NU 155 Exam 3 Medical-Surgical Nursing I (2026) PDF | Galen College of Nursing

NU 155 Exam 3 Medical-Surgical Nursing I (2026) PDF | Galen College of Nursing Table of Contents Section 1: Wound Healing Fundamentals (Questions 1-50) This section covers the phases of wound healing, types of healing (primary, secondary, tertiary intention), and the physiological processes involved. Section 2: Pressure Ulcers and Risk Factors (Questions 51-100) This section focuses on the etiology, staging, risk assessment (e.g., Braden Scale), and prevention strategies for pressure injuries. Section 3: Wound Assessment and Documentation (Questions 101-150) This section covers the clinical assessment of wounds, including appearance, drainage (exudate), odor, and surrounding skin, as well as proper documentation techniques. Section 4: Wound Care Interventions and Dressings (Questions 151-220) This section details various types of wound dressings (e.g., alginate, hydrocolloid, film, gauze), their indications, and the principles of hot and cold therapy. Section 5: Surgical Wounds and Complications (Questions 221-270) This section addresses the management of surgical incisions, potential complications like infection, dehiscence, and evisceration, and client education for post-operative care. Section 6: Special Populations and Client Education (Questions 271-300) This section covers considerations for diverse client populations (e.g., elderly, diabetic) and the principles of teaching clients and families about wound care at home. Section 1: Wound Healing Fundamentals (Questions 1-50) 1. A nurse is caring for a client who sustained a full-thickness burn. The wound is being allowed to heal from the base upward. The nurse correctly identifies this process as which type of healing? A. Primary intention B. Secondary intention C. Tertiary intention D. Delayed primary closure Answer: B Rationale: Secondary intention occurs when a wound is left open and heals by granulation tissue forming from the base up, common in burns and pressure ulcers. 2. A client has a surgically closed incision that is healing without complications. The nurse understands that this wound will heal primarily by which process? A. Granulation and contraction B. Scar formation and epithelialization C. Approximation of wound edges D. Infection and drainage Answer: C Rationale: Primary intention healing involves the direct approximation of wound edges with a minimal tissue defect, such as in a closed surgical incision. 3. Which phase of wound healing is characterized by the migration of fibroblasts and the synthesis of collagen? A. Hemostasis B. Inflammatory phase C. Proliferative phase D. Maturation phase Answer: C Rationale: The proliferative phase is marked by the building of new tissue, including collagen deposition by fibroblasts and the formation of new blood vessels (angiogenesis). 4. A nurse is assessing a client’s wound and notes the presence of a large amount of serosanguineous drainage. This finding is most consistent with which type of wound? A. A chronic wound with infection B. A healthy wound in the inflammatory phase C. A wound exhibiting purulent drainage D. A wound that has developed a hematoma Answer: B Rationale: Serosanguineous drainage, which is a mixture of clear and bloody fluid, is a common and normal finding in a healing wound, particularly during the early inflammatory phase. 5. The nurse is providing education to a client about factors that can delay wound healing. Which of the following statements by the client indicates a need for further teaching? A. “I should try to eat more foods rich in protein.” B. “My diabetes might make my wound heal slower.” C. “I can take an over-the-counter vitamin E supplement to speed up my recovery.” D. “It’s important for me to quit smoking before my surgery.” Answer: C Rationale: While vitamin supplements can be beneficial, taking large, unregulated doses of vitamin E can interfere with wound healing and should only be taken under a provider’s direction. 6. Which vitamin is essential for collagen synthesis and wound healing, and its deficiency can lead to impaired healing? A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin D Answer: C Rationale: Vitamin C is a crucial cofactor for hydroxylation of proline and lysine in collagen synthesis, and its deficiency leads to weak collagen and poor wound healing. 7. During the inflammatory phase of wound healing, histamine and prostaglandins are released. What is the primary effect of these chemicals? A. Vasoconstriction to reduce blood loss B. Vasodilation to increase blood flow to the area C. Fibroblast proliferation to lay down new tissue D. Contraction of the wound margins Answer: B Rationale: Histamine and prostaglandins cause vasodilation and increased capillary permeability, bringing inflammatory cells to the wound site to begin the healing process. 8. A nurse is assessing a client’s wound that is healing by tertiary intention. The nurse understands that this type of healing involves: A. Wound edges that are approximated and sutured B. Delayed closure after a period of open wound management C. Wound closure through the formation of granulation tissue only D. The use of skin grafts to close a large defect Answer: B Rationale: Tertiary intention, or delayed primary closure, involves leaving a wound open for a period to allow for drainage or infection control before it is surgically closed. 9. A client is 2 days post-operative from an abdominal surgery. The nurse notes that the wound edges are well-approximated and there is no redness or drainage. The nurse assesses that the wound is in which phase of healing? A. Hemostasis B. Inflammatory C. Proliferative D. Maturation Answer: B Rationale: The inflammatory phase begins immediately after injury and lasts for about 3-5 days, characterized by the body’s initial response to injury, including redness, warmth, and edema. 