NU 185
EXAM 3
3
NCLEX Style Questions w/ Rationales
Medical-Surgical Nursing II
Galen College of Nursing
This Document Description:
This document contains NCLEX-style Exam
questions tailored to the NU 185 course at
Galen College of Nursing
It covers core topics assessed in the course
and reflects the actual exam format and question style.
Each question is followed by a correct answer and rationale
to support exam preparation.
,A nurse is educating a UAP (unlicensed assistive
personnel) on how to prevent pressure injuries. Which
statement by the UAP indicates the need for further
teaching?
A. "I'll turn the client every two hours, even at night."
B. "I'll use pillows to keep the heels elevated off the bed."
C. "I'll report any skin redness that doesn't go away in 15
minutes."
D. "I'll apply powder to keep the client's skin dry."
Correct Answer: ✅ D. "I'll apply powder to keep the client's skin
dry."
Rationale:
Powders can dry out the skin and cause irritation or clumping,
especially when mixed with moisture. Skin should be kept clean
and dry, but with barrier creams, not powder.
The other statements reflect proper prevention.
Which finding would indicate that a client's pressure injury
care plan is effective?
A. Wound shows yellow slough with increased exudate
B. Client reports increased pain at wound site
C. Granulation tissue noted with minimal serous drainage
D. Surrounding skin is warm, red, and edematous
Correct Answer: ✅ C. Granulation tissue noted with minimal
serous drainage
Rationale:
Granulation tissue is a sign of healing. Minimal serous (clear)
drainage is expected.
• Yellow slough and increased drainage suggest worsening.
• Pain, warmth, and edema may indicate infection
,A nurse is caring for a malnourished client with multiple
pressure injuries. Which collaborative intervention should
the nurse prioritize?
A. Request a referral to physical therapy
B. Consult with a dietitian for nutritional support
C. Ask the pharmacist to review wound care products
D. Instruct UAP to increase repositioning frequency
Correct Answer: ✅ B. Consult with a dietitian for nutritional
support
Rationale:
Nutrition is a key component in wound healing. Collaborating with
a dietitian ensures the client receives the appropriate calories,
protein, vitamins (A, C), and zinc to promote tissue repair.
• Physical therapy is helpful but not the first priority.
• Pharmacist input is more relevant for medication-related care.
• UAP involvement is not a collaborative professional intervention.
A nurse is caring for a child with contact dermatitis after
exposure to poison ivy. Which intervention is most
appropriate to provide relief?
A. Apply an ice pack directly to the affected skin
B. Use a topical antibiotic ointment
C. Cleanse the area and apply calamine lotion
D. Cover the rash with a warm compressA nurse is caring
for a child with contact dermatitis after exposure to
poison ivy. Which intervention is most appropriate to
provide relief?
A. Apply an ice pack directly to the affected skin
B. Use a topical antibiotic ointment
, C. Cleanse the area and apply calamine lotion
D. Cover the rash with a warm compress
✅ Correct Answer: C
Rationale: Poison ivy exposure should be treated by cleansing
the area and applying calamine lotion to relieve itching. Topical
antibiotics are not typically indicated unless infection develops.
A child presents with linear streaks of vesicles after
hiking. Which exposure is the most likely cause?
A. Nickel from a bracelet
B. Laundry detergent
C. Poison ivy
D. Eczema
✅ Correct Answer: C
Rationale: Poison ivy often causes linear vesicular lesions due to
brushing contact with the plant.
A nurse is teaching parents about managing diaper
dermatitis. Which instruction is most important to prevent
worsening?
A. Apply baby powder with each diaper change
B. Avoid letting the infant go without a diaper
C. Remove wet diapers promptly and use zinc oxide
D. Bathe the baby twice daily with antibacterial soap
✅ Correct Answer: C
Rationale: Prompt diaper changes and zinc oxide protect the skin
and promote healing. Baby powder is not recommended due to
aspiration risk, and antibacterial soaps may worsen irritation.
