NU 155 EXAM 3: MEDICAL-SURGICAL NURSING I (2026) Galen College of Nursing |
Comprehensive Practice Examination
SECTION A: WOUND CARE AND TISSUE INTEGRITY
1. When changing the dressing on a client's partial-thickness wound, the nurse
observes a beefy-red translucent wound bed. Which action should the nurse take?
• A. Contact the primary healthcare provider immediately.
• B. Document the findings as abnormal and continue to observe.
• C. Culture the wound and place the client in isolation.
• D. Discard the old dressing and cover the wound with a new dressing.
Answer: D - A beefy-red translucent wound bed indicates healthy granulation tissue, which
is expected in a healing partial-thickness wound. The nurse should gently discard the old
dressing and apply a new dressing using sterile technique to promote healing. Immediate
contact with the provider or cultures is not indicated unless signs of infection are present.
2. 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 is most appropriate?
• A. Apply a sterile, normal-saline soaked dressing to the wound.
• B. Place a dry sterile dressing over the wound and apply pressure.
• C. Notify the surgeon immediately and prepare for wound closure.
• D. Apply an antibiotic ointment and cover with a transparent dressing.
Answer: A - These findings indicate wound dehiscence. The nurse should immediately
apply a sterile, normal-saline soaked dressing to keep the wound moist and protected
while notifying the healthcare provider. Applying pressure could further damage the tissue.
3. A client with a pressure injury on the sacrum has a wound that is covered with
yellow, stringy tissue that adheres to the wound bed. The nurse correctly identifies
this tissue as:
, • A. Granulation tissue
• B. Slough
• C. Eschar
• D. Epithelial tissue
Answer: B - Slough is yellow, stringy, or mucinous tissue that adheres to the wound bed
and must be removed for healing to occur. Granulation tissue is red and beefy; eschar is
black or brown and dry; epithelial tissue is pink.
4. Which of the following is the most important intervention for preventing pressure
injuries in an immobilized client?
• A. Massaging bony prominences daily
• B. Repositioning the client every 2 hours
• C. Using a foam mattress overlay
• D. Providing a high-protein diet
Answer: B - Repositioning every 2 hours is the most important intervention to relieve
pressure and prevent tissue ischemia. Massaging bony prominences is contraindicated as
it can damage capillary beds. While other interventions are helpful, repositioning is the
primary preventive measure.
5. The nurse is assessing a client's wound and notes dark, dry, leathery tissue covering
the wound surface. This tissue is classified as:
• A. Slough
• B. Granulation tissue
• C. Eschar
• D. Necrotic tissue with infection
Answer: C - Eschar is dark, dry, leathery necrotic tissue that often requires debridement
before healing can occur. Slough is yellow and stringy; granulation tissue is red and
vascular.
6. A client has a Stage 3 pressure injury. Which description best characterizes this
wound?
• A. Non-blanchable erythema of intact skin
, • B. Partial-thickness skin loss with exposed dermis
• C. Full-thickness skin loss with visible subcutaneous fat
• D. Full-thickness tissue loss with exposed bone or muscle
Answer: C - Stage 3 pressure injury involves full-thickness skin loss with visible
subcutaneous fat but no exposed bone, tendon, or muscle. Stage 1 is non-blanchable
erythema; Stage 2 is partial-thickness; Stage 4 involves exposed bone or muscle.
7. The nurse is irrigating a deep wound. Which technique is correct?
• A. Use a 30-mL syringe with a 19-gauge needle directed at the wound edges
• B. Use a 60-mL syringe with a 19-gauge needle directed at the wound bed
• C. Use a 10-mL syringe with a 22-gauge needle directed into the wound
• D. Use a bulb syringe to gently flush the wound from the center outward
Answer: B - A 60-mL syringe with a 19-gauge needle provides the appropriate pressure (8-
15 psi) for effective wound irrigation without damaging tissue. The stream should be
directed at the wound bed.
8. The nurse is assessing a surgical wound on postoperative day 3. Which finding
would indicate a wound infection?