10. A nurse is reviewing the lab results for a client with a non-healing pressure ulcer. Which lab value is most critical to monitor as a direct indicator of nutritional status and wound healing potential? A. Serum albumin B. White blood cell count C. Serum creatinine D. Hemoglobin Answer: A Rationale: Serum albumin is a key protein marker for nutritional status; low levels indicate protein deficiency, which is a significant risk factor for impaired wound healing. 11. Which cell type is predominantly responsible for the phagocytosis of bacteria and debris during the inflammatory phase of wound healing? A. Fibroblasts B. Neutrophils C. Erythrocytes D. Platelets Answer: B Rationale: Neutrophils are the first white blood cells to arrive at the wound site, and their primary function is to ingest and destroy bacteria and cellular debris (phagocytosis). 12. The nurse is educating a client about the importance of protein in wound healing. Which food would the nurse recommend as the best source of complete protein? A. White rice B. Broccoli C. Chicken breast D. Apple Answer: C Rationale: Chicken breast is a source of complete protein, providing all essential amino acids necessary for tissue repair, unlike the other options which are primarily carbohydrates or have incomplete proteins. 13. A client’s wound has been healing for several weeks, and the nurse observes a firm, pink, raised scar at the site. This finding is characteristic of which phase of wound healing? A. Hemostasis B. Inflammatory C. Proliferative D. Maturation Answer: D Rationale: During the maturation or remodeling phase, collagen fibers are reorganized and remodeled, resulting in a stronger, paler, and flatter scar, though some may remain raised or firm. 14. Which of the following is a systemic factor that can negatively impact wound healing? A. Smoking B. Wound infection C. Poor wound care technique D. Foreign bodies in the wound Answer: A Rationale: Smoking is a systemic factor that causes vasoconstriction and reduces oxygen delivery to tissues, impairing the entire wound healing process. 15. The nurse is caring for a client with a large wound that is healing by secondary intention. The nurse expects to observe which of the following during the healing process? A. Rapid wound closure B. Minimal to no scar formation C. Extensive granulation tissue formation D. Wound edges that are surgically sutured together Answer: C Rationale: Healing by secondary intention involves a large tissue loss that fills in with granulation tissue from the bottom up and contracts to close the wound. 16. What is the primary purpose of applying a sterile dressing to a newly closed surgical wound? A. To prevent infection B. To provide pain relief C. To absorb wound drainage D. To facilitate easier wound assessment Answer: A Rationale: While dressings have multiple purposes, the primary purpose for a closed, clean wound is to provide a barrier against external contaminants, thereby preventing infection. 17. A nurse is changing the dressing on a client’s surgical wound and notes that the wound edges are pulling apart slightly. The nurse should document this finding as: A. Evisceration B. Infection C. Dehiscence D. Hematoma Answer: C Rationale: Dehiscence is the partial or complete separation of wound edges, often occurring after a sudden strain on the wound. 18. Which mineral is a crucial cofactor for collagen synthesis and a deficiency can lead to delayed wound healing? A. Iron B. Zinc C. Magnesium D. Calcium Answer: B Rationale: Zinc is a vital trace element that acts as a cofactor for several enzymes, including those required for protein and collagen synthesis, making it essential for wound repair. 19. A nurse is teaching a client about the signs and symptoms of a wound infection. Which of the following should the nurse include in the teaching? A. Pallor and coldness of the skin B. A decrease in wound size C. An increase in serous drainage D. Purulent drainage and a foul odor Answer: D Rationale: Signs of a wound infection include purulent (pus-like) drainage that may be odorous, along with redness, heat, pain, and swelling. 20. The nurse is planning care for a client with a wound that is being treated with a wound vacuum-assisted closure (VAC) device. The nurse understands that the primary mechanism of action for this therapy is to: A. Increase temperature to promote vasodilation B. Provide a moist environment for healing C. Deliver antibiotics directly to the wound D. Remove excess fluid and reduce edema Answer: D Rationale: Wound VAC therapy uses negative pressure to remove exudate, reduce edema, and increase blood flow, promoting granulation tissue formation. 21. A patient asks the nurse why their wound feels warm to the touch. The nurse’s best response is based on the understanding that this is due to: A. An infection that is developing. B. Increased blood flow to the area from vasodilation. C. The evaporation of moisture from the wound. D. A decrease in local tissue metabolism. Answer: B Rationale: Warmth around a wound is a hallmark of the inflammatory phase, resulting from vasodilation and increased blood flow to the area. 22. Which of the following statements is true regarding the use of antibacterial ointments on a wound? A. They are always necessary for primary closure. B. They can be used on any open wound without risk. C. They are primarily used to prevent infection. D. They are used to promote moisture but not as an antibacterial. Answer: C Rationale: Antibacterial ointments like bacitracin or Neosporin are used to prevent infection in minor wounds, but not all wounds require them, and they can sometimes cause irritation. 23. What is the primary difference between serous and serosanguineous drainage? A. Serous drainage is thicker and purulent, while serosanguineous is thin and watery. B. Serous drainage is clear and watery, while serosanguineous is thin and pink-tinged.