep tissue pressure injury
Correct Answer: C) Partial thickness wound
Rationale: Partial thickness wounds are confined to the epidermis and dermis. Because the
deeper structures are not involved, these wounds heal by "regeneration," which is the
replacement of destroyed tissue by the same kind of cells. Full thickness wounds involve the
subcutaneous tissue and possibly muscle and bone, requiring connective tissue repair
rather than simple regeneration.
Question 3
A patient presents to the emergency department with a wound caused by a blunt instrument, such
as a baseball bat. The skin is intact but appears bruised due to damaged blood vessels. What is
the correct term for this wound?
A) Abrasion
B) Laceration
C) Incision
, 2
D) Contusion
E) Puncture
Correct Answer: D) Contusion
Rationale: A contusion is a closed wound caused by a blow from a blunt instrument. While
the skin surface remains closed, the underlying blood vessels are damaged, leading to
ecchymosis (bruising) and swelling. A laceration involves torn tissues with jagged edges,
and an abrasion is a superficial scrape of the skin surface.
Question 4
The nurse is documenting a surgical wound where the respiratory and gastrointestinal tracts were
entered, but no evidence of infection or inflammation was noted during the procedure. How
should this wound be classified regarding contamination?
A) Clean wound
B) Clean-Contaminated wound
C) Contaminated wound
D) Dirty or Infected wound
E) Colonized wound
Correct Answer: B) Clean-Contaminated wound
Rationale: Clean-contaminated wounds are surgical wounds in which the respiratory,
alimentary (GI), genital, or urinary tract has been entered under controlled conditions.
While these areas harbor bacteria, if there is no evidence of active infection or a major
break in sterile technique, they are classified as clean-contaminated. "Clean" wounds are
those in which these tracts are NOT entered.
Question 5
Which type of wound involves tissues being torn apart, often resulting from accidents with
machinery, where the edges of the open wound are jagged and irregular?
A) Incision
B) Laceration wound
C) Penetrating wound
D) Puncture wound
E) Pressure injury
Correct Answer: B) Laceration wound
Rationale: A laceration is characterized by tissues being torn apart. The edges are often
jagged or irregular. This is common in traumatic accidents. An incision, by contrast, is a
clean-cut wound made by a sharp instrument like a scalpel.
Question 6
A nurse is assessing a patient with a "Puncture wound" caused by a nail. What is the primary
concern for this type of wound?
, 3
A) Excessive bleeding on the surface
B) It is a shallow wound that heals too fast
C) It penetrates the skin and underlying tissues, potentially trapping bacteria deep inside
D) It only involves the epidermis
E) It is always an intentional wound
Correct Answer: C) It penetrates the skin and underlying tissues, potentially trapping
bacteria deep inside
Rationale: A puncture wound is an open wound made by a sharp instrument that goes "in
and out." Because the entry site is small and often closes quickly, bacteria (such as Tetanus)
can be trapped in the deeper tissues where there is less oxygen, providing a breeding
ground for infection.
Question 7
The nurse is applying an abdominal binder to a patient after major surgery. What is the correct
technique for application?
A) Start at the typhoid and fasten from the top down
B) Start at the typhoid and fasten from the bottom up
C) Fasten only the middle straps to allow for breathing
D) Keep it on for 24 hours without removal
E) Apply as tightly as possible to restrict all movement
Correct Answer: B) start at typhoid, fasten from the bottom up
Rationale: Abdominal binders should be applied starting at the xiphoid process (typhoid)
and fastened from the bottom up to provide uniform support to the surgical site. Binders
must be removed every two hours to assess the underlying skin for breakdown and to check
the status of the wound and dressing.
Question 8
Which of the following is considered a major risk factor for the development of pressure ulcers?
A) High-protein diet
B) Increased mental status
C) Friction and shearing
D) Frequent ambulation
E) Balanced vitamin C and zinc intake
Correct Answer: C) Friction and shearing
Rationale: Friction (skin rubbing against a surface) and shearing (skin remaining stationary
while the bone and muscle move) are primary mechanical causes of pressure ulcers. Other
risk factors include immobility, fecal/urinary incontinence (moisture), inadequate nutrition
(lack of protein/Vitamin C), and diminished sensation.
