NU 155 EXAM 3: MEDICAL-SURGICAL NURSING I 2026 |
Galen College of Nursing | Comprehensive Assessment |
Detailed Rationales | Pass Guaranteed - A+ Graded
Section 1: Wound Care & Pressure Injuries (22 Questions)
Q1: A nurse is assessing a patient's pressure injury on the sacrum. The wound has
full-thickness skin loss with visible subcutaneous fat and some slough in the wound
bed. There is no exposure of muscle, tendon, or bone. How should the nurse stage this
pressure injury?
A. Stage 2
B. Stage 3 [CORRECT]
C. Stage 4
D. Unstageable
Rationale: This describes a Stage 3 pressure injury, which involves full-thickness skin
loss extending through subcutaneous tissue. Subcutaneous fat may be visible, and
slough may be present, but muscle, tendon, and bone are not exposed. [CORRECT]
Option A (Stage 2) involves partial-thickness skin loss with exposed dermis only. Option
C (Stage 4) requires exposure of fascia, muscle, tendon, ligament, cartilage, or bone.
Option D (Unstageable) applies when the wound base is completely obscured by slough
or eschar, preventing accurate staging—here, the depth is visible enough to determine
stage.
,Q2: A patient presents with intact skin over the ischial tuberosity that has persistent
non-blanchable deep red discoloration with a purple maroon hue. The area feels warmer
and firmer than surrounding tissue. Which stage is this?
A. Stage 1
B. Stage 2
C. Deep tissue injury [CORRECT]
D. Stage 3
Rationale: This is deep tissue injury (DTI), characterized by intact skin with persistent
non-blanchable deep red, maroon, or purple discoloration, or a blood-filled blister.
[CORRECT] The skin remains intact but damage extends to underlying soft tissue. The
discoloration, temperature change, and firmness indicate tissue damage beneath intact
skin. Option A (Stage 1) shows non-blanchable erythema without the deep
purple/maroon discoloration of DTI. Options B and D involve broken skin, which is not
present here. DTIs may evolve rapidly to reveal actual depth of tissue damage.
Q3: A nurse is caring for a patient 3 days post-abdominal hysterectomy. The incision
edges are approximated, with redness extending 2 cm from the incision line, mild
warmth, and serosanguineous drainage. The patient reports pain rated 4/10. Which
interpretation is most accurate?
A. This indicates normal inflammatory phase of wound healing [CORRECT]
B. This indicates surgical site infection requiring antibiotics
,C. This indicates wound dehiscence
D. This indicates the proliferative phase has begun
Rationale: These findings describe the normal inflammatory phase of wound healing
(days 1-6). [CORRECT] Redness, warmth, and serosanguineous drainage are expected
during this phase as blood vessels dilate and phagocytic activity occurs. The
inflammatory response peaks at 48-72 hours. Peri-incisional erythema <2.5 cm without
purulent drainage or systemic signs is typically normal inflammation. Option B is
incorrect because infection would present with purulent drainage, increasing pain after
day 3, systemic symptoms (fever, tachycardia), or erythema >2.5 cm. Option C is
incorrect as dehiscence involves wound separation. Option D is incorrect as
proliferation begins around day 3-5 with granulation tissue formation, not these
inflammatory signs.
Q4: A wound care nurse is selecting a dressing for a Stage 2 pressure injury with light
exudate on the patient's heel. The wound bed is pink/red without slough. Which
dressing is most appropriate?
A. Alginate dressing
B. Hydrocolloid dressing [CORRECT]
C. Hydrogel
D. Wet-to-dry gauze
Rationale: Hydrocolloid dressings (e.g., DuoDERM) are appropriate for Stage 2 pressure
injuries with light-to-moderate exudate. [CORRECT] They maintain a moist wound
, environment, are waterproof, and promote autolytic debridement while protecting the
wound. Option A (Alginate) is for moderate-to-heavy exudate and Stage 3-4 wounds.
Option C (Hydrogel) is for dry wounds requiring moisture donation. Option D
(Wet-to-dry) is non-selective mechanical debridement that damages new granulation
tissue and is not recommended for clean, granulating Stage 2 wounds per current
evidence-based practice.
Q5: A patient has a full-thickness wound on the coccyx with extensive undermining and
80% of the wound bed covered with black, hard, leathery tissue. The periwound skin is
macerated. Using the RYB classification system, how should this wound be classified
and managed?
A. Red wound—protect and maintain moist environment
B. Yellow wound—cleanse and remove slough
C. Black wound—debride and remove eschar [CORRECT]
D. Mixed wound—treat as yellow priority
Rationale: This is a Black wound (B) requiring debridement to remove the black eschar.
[CORRECT] The black, hard, leathery tissue is necrotic eschar that must be removed
before healing can occur. Methods include surgical/sharp debridement (fastest),
mechanical, enzymatic, or autolytic debridement. The undermining and macerated
periwound skin also require attention. Option A is for red wounds with granulation
tissue. Option B is for yellow slough-covered wounds. While this wound may have
multiple colors, the black necrotic tissue takes priority for removal to prevent infection
and allow healing progression.
