NU 155 Exam 3 Mastery: 150 Medical-
Surgical Nursing Questions &
Rationales (2026)
Q1. The nurse is monitoring a client's surgical incision and notes an
increase in drainage, separation of the incision line, and appearance of
underlying tissue. Which action should the nurse take?
A) Cover the wound loosely with 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 with hydrogen peroxide and apply antibiotic ointment
Answer: B) Apply a sterile, normal-saline soaked dressing to the
wound
Rationale: This presentation indicates wound dehiscence. Covering with a
sterile saline-soaked dressing keeps tissues moist and prevents
contamination while minimizing trauma. Dry dressings cause tissue
desiccation, and hydrogen peroxide damages granulation tissue. Massaging
wound edges is contraindicated .
Q2. A patient has been bedridden for 5 days following hip surgery.
Skin assessment reveals an area on the sacrum with non-blanchable
,erythema of intact skin. Which pressure injury stage should the nurse
document?
A) Stage 1 pressure injury
B) Stage 2 pressure injury
C) Suspected deep tissue injury
D) Unstageable pressure injury
Answer: A) Stage 1 pressure injury
Rationale: Stage 1 is characterized by intact skin with non-blanchable
erythema over a bony prominence. The skin may be painful, firm, soft, or
warmer/cooler than adjacent tissue. Early recognition is critical as skin is still
intact and intervention can prevent progression .
Q3. A patient presents with a full-thickness wound on the right heel
with visible subcutaneous fat, but no exposure of muscle, tendon, or
bone. Slough is present but does not obscure wound depth. Which
stage should the nurse assign?
A) Stage 2 pressure injury
B) Stage 3 pressure injury
C) Stage 4 pressure injury
D) Unstageable pressure injury
Answer: B) Stage 3 pressure injury
Rationale: Stage 3 involves full-thickness skin loss with visible
subcutaneous fat, but muscle, tendon, or bone are NOT exposed. Slough
may be present but does not obscure depth. This differentiates it from
Stage 2 (partial-thickness) and Stage 4 (exposed bone/tendon/muscle) .
,Q4. Which wound drainage type would the nurse document when
observing thin, watery, clear or slightly yellow fluid draining from a
surgical incision on postoperative day 2?
A) Sanguineous drainage
B) Serosanguineous drainage
C) Serous drainage
D) Purulent drainage
Answer: C) Serous drainage
Rationale: Serous drainage is thin, watery, clear or slightly yellow plasma
that is normal during inflammatory and proliferative phases of wound
healing. Sanguineous is bright red (fresh bleeding). Serosanguineous is pale
red/pink (mixture). Purulent is thick, opaque, yellow/green (infection) .
Q5. A pressure injury presents as a localized area of purple/maroon
discolored intact skin on the coccyx following a prolonged surgical
procedure. Which documentation is most accurate?
A) Stage 1 pressure injury with deep tissue involvement
B) Suspected deep tissue injury (sDTI)
C) Stage 2 pressure injury with hematoma formation
D) Unstageable pressure injury due to eschar
Answer: B) Suspected deep tissue injury (sDTI)
Rationale: sDTI is characterized by localized persistent non-blanchable
deep red, maroon, or purple discoloration of intact skin or blood-filled
, blister due to damage to underlying soft tissue from pressure/shear. This
differs from Stage 1 (non-blanchable erythema without purple/maroon
color) .
Q6. The nurse is caring for a postoperative client. Which action
minimizes the client's risk of developing deep vein thrombosis (DVT)?
A) Keep the client on strict bed rest
B) Apply cold compresses to lower extremities
C) Assist the client to ambulate frequently as early as tolerated
D) Massage the client's calves
Answer: C) Assist the client to ambulate frequently as early as
tolerated
Rationale: Early ambulation promotes venous return and prevents venous
stasis, reducing DVT risk. Bed rest and massage (which can dislodge clots)
are contraindicated. Cold compresses do not prevent DVT .
Q7. A nurse is caring for a client with an abdominal surgical wound
that is healing by secondary intention. Which intervention is most
appropriate?
