Question

A client who has a Sodium level of 156 and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

Answer 1

Correct Answers:

0.45% Sodium Chloride

Rationale :

💧A sodium level of 156 mEq/L indicates hypernatremia, meaning the serum contains an abnormally high concentration of sodium.

🧪A client with hypernatremia generally requires a fluid that provides proportionally more water than sodium to gradually lower the serum sodium concentration.

🌊0.45% sodium chloride is a hypotonic IV solution that helps move water into cells while providing less sodium than isotonic saline.

⚕️Gradual correction with an appropriate hypotonic solution helps prevent dangerous complications associated with overly rapid changes in serum osmolality.

📌Core Message

Hypernatremia commonly requires cautious replacement of free water using an appropriate hypotonic IV solution such as 0.45% sodium chloride.

Answer 2

Correct Answers:

Nitroglycerin (Nitrostat) 0.4 mg sublingual (SL) for a patient experiencing chest pain.

Rationale :

❤️Active chest pain may indicate acute myocardial ischemia, which can rapidly progress to myocardial infarction or a life-threatening dysrhythmia.

💊Sublingual nitroglycerin rapidly dilates coronary and systemic blood vessels, reducing myocardial oxygen demand and potentially improving coronary blood flow.

🚨The client with possible acute coronary syndrome has the greatest immediate threat to circulation compared with the other patients described.

⏱️Prompt treatment of ischemic chest pain is therefore prioritized over medications or treatments addressing less immediately life-threatening problems.

📌Core Message

Acute ischemic chest pain requires rapid intervention because compromised coronary blood flow can quickly become life-threatening.

Answer 3

Correct Answers:

"When my child has an attack, she usually has to use her inhaler 4 times before her breathing improves."

Rationale :

🌬️Frequent repeated use of a rescue inhaler during one asthma episode suggests significant bronchospasm and inadequate control of symptoms.

💁‍♂️Needing approximately four rescue treatments before improvement may indicate poorly controlled asthma or an attack that is not responding appropriately to initial therapy.

⚠️Excessive reliance on a short-acting bronchodilator is concerning because worsening obstruction can progress to severe respiratory distress.

📋This finding warrants reassessment of the child's asthma action plan, medication technique, controller therapy, and overall disease management.

📌Core Message

Repeated need for a rescue inhaler before symptoms improve suggests inadequate asthma control and an increased risk of severe exacerbation.

Answer 4

Correct Answers:

"This is a normal response. Your other child is also affected by the diagnosis and anger and guilt are expected feelings for a 6-year-old."

Rationale :

👧A serious illness such as childhood leukemia affects the entire family, including healthy siblings who may struggle to understand the diagnosis.

💭A 6-year-old may experience anger, guilt, jealousy, fear, or sadness because children at this developmental stage often interpret events in highly personal ways.

👨‍👩‍👧Recognizing these emotions as a normal sibling response helps parents respond supportively rather than labeling the child's behavior as inappropriate.

🤝Providing reassurance and opportunities for the sibling to express feelings and concerns supports healthy coping and family adjustment.

📌Core Message

Anger and guilt can be developmentally normal responses in young siblings coping with a family member's serious illness.

Answer 5

Correct Answers:

Prepare to intubate the client

Rationale :

🚨The combination of dyspnea, wheezing, inability to speak, and perioral cyanosis indicates severe respiratory compromise following probable anaphylaxis.

💁‍♂️The inability to speak suggests critically impaired airflow, while cyanosis indicates inadequate oxygenation and a potentially failing airway.

🛡️Maintaining a patent airway takes immediate priority under the ABC framework when respiratory obstruction is imminent.

🏥Because severe allergic airway edema can progress rapidly, preparation for emergency intubation is necessary when the client shows signs of impending airway failure.

📌Core Message

Severe allergic respiratory distress with cyanosis and inability to speak signals impending airway failure requiring immediate airway protection.

Answer 6

Correct Answers:

The pain's history, onset, intensity, duration, and location

Rationale :

🩺A comprehensive pain assessment is the first step in determining the nature, severity, and possible cause of chronic pain.

👉Important assessment characteristics include location, intensity, onset, duration, quality, aggravating factors, and relieving factors.

🧒Accurate assessment also provides a baseline for evaluating the effectiveness of subsequent pain-management interventions.

💁‍♂️Emotional and family effects are important, but the nurse must first establish the child's fundamental pain characteristics before developing the plan of care.

📌Core Message

Effective management of chronic pain begins with a systematic assessment of its characteristics, severity, timing, and location.

Answer 7

Correct Answers:

Hemorrhage

Rationale :

🩸Hemorrhage decreases circulating blood volume and threatens adequate tissue perfusion.

🧠In response to reduced blood volume and pressure, the hypothalamus stimulates release of antidiuretic hormone from the posterior pituitary.

💧ADH increases water reabsorption in the kidneys, helping conserve circulating fluid and support blood pressure.