Galen College of Nursing | Comprehensive Assessment |
Detailed Rationales | Pass Guaranteed - A+ Graded
Section 1: Wound Care & Pressure Injuries (22 Questions)
Q1: A nurse is assessing a patient's pressure injury on the sacrum. The wound has
full-thickness skin loss with visible subcutaneous fat and some slough in the wound
bed. There is no exposure of muscle, tendon, or bone. How should the nurse stage this
pressure injury?
A. Stage 2
B. Stage 3 [CORRECT]
C. Stage 4
D. Unstageable
Rationale: This describes a Stage 3 pressure injury, which involves full-thickness skin
loss extending through subcutaneous tissue. Subcutaneous fat may be visible, and
slough may be present, but muscle, tendon, and bone are not exposed. [CORRECT]
Option A (Stage 2) involves partial-thickness skin loss with exposed dermis only. Option
C (Stage 4) requires exposure of fascia, muscle, tendon, ligament, cartilage, or bone.
Option D (Unstageable) applies when the wound base is completely obscured by slough
or eschar, preventing accurate staging—here, the depth is visible enough to determine
stage.
,Q2: A patient presents with intact skin over the ischial tuberosity that has persistent
non-blanchable deep red discoloration with a purple maroon hue. The area feels warmer
and firmer than surrounding tissue. Which stage is this?
A. Stage 1
B. Stage 2
C. Deep tissue injury [CORRECT]
D. Stage 3
Rationale: This is deep tissue injury (DTI), characterized by intact skin with persistent
non-blanchable deep red, maroon, or purple discoloration, or a blood-filled blister.
[CORRECT] The skin remains intact but damage extends to underlying soft tissue. The
discoloration, temperature change, and firmness indicate tissue damage beneath intact
skin. Option A (Stage 1) shows non-blanchable erythema without the deep
purple/maroon discoloration of DTI. Options B and D involve broken skin, which is not
present here. DTIs may evolve rapidly to reveal actual depth of tissue damage.
Q3: A nurse is caring for a patient 3 days post-abdominal hysterectomy. The incision
edges are approximated, with redness extending 2 cm from the incision line, mild
warmth, and serosanguineous drainage. The patient reports pain rated 4/10. Which
interpretation is most accurate?
A. This indicates normal inflammatory phase of wound healing [CORRECT]
B. This indicates surgical site infection requiring antibiotics
,C. This indicates wound dehiscence
D. This indicates the proliferative phase has begun
Rationale: These findings describe the normal inflammatory phase of wound healing
(days 1-6). [CORRECT] Redness, warmth, and serosanguineous drainage are expected
during this phase as blood vessels dilate and phagocytic activity occurs. The
inflammatory response peaks at 48-72 hours. Peri-incisional erythema <2.5 cm without
purulent drainage or systemic signs is typically normal inflammation. Option B is
incorrect because infection would present with purulent drainage, increasing pain after
day 3, systemic symptoms (fever, tachycardia), or erythema >2.5 cm. Option C is
incorrect as dehiscence involves wound separation. Option D is incorrect as
proliferation begins around day 3-5 with granulation tissue formation, not these
inflammatory signs.
Q4: A wound care nurse is selecting a dressing for a Stage 2 pressure injury with light
exudate on the patient's heel. The wound bed is pink/red without slough. Which
dressing is most appropriate?
A. Alginate dressing
B. Hydrocolloid dressing [CORRECT]
C. Hydrogel
D. Wet-to-dry gauze
Rationale: Hydrocolloid dressings (e.g., DuoDERM) are appropriate for Stage 2 pressure
injuries with light-to-moderate exudate. [CORRECT] They maintain a moist wound
, environment, are waterproof, and promote autolytic debridement while protecting the
wound. Option A (Alginate) is for moderate-to-heavy exudate and Stage 3-4 wounds.
Option C (Hydrogel) is for dry wounds requiring moisture donation. Option D
(Wet-to-dry) is non-selective mechanical debridement that damages new granulation
tissue and is not recommended for clean, granulating Stage 2 wounds per current
evidence-based practice.
Q5: A patient has a full-thickness wound on the coccyx with extensive undermining and
80% of the wound bed covered with black, hard, leathery tissue. The periwound skin is
macerated. Using the RYB classification system, how should this wound be classified
and managed?
A. Red wound—protect and maintain moist environment
B. Yellow wound—cleanse and remove slough
C. Black wound—debride and remove eschar [CORRECT]
D. Mixed wound—treat as yellow priority
Rationale: This is a Black wound (B) requiring debridement to remove the black eschar.
[CORRECT] The black, hard, leathery tissue is necrotic eschar that must be removed
before healing can occur. Methods include surgical/sharp debridement (fastest),
mechanical, enzymatic, or autolytic debridement. The undermining and macerated
periwound skin also require attention. Option A is for red wounds with granulation
tissue. Option B is for yellow slough-covered wounds. While this wound may have
multiple colors, the black necrotic tissue takes priority for removal to prevent infection
and allow healing progression.
