Test Bank for RN Adult Medical Surgical Exam
Page |1
Test Bank 2 for RN Adult Medical Surgical
Nursing: Content Mastery Series Edition 12.0
by Alissa Althoff | All Chapters Questions and
Answers | Latest 2026/2027
A client has a small-bore nasoenteric feeding tube. The nurse assesses the following vital signs:
temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and blood
pressure, 106/62 mm Hg. Which action by the nurse takes priority?
A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care provider.
C) Auscultate lung sounds and obtain oxygen saturation.
D) Add blue dye to the feeding tube formula. –
Correct AnswerC
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The client may have aspirated. The nurse should further assess the client's respiratory and
oxygenation status. The client may have another reason for the abnormal vital signs, so the nurse
should not pull out the tube before performing other assessments. Adding blue dye to the tube
feeding formula is not recommended to check for aspiration. Slowing the feeding down will not be
helpful.
A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is the
nurse's first action when the client reports burning at the site?
A) Apply a cold compress.
B) Discontinue the infusion.
C) Slow the rate of infusion.
D) Check for a blood return. –
Correct AnswerB
Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or she
should immediately stop the infusion. Even if the IV has a good blood return, some of the
chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not
sufficient to prevent further leakage and damage. Applying a cold compress may or may not be the
correct action, depending on the specific agent. However, the compress would be applied only after
the infusion has been discontinued.
which statement about a patient with a tube feeding indicates best practice for patient safety &
quality care?
A) if the tube becomes clogged, use 30 mL of water for flushing, while applying gentle pressure with a
50 mL piston syringe
B) when administering medications, use cold water to dissolve the drug before administering it
C) use cranberry juice to flush the tube if it is clogged
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D) administer drugs down the feeding tube without flushing first, but flush the feeding tube after the
drug is given –
Correct AnswerA
A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the
perimeter, and bone is exposed. Which is the nurse's best action?
A) Document as a stage I pressure ulcer and apply a transparent dressing.
B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
C) Document as a stage IV pressure ulcer and prepare the client for débridement.
D) Document as a stage III pressure ulcer and start antibiotic therapy.
- Correct AnswerC
A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue necrosis,
and/or damage to muscle, bone, or supporting structures. Eschar may be present. When the bone of
the trochanter area is visible, tissue loss includes muscle loss. A potential intervention consists of
débridement of the necrotic tissue and a possible graft to promote healing.
After initial placement of NG tubes is confirmed, how often must placement be checked? SELECT ALL
THAT APPLY?
A) before medication administration
B) it is not necessary to recheck placement
C) every 4-8 hours during feeding
D) before intermittent feeding
E) according to facility policy –
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Correct AnswerA,C,E
The nurse is preparing to administer tube feedings through a client's new Salem sump nasogastric
tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the
priority action of the nurse?
A) Start the tube feeding as ordered and check the residual in 30 minutes.
B) Inject air into the nasogastric tube while auscultating the client's epigastric area.
C) Lower the head of the client's bed and attempt to aspirate fluid again.
D) Obtain orders for a chest x-ray to confirm placement before starting the feeding. –
Correct AnswerD
The nurse must verify tube placement before beginning any tube feeding or administering any
medications through a tube. The most accurate way to determine placement is via chest x-ray. The
nurse could cause the client to aspirate if she or he started the feeding then checked later for
placement. Insufflation does not provide accurate results and should not be used to verify tube
placement. The nurse must keep the client's head elevated at least 30 degrees.
A client has a urinary tract infection. Which assessment by the nurse is most helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries –
Correct AnswerC
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Page |1
Test Bank 2 for RN Adult Medical Surgical
Nursing: Content Mastery Series Edition 12.0
by Alissa Althoff | All Chapters Questions and
Answers | Latest 2026/2027
A client has a small-bore nasoenteric feeding tube. The nurse assesses the following vital signs:
temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and blood
pressure, 106/62 mm Hg. Which action by the nurse takes priority?
A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care provider.
C) Auscultate lung sounds and obtain oxygen saturation.
D) Add blue dye to the feeding tube formula. –
Correct AnswerC
P a g e 1 | 74
, Test Bank for RN Adult Medical Surgical Exam
Page |2
The client may have aspirated. The nurse should further assess the client's respiratory and
oxygenation status. The client may have another reason for the abnormal vital signs, so the nurse
should not pull out the tube before performing other assessments. Adding blue dye to the tube
feeding formula is not recommended to check for aspiration. Slowing the feeding down will not be
helpful.
A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is the
nurse's first action when the client reports burning at the site?
A) Apply a cold compress.
B) Discontinue the infusion.
C) Slow the rate of infusion.
D) Check for a blood return. –
Correct AnswerB
Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or she
should immediately stop the infusion. Even if the IV has a good blood return, some of the
chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not
sufficient to prevent further leakage and damage. Applying a cold compress may or may not be the
correct action, depending on the specific agent. However, the compress would be applied only after
the infusion has been discontinued.
which statement about a patient with a tube feeding indicates best practice for patient safety &
quality care?
A) if the tube becomes clogged, use 30 mL of water for flushing, while applying gentle pressure with a
50 mL piston syringe
B) when administering medications, use cold water to dissolve the drug before administering it
C) use cranberry juice to flush the tube if it is clogged
P a g e 2 | 74
, Test Bank for RN Adult Medical Surgical Exam
Page |3
D) administer drugs down the feeding tube without flushing first, but flush the feeding tube after the
drug is given –
Correct AnswerA
A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the
perimeter, and bone is exposed. Which is the nurse's best action?
A) Document as a stage I pressure ulcer and apply a transparent dressing.
B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
C) Document as a stage IV pressure ulcer and prepare the client for débridement.
D) Document as a stage III pressure ulcer and start antibiotic therapy.
- Correct AnswerC
A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue necrosis,
and/or damage to muscle, bone, or supporting structures. Eschar may be present. When the bone of
the trochanter area is visible, tissue loss includes muscle loss. A potential intervention consists of
débridement of the necrotic tissue and a possible graft to promote healing.
After initial placement of NG tubes is confirmed, how often must placement be checked? SELECT ALL
THAT APPLY?
A) before medication administration
B) it is not necessary to recheck placement
C) every 4-8 hours during feeding
D) before intermittent feeding
E) according to facility policy –
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Correct AnswerA,C,E
The nurse is preparing to administer tube feedings through a client's new Salem sump nasogastric
tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the
priority action of the nurse?
A) Start the tube feeding as ordered and check the residual in 30 minutes.
B) Inject air into the nasogastric tube while auscultating the client's epigastric area.
C) Lower the head of the client's bed and attempt to aspirate fluid again.
D) Obtain orders for a chest x-ray to confirm placement before starting the feeding. –
Correct AnswerD
The nurse must verify tube placement before beginning any tube feeding or administering any
medications through a tube. The most accurate way to determine placement is via chest x-ray. The
nurse could cause the client to aspirate if she or he started the feeding then checked later for
placement. Insufflation does not provide accurate results and should not be used to verify tube
placement. The nurse must keep the client's head elevated at least 30 degrees.
A client has a urinary tract infection. Which assessment by the nurse is most helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries –
Correct AnswerC
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