A) Keep the wound dry and exposed to air
B) Pack the wound with dry gauze
C) Irrigate the wound with normal saline and pack with moist dressing
D) Apply a heating pad to promote circulation
Surgical Nursing Questions &
Rationales (2026)
Q1. The nurse is monitoring a client's surgical incision and notes an
increase in drainage, separation of the incision line, and appearance of
underlying tissue. Which action should the nurse take?
A) Cover the wound loosely with 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 with hydrogen peroxide and apply antibiotic ointment
Answer: B) Apply a sterile, normal-saline soaked dressing to the
wound
Rationale: This presentation indicates wound dehiscence. Covering with a
sterile saline-soaked dressing keeps tissues moist and prevents
contamination while minimizing trauma. Dry dressings cause tissue
desiccation, and hydrogen peroxide damages granulation tissue. Massaging
wound edges is contraindicated .
Q2. A patient has been bedridden for 5 days following hip surgery.
Skin assessment reveals an area on the sacrum with non-blanchable
,erythema of intact skin. Which pressure injury stage should the nurse
document?
A) Stage 1 pressure injury
B) Stage 2 pressure injury
C) Suspected deep tissue injury
D) Unstageable pressure injury
Answer: A) Stage 1 pressure injury
Rationale: Stage 1 is characterized by intact skin with non-blanchable
erythema over a bony prominence. The skin may be painful, firm, soft, or
warmer/cooler than adjacent tissue. Early recognition is critical as skin is still
intact and intervention can prevent progression .
Q3. A patient presents with a full-thickness wound on the right heel
with visible subcutaneous fat, but no exposure of muscle, tendon, or
bone. Slough is present but does not obscure wound depth. Which
stage should the nurse assign?
A) Stage 2 pressure injury
B) Stage 3 pressure injury
C) Stage 4 pressure injury
D) Unstageable pressure injury
Answer: B) Stage 3 pressure injury
Rationale: Stage 3 involves full-thickness skin loss with visible
subcutaneous fat, but muscle, tendon, or bone are NOT exposed. Slough
may be present but does not obscure depth. This differentiates it from
Stage 2 (partial-thickness) and Stage 4 (exposed bone/tendon/muscle) .
,Q4. Which wound drainage type would the nurse document when
observing thin, watery, clear or slightly yellow fluid draining from a
surgical incision on postoperative day 2?
A) Sanguineous drainage
B) Serosanguineous drainage
C) Serous drainage
D) Purulent drainage
Answer: C) Serous drainage
Rationale: Serous drainage is thin, watery, clear or slightly yellow plasma
that is normal during inflammatory and proliferative phases of wound
healing. Sanguineous is bright red (fresh bleeding). Serosanguineous is pale
red/pink (mixture). Purulent is thick, opaque, yellow/green (infection) .
Q5. A pressure injury presents as a localized area of purple/maroon
discolored intact skin on the coccyx following a prolonged surgical
procedure. Which documentation is most accurate?
A) Stage 1 pressure injury with deep tissue involvement
B) Suspected deep tissue injury (sDTI)
C) Stage 2 pressure injury with hematoma formation
D) Unstageable pressure injury due to eschar
Answer: B) Suspected deep tissue injury (sDTI)
Rationale: sDTI is characterized by localized persistent non-blanchable
deep red, maroon, or purple discoloration of intact skin or blood-filled
, blister due to damage to underlying soft tissue from pressure/shear. This
differs from Stage 1 (non-blanchable erythema without purple/maroon
color) .
Q6. The nurse is caring for a postoperative client. Which action
minimizes the client's risk of developing deep vein thrombosis (DVT)?
A) Keep the client on strict bed rest
B) Apply cold compresses to lower extremities
C) Assist the client to ambulate frequently as early as tolerated
D) Massage the client's calves
Answer: C) Assist the client to ambulate frequently as early as
tolerated
Rationale: Early ambulation promotes venous return and prevents venous
stasis, reducing DVT risk. Bed rest and massage (which can dislodge clots)
are contraindicated. Cold compresses do not prevent DVT .
Q7. A nurse is caring for a client with an abdominal surgical wound
that is healing by secondary intention. Which intervention is most
appropriate?
A) Keep the wound dry and exposed to air
B) Pack the wound with dry gauze
C) Irrigate the wound with normal saline and pack with moist dressing
D) Apply a heating pad to promote circulation
