NU 155 EXAM 3 MEDICAL-SURGICAL NURSING I (PDF) | 2026
QUESTIONS & ANSWERS + RATIONALES | STUDY GUIDE
1. 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
action should the nurse take first?
A) Cover the wound loosely with a sterile dry dressing
B) Apply a sterile, normal-saline soaked dressing to the wound
C) Massage the wound edges gently to promote healing
D) Clean the wound with hydrogen peroxide and apply antibiotic ointment
Correct Answer: Apply a sterile, normal-saline soaked dressing to the wound
Rationale: This presentation is consistent with wound dehiscence, where the surgical wound
separates. The priority is 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 damages new granulation tissue. Massaging wound edges is
contraindicated.
2. The nurse is providing preoperative instructions to a client scheduled for surgery to
correct spinal curvature. Which statement by the client best demonstrates correct
understanding of the teaching?
A) "I will take my blood pressure medication the morning of surgery."
B) "I will show you the method of turning I will use after surgery."
C) "I will eat a light breakfast the day of surgery."
D) "I will remove my hearing aids before going to the operating room."
Correct Answer: "I will show you the method of turning I will use after surgery."
Rationale: Demonstrating the turning method confirms the client understands postoperative
mobility expectations. Blood pressure medication instructions vary, eating before surgery is
contraindicated, and hearing aids should remain in place until the OR to maintain
communication.
3. The nurse is assessing a postoperative client with advanced cognitive impairment. Which
approach is most effective for assessing the client's pain level?
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: Monitor the client's body language, facial expressions, emotional status, and
consolability
,Rationale: Clients with advanced cognitive impairment may have limited ability to self-report
pain. Observational pain assessment tools using behavioral and emotional cues are the most
reliable strategies to identify pain in this population . Vital signs alone are insufficient.
4. The nurse is caring for a client with diabetes mellitus who reports sharp, burning pain in
bilateral lower extremities. Which type of pain is the client most likely experiencing?
A) Nociceptive pain
B) Referred pain
C) Neuropathic pain
D) Phantom limb pain
Correct Answer: Neuropathic pain
Rationale: Neuropathic pain results from nerve damage often associated with diabetes mellitus. It
is characterized by sharp, burning sensations typically in a "stocking-glove" distribution in the
lower extremities . Nociceptive pain arises from tissue injury, not nerve damage.
5. The nurse is caring for a client scheduled for surgery the following day. Which finding
requires notification of the primary healthcare provider?
A) History of smoking
B) Family history of high fever during a surgical procedure
C) Allergy to latex
D) Recent upper respiratory infection
Correct Answer: Reports a family history of high fever during a surgical procedure
Rationale: A family history of malignant hyperthermia—a life-threatening hypermetabolic
reaction to certain anesthetics—requires urgent notification to ensure anesthesia precautions are
in place . Smoking, latex allergy, and respiratory infections are important but do not carry the
same immediate surgical risk.
6. The nurse is caring for a postoperative client. Which action minimizes the client's risk of
developing deep vein thrombosis (DVT)?
A) Limit client movement to prevent wound disruption
B) Assist the client to ambulate frequently as early as tolerated
C) Apply warm compresses to the lower extremities regularly
D) Maintain strict bed rest
Correct Answer: Assist the client to ambulate frequently as early as tolerated
Rationale: Early ambulation stimulates venous return and reduces venous stasis, which is critical
in preventing DVT formation postoperatively . Bed rest increases DVT risk. Warm compresses
may be used for comfort but are not the primary preventive measure.
7. The nurse is caring for a group of assigned clients. Which client requires immediate
follow-up?
A) Client with a healing surgical wound reporting mild pain
B) Client who had a cardiac catheterization via the right femoral artery 1 hour ago
, 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: The client who had a cardiac catheterization via the right femoral artery 1 hour
ago who is reporting numbness in the right leg
Rationale: Numbness could indicate compromised circulation or nerve injury following femoral
artery catheterization, requiring immediate assessment to prevent serious complications such as
limb ischemia . Mild pain and fatigue are expected; stable post-transfusion vitals are reassuring.
8. The nurse has reinforced teaching with a client about risk factors for deep vein
thrombosis (DVT). Which risk factor 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: Intake of foods high in calcium
Rationale: High calcium intake is not a recognized risk factor for DVT. Common risk factors
include oral contraceptives, immobility, and smoking . This misconception must be corrected to
promote accurate client understanding.
9. A patient with left-sided heart failure has developed a cough, crackles, and weak
peripheral pulses. Which additional finding should the nurse expect?
A) Jugular venous distension
B) Peripheral edema
C) Orthopnea
D) Hepatomegaly
Correct Answer: Orthopnea
Rationale: Left-sided heart failure causes pulmonary congestion, leading to orthopnea (difficulty
breathing when lying flat). Jugular venous distension, peripheral edema, and hepatomegaly are
signs of right-sided heart failure.
10. The nurse has reinforced dietary teaching with a client who has hypercholesterolemia.
Which statement by the client indicates correct understanding?
A) "I will increase my intake of red meat for protein."
B) "I will choose low-fat dairy products and lean meats."
C) "I will add butter to my vegetables for flavor."
D) "I will eat eggs every day for breakfast."