, 4
Question 9
During a skin assessment, the nurse finds an area of redness over the sacrum that does not turn
white when pressed (non-blanchable). The skin is intact. What is the correct staging for this
pressure ulcer?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
E) Unstageable
Correct Answer: A) Stage I
Rationale: A Stage I pressure ulcer is characterized by intact skin with non-blanchable
redness, usually over a bony prominence. "Non-blanchable" means the area stays red even
when pressure is applied, indicating that tissue damage has started. There is no break in
the skin at this stage.
Question 10
A nurse identifies a pressure ulcer that looks like a shallow crater or a blister with partial
thickness skin loss involving the epidermis and dermis. The patient reports pain at the site. This
is a:
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
E) Deep tissue injury
Correct Answer: B) Stage II
Rationale: Stage II pressure ulcers involve partial thickness loss of the dermis. They present
as a shallow open ulcer with a red-pink wound bed, or as an intact or ruptured serum-filled
blister. This stage is typically painful because nerve endings are exposed.
Question 11
What stage of pressure ulcer is characterized by full thickness skin loss, involving damage or
necrosis of the subcutaneous tissue, but does not yet extend through the underlying fascia?
A) Stage I
B) Stage II
/C) Stage III
D) Stage IV
E) Suspected deep tissue injury
Correct Answer: C) Stage III
Rationale: Stage III involves full thickness tissue loss. Subcutaneous fat may be visible, but
Questions And Correct Answers With Rationales | Already Graded A+||Brand
New Version!!
Question 1
A nurse is preparing a patient for a scheduled surgical procedure. The incision that will be made
by the surgeon is classified as which type of wound?
A) Unintentional wound
B) Intentional wound
C) Chronic wound
D) Open contaminated wound
E) Penetrating accidental wound
Correct Answer: B) Intentional wound
Rationale: An intentional wound occurs during therapy, such as a surgical incision or a
venipuncture. These are created under sterile conditions with a specific therapeutic
purpose. Unintentional wounds, conversely, are accidental (such as a fracture from a car
accident) and occur under non-sterile conditions, increasing the risk of infection.
Question 2
When assessing a wound that is confined specifically to the skin layers (the dermis and
epidermis) and is expected to heal by the replacement of destroyed tissue with the same kind of
cells, the nurse identifies this as:
A) Full thickness wound
B) Complex wound
C) Partial thickness wound
D) Tertiary intention wound
E) Deep tissue pressure injury
Correct Answer: C) Partial thickness wound
Rationale: Partial thickness wounds are confined to the epidermis and dermis. Because the
deeper structures are not involved, these wounds heal by "regeneration," which is the
replacement of destroyed tissue by the same kind of cells. Full thickness wounds involve the
subcutaneous tissue and possibly muscle and bone, requiring connective tissue repair
rather than simple regeneration.
Question 3
A patient presents to the emergency department with a wound caused by a blunt instrument, such
as a baseball bat. The skin is intact but appears bruised due to damaged blood vessels. What is
the correct term for this wound?
A) Abrasion
B) Laceration
C) Incision
, 2
D) Contusion
E) Puncture
Correct Answer: D) Contusion
Rationale: A contusion is a closed wound caused by a blow from a blunt instrument. While
the skin surface remains closed, the underlying blood vessels are damaged, leading to
ecchymosis (bruising) and swelling. A laceration involves torn tissues with jagged edges,
and an abrasion is a superficial scrape of the skin surface.
Question 4
The nurse is documenting a surgical wound where the respiratory and gastrointestinal tracts were
entered, but no evidence of infection or inflammation was noted during the procedure. How
should this wound be classified regarding contamination?
A) Clean wound
B) Clean-Contaminated wound
C) Contaminated wound
D) Dirty or Infected wound
E) Colonized wound
Correct Answer: B) Clean-Contaminated wound
Rationale: Clean-contaminated wounds are surgical wounds in which the respiratory,
alimentary (GI), genital, or urinary tract has been entered under controlled conditions.
