Question

A client is admitted for drug intoxication. What is a sign that a client may physically attack a nurse?

Answer 1

Correct Answers:

The client is glaring at the nurse

Rationale :

🔷 Glaring at the nurse is a warning sign of possible escalating aggression and may indicate that the client is becoming hostile.

🔷 Nonverbal behaviors such as staring, clenched fists, pacing, and a tense posture often appear before an actual physical attack.

🔷 The nurse should recognize this behavior early and use de-escalation techniques while maintaining safety.

🔷 Identifying threatening body language is important because violent behavior is often preceded by visible signs of anger or intimidation.

🔷 For this reason, glaring at the nurse is the finding most suggestive that the client may physically attack.

The client has increased blood pressure

🔷 Increased blood pressure can occur with stress, intoxication, pain, or anxiety, but it does not specifically predict violent behavior by itself.

🔷 Behavioral warning signs are more reliable indicators of an immediate risk for assault.

The client has a language barrier

🔷 A language barrier can make communication difficult, but it is not a direct sign that the client is about to become physically violent.

🔷 The nurse should use an interpreter or other communication aids rather than assume aggression.

The client has difficulty hearing

🔷 Difficulty hearing may lead to misunderstanding or frustration, but it is not a classic predictor of physical attack.

🔷 Safety risk is more strongly suggested by hostile verbal or nonverbal behavior.

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Answer 2

Correct Answers:

Oliguria

Rationale :

💠 Oliguria is the term used to describe low urine output, usually less than about 400 mL/day in adults.

💠 It often occurs with conditions such as dehydration, renal failure, or shock, where kidney perfusion or function is decreased.

💠 Recognizing oliguria is important because it can signal worsening fluid imbalance or impaired renal status.

💠 This term specifically refers to reduced urine production, not involuntary urination or pus in the urine.

💠 For this reason, oliguria is the correct term for low production of urine.

Enuresis

💠 Enuresis means involuntary urination, often during sleep.

💠 It does not refer to decreased urine formation.

Diuresis

💠 Diuresis means increased formation and excretion of urine.

💠 It is the opposite of low urine production.

Pyuria

💠 Pyuria means the presence of pus or white blood cells in the urine.

💠 It indicates inflammation or infection, not reduced urine output.

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Answer 3

Correct Answers:

Pale stoma

Rationale :

🟢 A pale stoma following a ureterostomy is abnormal and may indicate impaired blood supply to the stoma.

🟢 A healthy stoma should appear moist and pink to red, showing adequate perfusion.

🟢 Loss of normal color can be an early sign of ischemia or necrosis, which requires immediate medical attention.

🟢 Prompt reporting is essential because compromised circulation can threaten stoma viability.

🟢 For this reason, the nurse should report a pale stoma immediately to the healthcare provider.

Light reddish-pink urine

🟢 Light reddish-pink urine can be expected early after urinary tract surgery because some blood may be present initially.

🟢 This finding should be monitored, but it is not as urgent as a pale stoma.

Sleepiness following procedure

🟢 Sleepiness 6 hours after surgery is commonly related to anesthesia or analgesic effects.

🟢 It is not unusual unless accompanied by respiratory depression or other concerning findings.

Pain rated at 4/10

🟢 Pain rated at 4/10 is a mild to moderate postoperative finding and is often expected after surgery.

🟢 It should be managed, but it does not require the most urgent reporting here.

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Answer 4

Correct Answers:

100% humidified oxygen by face mask

Rationale :

🟣 In a client with smoke inhalation injury, the immediate priority is to improve oxygenation and treat possible carbon monoxide exposure.

🟣 100% humidified oxygen by face mask helps displace carbon monoxide from hemoglobin and improves oxygen delivery to tissues.

🟣 Humidification also helps soothe irritated airways and loosen secretions after inhalation injury.

🟣 Although intubation may become necessary, the first treatment usually started right away is high-concentration oxygen.

🟣 For this reason, the initial nursing action is to prepare the client to receive 100% humidified oxygen by face mask.

Pain medication

🟣 Pain medication may be needed later, but airway and oxygenation take priority in smoke inhalation injury.

🟣 The nurse must first address the immediate life-threatening respiratory risk.

Oxygen via nasal cannula

🟣 Oxygen via nasal cannula does not provide the high concentration of oxygen needed for smoke inhalation and possible carbon monoxide poisoning.

🟣 A face mask delivering 100% oxygen is more appropriate initially.

Endotracheal intubation

🟣 Endotracheal intubation may be required if airway edema or severe respiratory compromise develops.

🟣 However, the initial treatment to prepare for first is high-flow 100% humidified oxygen unless the airway is already severely compromised.

