ADULT HEALTH MED SURG EXAM TESTBANK QUESTIONS AND
ANSWERS 2025.
1. What nursing actions should be taken for a client receiving total parenteral nutrition
(TPN) for ongoing care?
• Check vital signs daily; change tubing weekly
• Assess vital signs every 4–8 hr, weigh daily; change tubing and solution bag every 24
hr
• Use the TPN line for other IV boluses
• Add medications to the TPN solution
Rationale: Frequent monitoring and sterile tubing changes prevent complications like
sepsis; avoiding additional IV use maintains TPN integrity.
2. What client education and nursing actions are essential following nasogastric
decompression for gastric bleeding?
• Allow oral intake immediately; reposition once daily
• Maintain NPO status; monitor vital signs and assess for absence of blood in NG
tube
• Remove the NG tube without lavage
• Ignore abdominal girth changes
Rationale: NPO status and monitoring prevent aspiration and assess bleeding cessation;
lavage stops active gastric bleeds.
3. What post-procedure nursing considerations apply to a client with an ostomy (ileostomy
or colostomy)?
• Empty the ostomy bag when full; ignore stoma color
• Empty the ostomy bag when one-third to one-half full; assess stoma for pink, moist
appearance
• Avoid skin barriers around the stoma
• Expect solid output from an ileostomy
Rationale: Early emptying prevents leakage; a healthy stoma is pink and moist,
indicating good blood supply.
4. What are the main types of ostomies performed in the abdominal area and their
indications?
• Ileostomy: Drains urine; Colostomy: Drains bile
• Ileostomy: Drains liquid stool from the ileum (e.g., Crohn’s disease); Colostomy:
Drains stool from the colon (e.g., cancer)
• Ileostomy: Solid stool; Colostomy: Liquid stool
• Both are for kidney drainage
Rationale: Ileostomy bypasses the colon, producing liquid stool; colostomy varies by
colon segment, indicated for disease or injury.
,5. What physical assessment findings should a nurse expect in a client with deep vein
thrombosis (DVT)?
• Cool skin and reduced edema
• Calf/groin pain, warmth, edema; induration over the vessel
• Bilateral leg swelling
• No change in limb circumference
Rationale: DVT causes localized inflammation, leading to pain, warmth, and swelling in
the affected area.
6. How do osteoarthritis and rheumatoid arthritis (RA) differ in presentation and
pathology?
• Osteoarthritis: Systemic autoimmune; RA: Unilateral joint
• Osteoarthritis: Unilateral joint impairment, degenerative; RA: Symmetrical joint
impairment, autoimmune
• Osteoarthritis: Affects all organs; RA: Joints only
• Both are symmetrical and degenerative
Rationale: Osteoarthritis is wear-and-tear joint damage; RA is an autoimmune attack on
joints and organs.
7. What are the expected findings in macular degeneration?
• Improved central vision
• Lack of depth perception; loss of central vision
• Enhanced peripheral vision
• No visual distortion
Rationale: Macular degeneration damages the macula, impairing central vision and
depth perception.
8. What are the manifestations of cataracts in a client?
• Improved night vision
• Decreased visual acuity; blurred or dim vision
• Reduced light sensitivity
• Clear lens appearance
Rationale: Cataracts cloud the lens, reducing clarity and causing glare or halos.
9. What are the manifestations of acute angle-closure glaucoma?
• Mild eye discomfort
• Severe eye pain; halo around lights
• Improved peripheral vision
• Reactive pupils
Rationale: Acute angle-closure glaucoma causes rapid pressure buildup, leading to pain
and visual halos.
, 10. What general rule should guide a nurse when multiple answers seem plausible on an
exam regarding a client’s condition?
• Choose the option with the highest vital sign value
• Select low urine output (less than 30 mL/hr) when in doubt
• Pick the answer related to respiratory rate
• Opt for the longest symptom duration
Rationale: Low urine output (<30 mL/hr) often signals critical conditions like shock or
renal failure, making it a frequent correct choice.
11. What physical finding strongly suggests a hematologic disorder in a client?
• Increased hair growth on the legs
• Absence of hair on the legs
• Redness of the extremities
• Thickened skin on the legs
Rationale: Hair loss indicates poor circulation, often tied to hematologic or vascular
issues.
12. What is brachytherapy, and what are its key nursing considerations?
• External radiation applied to the skin
• Internal placement of radioactive material; nurse wears a lead apron, limits visitor
time to 30 minutes/day
• A non-radioactive implant procedure
• Requires no protective equipment
Rationale: Brachytherapy uses internal radiation, requiring protection and limited
exposure to prevent harm.
13. What laboratory findings indicate pancreatitis in a client?
• Decreased serum lipase and normal glucose
• Increased serum lipase; increased blood glucose due to reduced insulin production
• Normal WBC count and albumin
• Decreased amylase levels
Rationale: Pancreatitis releases lipase and impairs insulin, elevating glucose.
14. What nursing interventions are recommended for a client with polycythemia vera?
• Keep legs dependent when sitting
• Elevate legs when sitting; drink at least 3 L of fluid daily
• Avoid support hose
• Use a hard toothbrush
Rationale: Elevation and hydration reduce clotting risk by preventing venous pooling
and lowering blood viscosity.