• A. Serosanguineous drainage
• B. Wound edges that are well-approximated
• C. Purulent drainage with foul odor
• D. Mild erythema at the incision site
Answer: C - Purulent drainage with a foul odor is a classic sign of wound infection.
Serosanguineous drainage and mild erythema are expected findings in the early
postoperative period.
9. A client with a chronic wound asks the nurse why the wound is not healing. Which of
the following is a systemic factor that impairs wound healing?
• A. Wound infection
• B. Diabetes mellitus
• C. Poor wound care technique
, • D. Pressure on the wound
Answer: B - Diabetes mellitus is a systemic factor that impairs wound healing due to poor
perfusion, neuropathy, and impaired immune function. The other options are local factors
affecting wound healing.
10. The nurse is preparing to remove a client's sutures. Which action is correct?
• A. Remove every other suture first to assess wound integrity
• B. Cut the suture at the knot and pull the suture through the tissue
• C. Remove all sutures at once to minimize discomfort
• D. Apply sterile saline to the sutures to loosen them before removal
Answer: A - Removing every other suture first allows the nurse to assess wound integrity
before removing the remaining sutures. This prevents wound dehiscence if the wound is
not healing properly.
SECTION B: PREOPERATIVE AND POSTOPERATIVE CARE
11. The nurse is providing preoperative instructions to a client scheduled for surgery to
correct spinal curvature. Which statement by the client demonstrates correct
understanding of the teaching?
• A. "I will not need to turn or move after surgery."
• B. "I will show you the method of turning I will use after surgery."
• C. "I will remain flat in bed for 24 hours after surgery."
• D. "I will ask for pain medication only when the pain is severe."
Answer: B - Demonstrating the turning method shows the client understands how to move
safely after spinal surgery to maintain alignment and prevent complications. Early mobility
is encouraged, and pain should be managed before it becomes severe.
12. The nurse is caring for a client who is scheduled for surgery the following day. It
requires notification to the primary healthcare provider if the client:
• A. Reports a family history of high fever during a surgical procedure.
• B. Reports having had a glass of wine the previous evening.
• C. Requests to speak with the anesthesiologist.
Comprehensive Practice Examination
SECTION A: WOUND CARE AND TISSUE INTEGRITY
1. When changing the dressing on a client's partial-thickness wound, the nurse
observes a beefy-red translucent wound bed. Which action should the nurse take?
• A. Contact the primary healthcare provider immediately.
• B. Document the findings as abnormal and continue to observe.
• C. Culture the wound and place the client in isolation.
• D. Discard the old dressing and cover the wound with a new dressing.
Answer: D - A beefy-red translucent wound bed indicates healthy granulation tissue, which
is expected in a healing partial-thickness wound. The nurse should gently discard the old
dressing and apply a new dressing using sterile technique to promote healing. Immediate
contact with the provider or cultures is not indicated unless signs of infection are present.
2. 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 is most appropriate?
• A. Apply a sterile, normal-saline soaked dressing to the wound.
• B. Place a dry sterile dressing over the wound and apply pressure.
• C. Notify the surgeon immediately and prepare for wound closure.
• D. Apply an antibiotic ointment and cover with a transparent dressing.
Answer: A - These findings indicate wound dehiscence. The nurse should immediately
apply a sterile, normal-saline soaked dressing to keep the wound moist and protected
while notifying the healthcare provider. Applying pressure could further damage the tissue.
3. A client with a pressure injury on the sacrum has a wound that is covered with
yellow, stringy tissue that adheres to the wound bed. The nurse correctly identifies
this tissue as:
, • A. Granulation tissue
• B. Slough
• C. Eschar
• D. Epithelial tissue
Answer: B - Slough is yellow, stringy, or mucinous tissue that adheres to the wound bed
and must be removed for healing to occur. Granulation tissue is red and beefy; eschar is
black or brown and dry; epithelial tissue is pink.
4. Which of the following is the most important intervention for preventing pressure
injuries in an immobilized client?