⚙️This compensatory response is part of the body's effort to maintain intravascular volume and hemodynamic stability during significant blood loss.

📌Core Message

Significant blood loss stimulates ADH release to increase renal water retention and preserve circulating volume.

Answer 8

Correct Answers:

Language delay

Rationale :

🗣️Language development is closely related to cognitive development and often reveals intellectual impairment early in childhood.

🧩A significant language delay may reflect difficulty with comprehension, learning, conceptualization, and communication.

📚Because intellectual disability involves limitations in intellectual functioning and adaptive behavior, delayed speech and language are especially useful developmental warning signs.

👶Although several medical conditions may be associated with developmental problems, language delay more directly reflects impaired developmental functioning than isolated historical risk factors.

📌Core Message

Persistent language delay is an important early indicator of possible impairment in cognitive and developmental functioning.

Answer 9

Correct Answers:

Scarlet fever

Rationale :

🎧Wheezing is a musical breath sound produced when air moves through narrowed lower airways.

🌬️Conditions such as asthma and bronchiolitis commonly cause bronchial narrowing and therefore frequently produce wheezing.

🧬Children with cystic fibrosis may also develop airway obstruction from thick secretions, making wheezing possible.

🦠Scarlet fever is primarily a streptococcal infection characterized by fever, pharyngitis, and a characteristic rash rather than lower-airway obstruction.

📌Core Message

Wheezing primarily indicates narrowing of the lower airways and is therefore least characteristic of scarlet fever.

Answer 10

Correct Answers:

The patient's insulin levels are inadequate

Rationale :

🧪Positive urine ketones in a client with type 1 diabetes indicate increased breakdown of fat for energy.

💉Fat breakdown occurs when there is insufficient insulin available for glucose to enter insulin-dependent cells and be used effectively as fuel.

🔥The resulting fatty acid metabolism produces ketone bodies, which can accumulate and contribute to metabolic acidosis.

🚑In a client with type 1 diabetes, significant ketonuria may indicate developing diabetic ketoacidosis, requiring prompt assessment and appropriate insulin management.

📌Core Message

Positive ketones in type 1 diabetes indicate increased fat metabolism caused by insufficient insulin activity and may signal developing diabetic ketoacidosis.

NSG 120 HCC Final Exam 2026

No.

1 :
A client who has a Sodium level of 156 and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

2 :
A nurse receives the following medication orders while caring for multiple patients. Which medication should the nurse plan to administer first?

3 :
A nurse is evaluating the management of a child with a history of asthma. Which of the following statements from the child's mother would be most concerning?

5 :
The client comes to the ED complaining of dyspnea and wheezing after eating at a seafood restaurant. The client now cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first?

6 :
The nurse is caring for a child who is complaining of chronic pain. Which of the following is the priority nursing assessment?

7 :
Which of the following pathologic conditions would result in release of antidiuretic hormone by the posterior pituitary?

8 :
When reviewing the medical record of a child, which of the following would the nurse interpret as the most sensitive indicator of intellectual disability?

9 :
The nurse hears wheezing when auscultating a 4-year-old. Which condition is least likely based on the assessment finding?

10 :
A client with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most likely conclusion based on this finding?

NSG 120 HCC Final Exam 2026

No.

1 : A client who has a Sodium level of 156 and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

2 : A nurse receives the following medication orders while caring for multiple patients. Which medication should the nurse plan to administer first?

3 : A nurse is evaluating the management of a child with a history of asthma. Which of the following statements from the child's mother would be most concerning?

5 : The client comes to the ED complaining of dyspnea and wheezing after eating at a seafood restaurant. The client now cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first?

6 : The nurse is caring for a child who is complaining of chronic pain. Which of the following is the priority nursing assessment?

7 : Which of the following pathologic conditions would result in release of antidiuretic hormone by the posterior pituitary?

8 : When reviewing the medical record of a child, which of the following would the nurse interpret as the most sensitive indicator of intellectual disability?

9 : The nurse hears wheezing when auscultating a 4-year-old. Which condition is least likely based on the assessment finding?

10 : A client with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most likely conclusion based on this finding?

1 :
A client who has a Sodium level of 156 and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

2 :
A nurse receives the following medication orders while caring for multiple patients. Which medication should the nurse plan to administer first?

3 :
A nurse is evaluating the management of a child with a history of asthma. Which of the following statements from the child's mother would be most concerning?

5 :
The client comes to the ED complaining of dyspnea and wheezing after eating at a seafood restaurant. The client now cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first?

6 :
The nurse is caring for a child who is complaining of chronic pain. Which of the following is the priority nursing assessment?

7 :
Which of the following pathologic conditions would result in release of antidiuretic hormone by the posterior pituitary?

8 :
When reviewing the medical record of a child, which of the following would the nurse interpret as the most sensitive indicator of intellectual disability?

9 :
The nurse hears wheezing when auscultating a 4-year-old. Which condition is least likely based on the assessment finding?

10 :
A client with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most likely conclusion based on this finding?