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Answer 5

Correct Answers:

15 mg/dL

Rationale :

🌸 A BUN level of 15 mg/dL falls within the expected normal range and suggests that the client’s hydration status has improved.

🌸 In dehydration, BUN often becomes elevated because reduced fluid volume decreases renal perfusion and concentrates waste products in the blood.

🌸 Adequate volume replacement restores kidney blood flow and helps return BUN toward normal.

🌸 A normalizing BUN indicates that fluid therapy is effective in correcting the client’s volume deficit.

🌸 For this reason, a BUN of 15 mg/dL reflects adequate volume replacement.

6 mg/dL

🌸 A BUN of 6 mg/dL is low-normal, but the best answer for improvement after dehydration is the value that clearly reflects a typical normal level without suggesting dilution.

🌸 The standard expected value indicating correction here is 15 mg/dL.

29 mg/dL

🌸 A BUN of 29 mg/dL remains elevated and suggests that dehydration or impaired renal perfusion may still be present.

🌸 This does not indicate adequate volume replacement.

35 mg/dL

🌸 A BUN of 35 mg/dL is significantly elevated and is consistent with persistent dehydration or renal dysfunction.

🌸 This would require further evaluation and treatment.

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Answer 6

Correct Answers:

Serum potassium 6 mEq/L (mmol/L)

Rationale :

⭐ A serum potassium of 6 mEq/L is dangerously high and indicates hyperkalemia, which can cause life-threatening cardiac dysrhythmias.

⭐ In acute renal failure, potassium may rise rapidly because the kidneys are unable to excrete it effectively.

⭐ This electrolyte imbalance can lead to conduction abnormalities, ventricular arrhythmias, and cardiac arrest if not treated promptly.

⭐ Because of the immediate risk to the heart, this laboratory result must be reported without delay.

⭐ For this reason, the nurse should report serum potassium 6 mEq/L immediately.

Blood urea nitrogen 50 mg/dL

⭐ A BUN of 50 mg/dL is elevated and expected in acute renal failure, but it is not the most immediately life-threatening lab in the options.

⭐ Hyperkalemia takes priority because it can quickly affect cardiac function.

Venous blood pH 7.30

⭐ A pH of 7.30 indicates acidosis and is concerning, but it is less immediately dangerous than severe hyperkalemia.

⭐ This finding should be addressed, though potassium is the priority report.

Hemoglobin of 10.3 mg/dL

⭐ A hemoglobin of 10.3 mg/dL indicates mild anemia.

⭐ It does not present the same urgent risk as a dangerously elevated potassium level.

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Answer 7

Correct Answers:

Check the pulse distal to the site at least every 6 hours

Rationale :

💎 An arteriovenous fistula must be monitored for adequate circulation, and checking the pulse distal to the site helps assess blood flow to the extremity.

💎 Ongoing assessment also helps detect complications such as decreased perfusion, clotting, or vascular compromise.

💎 Clients with fistulas require regular evaluation of circulation, as well as monitoring for a thrill and bruit.

💎 Protecting the access site is essential because it is the client’s lifeline for dialysis treatment.

💎 For this reason, checking the pulse distal to the site is an appropriate nursing action.

Assess the site once per day for signs of infection

💎 The site should be assessed more frequently than once per day, especially for patency and circulation, not only infection.

💎 Daily-only assessment is not sufficient for a dialysis access site.

Check blood pressure above the fistula to protect the site

💎 Blood pressure should not be taken in the arm with the fistula.

💎 Compression from the cuff can damage the access and reduce blood flow.

Draw blood from the arm distal to the site once daily

💎 Blood should not be drawn from the arm with the fistula.

💎 Venipuncture can damage the access and increase the risk of thrombosis.

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Answer 8

Correct Answers:

Between the shoulder blades in the back

Rationale :

🔶 Stomach pain can produce referred pain that is felt between the shoulder blades in the back because visceral pain may be perceived in distant areas sharing similar nerve pathways.

🔶 Referred pain occurs when the brain interprets signals from internal organs as coming from another somatic location.

🔶 Gastrointestinal conditions, especially upper abdominal disorders, can radiate discomfort to the back.

🔶 Recognizing referred pain patterns helps the nurse better interpret client symptoms and possible organ involvement.

🔶 For this reason, stomach pain may be experienced between the shoulder blades in the back.

In the abdomen

🔶 Pain felt in the abdomen is local pain, not referred pain.

🔶 Referred pain is perceived in an area distant from the actual source.

In the shoulders

🔶 Pain felt in the shoulders is more classically associated with irritation of the diaphragm or gallbladder disease.