ANSWERS 2025.
1. What nursing actions should be taken for a client receiving total parenteral nutrition
(TPN) for ongoing care?
• Check vital signs daily; change tubing weekly
• Assess vital signs every 4–8 hr, weigh daily; change tubing and solution bag every 24
hr
• Use the TPN line for other IV boluses
• Add medications to the TPN solution
Rationale: Frequent monitoring and sterile tubing changes prevent complications like
sepsis; avoiding additional IV use maintains TPN integrity.
2. What client education and nursing actions are essential following nasogastric
decompression for gastric bleeding?
• Allow oral intake immediately; reposition once daily
• Maintain NPO status; monitor vital signs and assess for absence of blood in NG
tube
• Remove the NG tube without lavage
• Ignore abdominal girth changes
Rationale: NPO status and monitoring prevent aspiration and assess bleeding cessation;
lavage stops active gastric bleeds.
3. What post-procedure nursing considerations apply to a client with an ostomy (ileostomy
or colostomy)?
• Empty the ostomy bag when full; ignore stoma color
• Empty the ostomy bag when one-third to one-half full; assess stoma for pink, moist
appearance
• Avoid skin barriers around the stoma
• Expect solid output from an ileostomy
Rationale: Early emptying prevents leakage; a healthy stoma is pink and moist,
indicating good blood supply.
4. What are the main types of ostomies performed in the abdominal area and their
indications?
• Ileostomy: Drains urine; Colostomy: Drains bile
• Ileostomy: Drains liquid stool from the ileum (e.g., Crohn’s disease); Colostomy:
Drains stool from the colon (e.g., cancer)
• Ileostomy: Solid stool; Colostomy: Liquid stool
• Both are for kidney drainage
Rationale: Ileostomy bypasses the colon, producing liquid stool; colostomy varies by
colon segment, indicated for disease or injury.
,5. What physical assessment findings should a nurse expect in a client with deep vein
thrombosis (DVT)?
• Cool skin and reduced edema
• Calf/groin pain, warmth, edema; induration over the vessel
• Bilateral leg swelling
• No change in limb circumference
Rationale: DVT causes localized inflammation, leading to pain, warmth, and swelling in
the affected area.
6. How do osteoarthritis and rheumatoid arthritis (RA) differ in presentation and
pathology?
• Osteoarthritis: Systemic autoimmune; RA: Unilateral joint
• Osteoarthritis: Unilateral joint impairment, degenerative; RA: Symmetrical joint
impairment, autoimmune
• Osteoarthritis: Affects all organs; RA: Joints only
• Both are symmetrical and degenerative
Rationale: Osteoarthritis is wear-and-tear joint damage; RA is an autoimmune attack on
joints and organs.
7. What are the expected findings in macular degeneration?
• Improved central vision
• Lack of depth perception; loss of central vision
• Enhanced peripheral vision
• No visual distortion
Rationale: Macular degeneration damages the macula, impairing central vision and
depth perception.
8. What are the manifestations of cataracts in a client?
• Improved night vision
• Decreased visual acuity; blurred or dim vision
• Reduced light sensitivity
• Clear lens appearance
Rationale: Cataracts cloud the lens, reducing clarity and causing glare or halos.
9. What are the manifestations of acute angle-closure glaucoma?
• Mild eye discomfort
• Severe eye pain; halo around lights
• Improved peripheral vision
• Reactive pupils
Rationale: Acute angle-closure glaucoma causes rapid pressure buildup, leading to pain
and visual halos.
, 10. What general rule should guide a nurse when multiple answers seem plausible on an
exam regarding a client’s condition?
• Choose the option with the highest vital sign value
• Select low urine output (less than 30 mL/hr) when in doubt
• Pick the answer related to respiratory rate
• Opt for the longest symptom duration
Rationale: Low urine output (<30 mL/hr) often signals critical conditions like shock or
renal failure, making it a frequent correct choice.
11. What physical finding strongly suggests a hematologic disorder in a client?
• Increased hair growth on the legs
• Absence of hair on the legs
• Redness of the extremities
• Thickened skin on the legs
Rationale: Hair loss indicates poor circulation, often tied to hematologic or vascular
issues.
12. What is brachytherapy, and what are its key nursing considerations?
• External radiation applied to the skin
• Internal placement of radioactive material; nurse wears a lead apron, limits visitor
time to 30 minutes/day
• A non-radioactive implant procedure
• Requires no protective equipment
Rationale: Brachytherapy uses internal radiation, requiring protection and limited
exposure to prevent harm.
13. What laboratory findings indicate pancreatitis in a client?
• Decreased serum lipase and normal glucose
• Increased serum lipase; increased blood glucose due to reduced insulin production
• Normal WBC count and albumin
• Decreased amylase levels
Rationale: Pancreatitis releases lipase and impairs insulin, elevating glucose.
14. What nursing interventions are recommended for a client with polycythemia vera?
• Keep legs dependent when sitting
• Elevate legs when sitting; drink at least 3 L of fluid daily
• Avoid support hose
• Use a hard toothbrush
Rationale: Elevation and hydration reduce clotting risk by preventing venous pooling
and lowering blood viscosity.