A worsening diaper rash with satellite lesions and raised
borders is likely caused by:
A. Mechanical friction
EXAM 3
3
NCLEX Style Questions w/ Rationales
Medical-Surgical Nursing II
Galen College of Nursing
This Document Description:
This document contains NCLEX-style Exam
questions tailored to the NU 185 course at
Galen College of Nursing
It covers core topics assessed in the course
and reflects the actual exam format and question style.
Each question is followed by a correct answer and rationale
to support exam preparation.
,A nurse is educating a UAP (unlicensed assistive
personnel) on how to prevent pressure injuries. Which
statement by the UAP indicates the need for further
teaching?
A. "I'll turn the client every two hours, even at night."
B. "I'll use pillows to keep the heels elevated off the bed."
C. "I'll report any skin redness that doesn't go away in 15
minutes."
D. "I'll apply powder to keep the client's skin dry."
Correct Answer: ✅ D. "I'll apply powder to keep the client's skin
dry."
Rationale:
Powders can dry out the skin and cause irritation or clumping,
especially when mixed with moisture. Skin should be kept clean
and dry, but with barrier creams, not powder.
The other statements reflect proper prevention.
Which finding would indicate that a client's pressure injury
care plan is effective?
A. Wound shows yellow slough with increased exudate
B. Client reports increased pain at wound site
C. Granulation tissue noted with minimal serous drainage
D. Surrounding skin is warm, red, and edematous
Correct Answer: ✅ C. Granulation tissue noted with minimal
serous drainage
Rationale:
Granulation tissue is a sign of healing. Minimal serous (clear)
drainage is expected.
• Yellow slough and increased drainage suggest worsening.
• Pain, warmth, and edema may indicate infection
,A nurse is caring for a malnourished client with multiple
pressure injuries. Which collaborative intervention should
the nurse prioritize?
A. Request a referral to physical therapy
B. Consult with a dietitian for nutritional support
C. Ask the pharmacist to review wound care products
D. Instruct UAP to increase repositioning frequency
Correct Answer: ✅ B. Consult with a dietitian for nutritional
support
Rationale:
Nutrition is a key component in wound healing. Collaborating with
a dietitian ensures the client receives the appropriate calories,
protein, vitamins (A, C), and zinc to promote tissue repair.
• Physical therapy is helpful but not the first priority.
• Pharmacist input is more relevant for medication-related care.
• UAP involvement is not a collaborative professional intervention.
A nurse is caring for a child with contact dermatitis after
exposure to poison ivy. Which intervention is most
appropriate to provide relief?
A. Apply an ice pack directly to the affected skin
B. Use a topical antibiotic ointment
C. Cleanse the area and apply calamine lotion
D. Cover the rash with a warm compressA nurse is caring
for a child with contact dermatitis after exposure to
poison ivy. Which intervention is most appropriate to
provide relief?
A. Apply an ice pack directly to the affected skin
B. Use a topical antibiotic ointment
, C. Cleanse the area and apply calamine lotion
D. Cover the rash with a warm compress
✅ Correct Answer: C
Rationale: Poison ivy exposure should be treated by cleansing
the area and applying calamine lotion to relieve itching. Topical
antibiotics are not typically indicated unless infection develops.
A child presents with linear streaks of vesicles after
hiking. Which exposure is the most likely cause?
A. Nickel from a bracelet
B. Laundry detergent
C. Poison ivy
D. Eczema
✅ Correct Answer: C
Rationale: Poison ivy often causes linear vesicular lesions due to
brushing contact with the plant.
A nurse is teaching parents about managing diaper
dermatitis. Which instruction is most important to prevent
worsening?
A. Apply baby powder with each diaper change
B. Avoid letting the infant go without a diaper
C. Remove wet diapers promptly and use zinc oxide
D. Bathe the baby twice daily with antibacterial soap
✅ Correct Answer: C
Rationale: Prompt diaper changes and zinc oxide protect the skin
and promote healing. Baby powder is not recommended due to
aspiration risk, and antibacterial soaps may worsen irritation.
A worsening diaper rash with satellite lesions and raised
borders is likely caused by:
A. Mechanical friction
