NU 155
EXAM 3
Tested Questions with
Rationales Medical-Surgical
Nursing I
Galen College of Nursing
This Document Description:
This document contains a collection of tested and
verified questions with accurate answers from
Exam 3 of NU 155 at the Galen College of
Nursing. It covers core topics assessed in the
course and reflects the actual exam format and
,question style. Ideal for exam preparation and concept
reinforcement.
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 of the
following is an appropriate action for the nurse to take?
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:** B) Apply a sterile, normal-saline soaked dressing to the wound.
**Expert Rationale:**
This presentation is consistent with wound dehiscence, a complication where the surgical wound
separates. It is crucial to cover the area with a sterile saline-soaked dressing to keep the tissues moist
and prevent contamination while minimizing trauma. Dry dressings can cause tissue desiccation, and
hydrogen peroxide can damage new granulation tissue. Massaging the wound edges is contraindicated.
---
### 2.
The nurse is providing preoperative instructions to a client who is scheduled for surgery to
correct spinal curvature. Which of the following statements by the client best demonstrates a
correct understanding of the teaching?
A) "I will limit my movements completely after surgery."
B) "I will show you the method of turning I will use after surgery."
C) "I can get out of bed as soon as I feel like it."
,D) "Pain medication will not be necessary after surgery."
**Correct Answer:** B) "I will show you the method of turning I will use after surgery."
**Expert Rationale:**
Preoperative teaching often involves instructing clients on postoperative mobility techniques to prevent
injury and promote healing. Demonstrating turning techniques shows patient engagement and
understanding. Early mobilization prevents complications, and pain management is necessary for
recovery.
---
### 3.
The nurse is assessing a postoperative client who has advanced cognitive impairment. Which of
the following actions by the nurse is most effective when assessing the client's level of pain?
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:** B) Monitor the client's body language, facial expressions, emotional status, and
consolability.
**Expert Rationale:**
Clients with advanced cognitive impairment may have limited ability to self-report pain. Observational pain
assessment tools that include behavior and emotional cues are considered the most reliable strategies to
identify pain in this population.
---
### 4.
, The nurse is caring for a client who has diabetes mellitus and reports sharp, burning pain in
bilateral lower extremities. The nurse understands that the client may be experiencing:
A) Nociceptive pain.
B) Referred pain.
C) Neuropathic pain.
D) Phantom limb pain.
**Correct Answer:** C) Neuropathic pain.
**Expert Rationale:**
Neuropathic pain results from nerve damage often associated with diabetes mellitus, characterized by
sharp, burning sensations typically in a “stocking-glove” distribution in the lower extremities.
---
### 5.
The nurse is caring for a client who is scheduled to have surgery the following day. It requires
notification to the primary health care provider (PHCP) if the client:
A) Has a history of smoking.
B) Reports a family history of high fever during a surgical procedure.
C) Is allergic to latex.
D) Has a recent upper respiratory infection.
**Correct Answer:** B) Reports a family history of high fever during a surgical procedure.
**Expert Rationale:**
A family history of malignant hyperthermia (a life-threatening hypermetabolic reaction to certain
anesthetics) requires urgent notification to the PHCP to ensure anesthesia precautions are in place.
---
EXAM 3
Tested Questions with
Rationales Medical-Surgical
Nursing I
Galen College of Nursing
This Document Description:
This document contains a collection of tested and
verified questions with accurate answers from
Exam 3 of NU 155 at the Galen College of
Nursing. It covers core topics assessed in the
course and reflects the actual exam format and
,question style. Ideal for exam preparation and concept
reinforcement.
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 of the
following is an appropriate action for the nurse to take?
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:** B) Apply a sterile, normal-saline soaked dressing to the wound.
**Expert Rationale:**
This presentation is consistent with wound dehiscence, a complication where the surgical wound
separates. It is crucial to cover the area with a sterile saline-soaked dressing to keep the tissues moist
and prevent contamination while minimizing trauma. Dry dressings can cause tissue desiccation, and
hydrogen peroxide can damage new granulation tissue. Massaging the wound edges is contraindicated.
---
### 2.
The nurse is providing preoperative instructions to a client who is scheduled for surgery to
correct spinal curvature. Which of the following statements by the client best demonstrates a
correct understanding of the teaching?
A) "I will limit my movements completely after surgery."
B) "I will show you the method of turning I will use after surgery."
C) "I can get out of bed as soon as I feel like it."
,D) "Pain medication will not be necessary after surgery."
**Correct Answer:** B) "I will show you the method of turning I will use after surgery."
**Expert Rationale:**
Preoperative teaching often involves instructing clients on postoperative mobility techniques to prevent
injury and promote healing. Demonstrating turning techniques shows patient engagement and
understanding. Early mobilization prevents complications, and pain management is necessary for
recovery.
---
### 3.
The nurse is assessing a postoperative client who has advanced cognitive impairment. Which of
the following actions by the nurse is most effective when assessing the client's level of pain?
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:** B) Monitor the client's body language, facial expressions, emotional status, and
consolability.
**Expert Rationale:**
Clients with advanced cognitive impairment may have limited ability to self-report pain. Observational pain
assessment tools that include behavior and emotional cues are considered the most reliable strategies to
identify pain in this population.
---
### 4.
, The nurse is caring for a client who has diabetes mellitus and reports sharp, burning pain in
bilateral lower extremities. The nurse understands that the client may be experiencing:
A) Nociceptive pain.
B) Referred pain.
C) Neuropathic pain.
D) Phantom limb pain.
**Correct Answer:** C) Neuropathic pain.
**Expert Rationale:**
Neuropathic pain results from nerve damage often associated with diabetes mellitus, characterized by
sharp, burning sensations typically in a “stocking-glove” distribution in the lower extremities.
---
### 5.
The nurse is caring for a client who is scheduled to have surgery the following day. It requires
notification to the primary health care provider (PHCP) if the client:
A) Has a history of smoking.
B) Reports a family history of high fever during a surgical procedure.
C) Is allergic to latex.
D) Has a recent upper respiratory infection.
**Correct Answer:** B) Reports a family history of high fever during a surgical procedure.
**Expert Rationale:**
A family history of malignant hyperthermia (a life-threatening hypermetabolic reaction to certain
anesthetics) requires urgent notification to the PHCP to ensure anesthesia precautions are in place.
---