Correct Answer: "I will choose low-fat dairy products and lean meats."
QUESTIONS & ANSWERS + RATIONALES | STUDY GUIDE
1. 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
action should the nurse take first?
A) Cover the wound loosely with a sterile dry dressing
B) Apply a sterile, normal-saline soaked dressing to the wound
C) Massage the wound edges gently to promote healing
D) Clean the wound with hydrogen peroxide and apply antibiotic ointment
Correct Answer: Apply a sterile, normal-saline soaked dressing to the wound
Rationale: This presentation is consistent with wound dehiscence, where the surgical wound
separates. The priority is 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 damages new granulation tissue. Massaging wound edges is
contraindicated.
2. The nurse is providing preoperative instructions to a client scheduled for surgery to
correct spinal curvature. Which statement by the client best demonstrates correct
understanding of the teaching?
A) "I will take my blood pressure medication the morning of surgery."
B) "I will show you the method of turning I will use after surgery."
C) "I will eat a light breakfast the day of surgery."
D) "I will remove my hearing aids before going to the operating room."
Correct Answer: "I will show you the method of turning I will use after surgery."
Rationale: Demonstrating the turning method confirms the client understands postoperative
mobility expectations. Blood pressure medication instructions vary, eating before surgery is
contraindicated, and hearing aids should remain in place until the OR to maintain
communication.
3. The nurse is assessing a postoperative client with advanced cognitive impairment. Which
approach is most effective for assessing the client's pain level?
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: Monitor the client's body language, facial expressions, emotional status, and
consolability
,Rationale: Clients with advanced cognitive impairment may have limited ability to self-report
pain. Observational pain assessment tools using behavioral and emotional cues are the most
reliable strategies to identify pain in this population . Vital signs alone are insufficient.
4. The nurse is caring for a client with diabetes mellitus who reports sharp, burning pain in
bilateral lower extremities. Which type of pain is the client most likely experiencing?
A) Nociceptive pain
B) Referred pain
C) Neuropathic pain
D) Phantom limb pain
Correct Answer: Neuropathic pain
Rationale: Neuropathic pain results from nerve damage often associated with diabetes mellitus. It
is characterized by sharp, burning sensations typically in a "stocking-glove" distribution in the
lower extremities . Nociceptive pain arises from tissue injury, not nerve damage.
5. The nurse is caring for a client scheduled for surgery the following day. Which finding
requires notification of the primary healthcare provider?
A) History of smoking
B) Family history of high fever during a surgical procedure
C) Allergy to latex
D) Recent upper respiratory infection
Correct Answer: Reports a family history of high fever during a surgical procedure
Rationale: A family history of malignant hyperthermia—a life-threatening hypermetabolic
reaction to certain anesthetics—requires urgent notification to ensure anesthesia precautions are
in place . Smoking, latex allergy, and respiratory infections are important but do not carry the
same immediate surgical risk.
6. The nurse is caring for a postoperative client. Which action minimizes the client's risk of
developing deep vein thrombosis (DVT)?
A) Limit client movement to prevent wound disruption
B) Assist the client to ambulate frequently as early as tolerated
C) Apply warm compresses to the lower extremities regularly
D) Maintain strict bed rest
Correct Answer: Assist the client to ambulate frequently as early as tolerated
Rationale: Early ambulation stimulates venous return and reduces venous stasis, which is critical
in preventing DVT formation postoperatively . Bed rest increases DVT risk. Warm compresses
may be used for comfort but are not the primary preventive measure.
7. The nurse is caring for a group of assigned clients. Which client requires immediate
follow-up?
A) Client with a healing surgical wound reporting mild pain
B) Client who had a cardiac catheterization via the right femoral artery 1 hour ago
, 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: The client who had a cardiac catheterization via the right femoral artery 1 hour
ago who is reporting numbness in the right leg
Rationale: Numbness could indicate compromised circulation or nerve injury following femoral
artery catheterization, requiring immediate assessment to prevent serious complications such as
limb ischemia . Mild pain and fatigue are expected; stable post-transfusion vitals are reassuring.
8. The nurse has reinforced teaching with a client about risk factors for deep vein
thrombosis (DVT). Which risk factor 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: Intake of foods high in calcium
Rationale: High calcium intake is not a recognized risk factor for DVT. Common risk factors
include oral contraceptives, immobility, and smoking . This misconception must be corrected to
promote accurate client understanding.
9. A patient with left-sided heart failure has developed a cough, crackles, and weak
peripheral pulses. Which additional finding should the nurse expect?
A) Jugular venous distension
B) Peripheral edema
C) Orthopnea
D) Hepatomegaly
Correct Answer: Orthopnea
Rationale: Left-sided heart failure causes pulmonary congestion, leading to orthopnea (difficulty
breathing when lying flat). Jugular venous distension, peripheral edema, and hepatomegaly are
signs of right-sided heart failure.
10. The nurse has reinforced dietary teaching with a client who has hypercholesterolemia.
Which statement by the client indicates correct understanding?
A) "I will increase my intake of red meat for protein."
B) "I will choose low-fat dairy products and lean meats."
C) "I will add butter to my vegetables for flavor."
D) "I will eat eggs every day for breakfast."
Correct Answer: "I will choose low-fat dairy products and lean meats."