While these areas harbor bacteria, if there is no evidence of active infection or a major
break in sterile technique, they are classified as clean-contaminated. "Clean" wounds are
those in which these tracts are NOT entered.
Question 5
Which type of wound involves tissues being torn apart, often resulting from accidents with
machinery, where the edges of the open wound are jagged and irregular?
A) Incision
B) Laceration wound
C) Penetrating wound
D) Puncture wound
E) Pressure injury
Correct Answer: B) Laceration wound
Rationale: A laceration is characterized by tissues being torn apart. The edges are often
jagged or irregular. This is common in traumatic accidents. An incision, by contrast, is a
clean-cut wound made by a sharp instrument like a scalpel.
Question 6
A nurse is assessing a patient with a "Puncture wound" caused by a nail. What is the primary
concern for this type of wound?
, 3
A) Excessive bleeding on the surface
B) It is a shallow wound that heals too fast
C) It penetrates the skin and underlying tissues, potentially trapping bacteria deep inside
D) It only involves the epidermis
E) It is always an intentional wound
Correct Answer: C) It penetrates the skin and underlying tissues, potentially trapping
bacteria deep inside
Rationale: A puncture wound is an open wound made by a sharp instrument that goes "in
and out." Because the entry site is small and often closes quickly, bacteria (such as Tetanus)
can be trapped in the deeper tissues where there is less oxygen, providing a breeding
ground for infection.
Question 7
The nurse is applying an abdominal binder to a patient after major surgery. What is the correct
technique for application?
A) Start at the typhoid and fasten from the top down
B) Start at the typhoid and fasten from the bottom up
C) Fasten only the middle straps to allow for breathing
D) Keep it on for 24 hours without removal
E) Apply as tightly as possible to restrict all movement
Correct Answer: B) start at typhoid, fasten from the bottom up
Rationale: Abdominal binders should be applied starting at the xiphoid process (typhoid)
and fastened from the bottom up to provide uniform support to the surgical site. Binders
must be removed every two hours to assess the underlying skin for breakdown and to check
the status of the wound and dressing.
Question 8
Which of the following is considered a major risk factor for the development of pressure ulcers?
A) High-protein diet
B) Increased mental status
C) Friction and shearing
D) Frequent ambulation
E) Balanced vitamin C and zinc intake
Correct Answer: C) Friction and shearing
Rationale: Friction (skin rubbing against a surface) and shearing (skin remaining stationary
while the bone and muscle move) are primary mechanical causes of pressure ulcers. Other
risk factors include immobility, fecal/urinary incontinence (moisture), inadequate nutrition
(lack of protein/Vitamin C), and diminished sensation.
, 4
Question 9
During a skin assessment, the nurse finds an area of redness over the sacrum that does not turn
white when pressed (non-blanchable). The skin is intact. What is the correct staging for this
pressure ulcer?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
E) Unstageable
Correct Answer: A) Stage I
Rationale: A Stage I pressure ulcer is characterized by intact skin with non-blanchable
redness, usually over a bony prominence. "Non-blanchable" means the area stays red even
when pressure is applied, indicating that tissue damage has started. There is no break in
the skin at this stage.
Question 10
A nurse identifies a pressure ulcer that looks like a shallow crater or a blister with partial
thickness skin loss involving the epidermis and dermis. The patient reports pain at the site. This
is a:
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
E) Deep tissue injury
Correct Answer: B) Stage II
Rationale: Stage II pressure ulcers involve partial thickness loss of the dermis. They present
as a shallow open ulcer with a red-pink wound bed, or as an intact or ruptured serum-filled
blister. This stage is typically painful because nerve endings are exposed.
Question 11
What stage of pressure ulcer is characterized by full thickness skin loss, involving damage or
necrosis of the subcutaneous tissue, but does not yet extend through the underlying fascia?
A) Stage I
B) Stage II
/C) Stage III
D) Stage IV
E) Suspected deep tissue injury
Correct Answer: C) Stage III
Rationale: Stage III involves full thickness tissue loss. Subcutaneous fat may be visible, but