🔶 It is not the best pattern for referred stomach pain in this question.

In the rectal area

🔶 Pain in the rectal area is not a common referred pain location for stomach disorders.

🔶 This finding suggests a different source of discomfort.

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Answer 9

Correct Answers:

250

Rationale :

✍️Formula

✅Rate = Total volume ÷ Time

✅Rate = 2000 mL ÷ 8 hr

📌 250 mL/hr

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Answer 10

Correct Answers:

Spontaneous relief of pain is unusual.

Rationale :

🟡 Chronic pain usually persists for a long time and often does not resolve spontaneously without ongoing management.

🟡 It may continue beyond the expected healing period and can affect sleep, mood, mobility, and quality of life.

🟡 Unlike acute pain, chronic pain often has a less predictable course and may not respond fully to standard treatment.

🟡 Clients with chronic pain commonly require long-term coping strategies, multidisciplinary care, and individualized pain management plans.

🟡 For this reason, spontaneous relief of pain is unusual is a characteristic associated with chronic pain.

Medication is usually beneficial; surgery is often helpful

🟡 Chronic pain is often difficult to treat, and medications or surgery are not always consistently effective.

🟡 This statement is more consistent with acute pain that has a clearly treatable cause.

Cause of the pain is easy to identify

🟡 In chronic pain, the cause is often complex or may not be clearly identifiable.

🟡 Difficulty finding a simple cause is common in long-standing pain syndromes.

The pain lasts hours to days

🟡 Pain that lasts hours to days is more characteristic of acute pain.

🟡 Chronic pain typically lasts for months or longer.

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PN Medsurg Exam 2026

No.

1 :
A client is admitted for drug intoxication. What is a sign that a client may physically attack a nurse?

2 :
Which term corresponds to the condition characterized by a low production of urine?

3 :
The nurse cares for a client who underwent surgery for renal cancer 6 hours ago and has received a ureterostomy. Which finding should the nurse report to the healthcare provider immediately?

4 :
A client is brought to the emergency department following a smoke inhalation injury. The initial nursing action is to prepare the client to receive which treatment?

5 :
A client has been admitted for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

6 :
The LPN is caring for a 60 year old female with acute renal failure. Which of the following labs should be reported immediately to the MD?

7 :
The nurse cares for a client who has an arteriovenous fistula in place for dialysis. Which nursing action is appropriate for this client?

8 :
Which location will a client with stomach pain experience referred pain?

9 :
The healthcare provider orders a bolus of 2 Liters normal saline over 8 hours. The nurse will set the infusion rate at ______ mL/hour.

10 :
Which of the following are characteristics associated with chronic pain?

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PN Medsurg Exam 2026

No.

1 : A client is admitted for drug intoxication. What is a sign that a client may physically attack a nurse?

2 : Which term corresponds to the condition characterized by a low production of urine?

3 : The nurse cares for a client who underwent surgery for renal cancer 6 hours ago and has received a ureterostomy. Which finding should the nurse report to the healthcare provider immediately?

4 : A client is brought to the emergency department following a smoke inhalation injury. The initial nursing action is to prepare the client to receive which treatment?

5 : A client has been admitted for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

6 : The LPN is caring for a 60 year old female with acute renal failure. Which of the following labs should be reported immediately to the MD?

7 : The nurse cares for a client who has an arteriovenous fistula in place for dialysis. Which nursing action is appropriate for this client?

8 : Which location will a client with stomach pain experience referred pain?

9 : The healthcare provider orders a bolus of 2 Liters normal saline over 8 hours. The nurse will set the infusion rate at ______ mL/hour.

10 : Which of the following are characteristics associated with chronic pain?

1 :
A client is admitted for drug intoxication. What is a sign that a client may physically attack a nurse?

2 :
Which term corresponds to the condition characterized by a low production of urine?

3 :
The nurse cares for a client who underwent surgery for renal cancer 6 hours ago and has received a ureterostomy. Which finding should the nurse report to the healthcare provider immediately?

4 :
A client is brought to the emergency department following a smoke inhalation injury. The initial nursing action is to prepare the client to receive which treatment?

5 :
A client has been admitted for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

6 :
The LPN is caring for a 60 year old female with acute renal failure. Which of the following labs should be reported immediately to the MD?

7 :
The nurse cares for a client who has an arteriovenous fistula in place for dialysis. Which nursing action is appropriate for this client?

8 :
Which location will a client with stomach pain experience referred pain?

9 :
The healthcare provider orders a bolus of 2 Liters normal saline over 8 hours. The nurse will set the infusion rate at ______ mL/hour.

10 :
Which of the following are characteristics associated with chronic pain?