• A. Massaging bony prominences daily
• B. Repositioning the client every 2 hours
• C. Using a foam mattress overlay
• D. Providing a high-protein diet
Answer: B - Repositioning every 2 hours is the most important intervention to relieve
pressure and prevent tissue ischemia. Massaging bony prominences is contraindicated as
it can damage capillary beds. While other interventions are helpful, repositioning is the
primary preventive measure.
5. The nurse is assessing a client's wound and notes dark, dry, leathery tissue covering
the wound surface. This tissue is classified as:
• A. Slough
• B. Granulation tissue
• C. Eschar
• D. Necrotic tissue with infection
Answer: C - Eschar is dark, dry, leathery necrotic tissue that often requires debridement
before healing can occur. Slough is yellow and stringy; granulation tissue is red and
vascular.
6. A client has a Stage 3 pressure injury. Which description best characterizes this
wound?
• A. Non-blanchable erythema of intact skin
, • B. Partial-thickness skin loss with exposed dermis
• C. Full-thickness skin loss with visible subcutaneous fat
• D. Full-thickness tissue loss with exposed bone or muscle
Answer: C - Stage 3 pressure injury involves full-thickness skin loss with visible
subcutaneous fat but no exposed bone, tendon, or muscle. Stage 1 is non-blanchable
erythema; Stage 2 is partial-thickness; Stage 4 involves exposed bone or muscle.
7. The nurse is irrigating a deep wound. Which technique is correct?
• A. Use a 30-mL syringe with a 19-gauge needle directed at the wound edges
• B. Use a 60-mL syringe with a 19-gauge needle directed at the wound bed
• C. Use a 10-mL syringe with a 22-gauge needle directed into the wound
• D. Use a bulb syringe to gently flush the wound from the center outward
Answer: B - A 60-mL syringe with a 19-gauge needle provides the appropriate pressure (8-
15 psi) for effective wound irrigation without damaging tissue. The stream should be
directed at the wound bed.
8. The nurse is assessing a surgical wound on postoperative day 3. Which finding
would indicate a wound infection?
• A. Serosanguineous drainage
• B. Wound edges that are well-approximated
• C. Purulent drainage with foul odor
• D. Mild erythema at the incision site
Answer: C - Purulent drainage with a foul odor is a classic sign of wound infection.
Serosanguineous drainage and mild erythema are expected findings in the early
postoperative period.
9. A client with a chronic wound asks the nurse why the wound is not healing. Which of
the following is a systemic factor that impairs wound healing?
• A. Wound infection
• B. Diabetes mellitus
• C. Poor wound care technique
, • D. Pressure on the wound
Answer: B - Diabetes mellitus is a systemic factor that impairs wound healing due to poor
perfusion, neuropathy, and impaired immune function. The other options are local factors
affecting wound healing.
10. The nurse is preparing to remove a client's sutures. Which action is correct?
• A. Remove every other suture first to assess wound integrity
• B. Cut the suture at the knot and pull the suture through the tissue
• C. Remove all sutures at once to minimize discomfort
• D. Apply sterile saline to the sutures to loosen them before removal
Answer: A - Removing every other suture first allows the nurse to assess wound integrity
before removing the remaining sutures. This prevents wound dehiscence if the wound is
not healing properly.
SECTION B: PREOPERATIVE AND POSTOPERATIVE CARE
11. The nurse is providing preoperative instructions to a client scheduled for surgery to
correct spinal curvature. Which statement by the client demonstrates correct
understanding of the teaching?
• A. "I will not need to turn or move after surgery."
• B. "I will show you the method of turning I will use after surgery."
• C. "I will remain flat in bed for 24 hours after surgery."
• D. "I will ask for pain medication only when the pain is severe."
Answer: B - Demonstrating the turning method shows the client understands how to move
safely after spinal surgery to maintain alignment and prevent complications. Early mobility
is encouraged, and pain should be managed before it becomes severe.
12. The nurse is caring for a client who is scheduled for surgery the following day. It
requires notification to the primary healthcare provider if the client:
• A. Reports a family history of high fever during a surgical procedure.
• B. Reports having had a glass of wine the previous evening.
• C. Requests to speak with the anesthesiologist.
