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 serum sodium level of 156 mEq/L indicates hypernatremia, because the normal sodium range is approximately 135–145 mEq/L.

✳️ Hypernatremia usually represents a deficit of water relative to sodium in the extracellular fluid.

✳️ 0.45% sodium chloride, also called half-normal saline, is a hypotonic IV solution compared with plasma.

✳️ This solution provides free water that helps dilute the elevated serum sodium and restore intracellular hydration.

✳️ Water moves from the extracellular compartment into relatively dehydrated cells, helping correct the cellular dehydration associated with hypernatremia.

✳️ Correction of significant hypernatremia must occur gradually because a rapid reduction in serum sodium can cause excessive water movement into brain cells.

✳️ Excessively rapid correction increases the risk of cerebral edema, seizures, and neurologic deterioration.

✳️ The nurse should closely monitor serum sodium, neurologic status, intake and output, and fluid balance while the client receives IV fluid therapy.

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Answer 2

Correct Answers:

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

Rationale :

💎 Nitroglycerin should be administered first because the patient is experiencing acute chest pain, which may indicate myocardial ischemia or acute coronary syndrome.

💎 Nitroglycerin produces vasodilation, particularly venodilation, which decreases venous return and cardiac preload.

💎 Reduced preload lowers myocardial oxygen demand, helping relieve ischemic chest discomfort.

💎 Nitroglycerin also promotes coronary vasodilation, which can improve blood flow to ischemic myocardial tissue.

💎 The sublingual route provides a rapid onset of action, making it appropriate when immediate relief of suspected ischemic chest pain is required.

💎 The nurse should assess blood pressure before administration because nitroglycerin can cause significant hypotension.

💎 The nurse should also verify that the patient has not recently taken a phosphodiesterase-5 inhibitor, because combining these medications can cause profound hypotension.

💎 Using priority principles, an immediate threat to cardiac circulation and tissue perfusion takes precedence over non-life-threatening pain, moderate anemia, or restlessness.

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Answer 3

Correct Answers:

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

Rationale :

⚽ Requiring the rescue inhaler four times during an asthma attack is the most concerning finding because it suggests that the child's bronchospasm is not responding adequately to initial treatment.

⚽ A short-acting beta₂-agonist (SABA) such as albuterol should normally produce relatively rapid bronchodilation and improvement in acute asthma symptoms.

⚽ Repeated doses before obtaining relief can indicate significant airway obstruction or inadequately controlled asthma.

⚽ Poor response to a rescue inhaler increases concern for progression toward a severe asthma exacerbation, which can become life-threatening.

⚽ The child's overall asthma management plan should be reassessed, including medication technique, adherence, triggers, and the need for controller therapy.

⚽ The parent should understand the child's asthma action plan and know when persistent symptoms require urgent medical evaluation rather than continued reliance on repeated rescue doses.

⚽ Worsening respiratory distress, inability to speak normally, retractions, cyanosis, decreasing peak expiratory flow, or reduced response to albuterol requires prompt medical attention.

⚽ Frequent or ineffective rescue medication use is therefore an important warning sign of poor asthma control and potentially severe airway obstruction.

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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 sibling's anger and guilt can be a normal emotional response when another child in the family develops a serious illness such as leukemia.

🧿 A 6-year-old may not completely understand the causes of cancer and may use magical thinking to interpret what has happened.

🧿 Magical thinking can cause the child to believe that previous angry thoughts, arguments, or wishes somehow caused the sibling's leukemia, resulting in guilt.

🧿 The healthy sibling may also experience anger or jealousy because parental attention, family routines, and activities become focused on the child who is ill.

🧿 Other expected emotions can include fear, sadness, resentment, loneliness, and anxiety about whether the sibling will recover.

🧿 The nurse should encourage the parents to provide age-appropriate explanations about leukemia and reassure the sibling that nothing they thought, said, or did caused the illness.

🧿 The child's cultural and family background should also be respected when assessing how the family understands illness and expresses emotions.

🧿 Supporting open communication and allowing the sibling to safely express anger, guilt, and fears promotes healthy coping for the entire family.

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Answer 5

Correct Answers:

Prepare to intubate the client

Rationale :

🍊 The combination of dyspnea, wheezing, inability to speak, and perioral cyanosis after eating seafood indicates a severe anaphylactic reaction with impending airway compromise.

🍊 The client's inability to speak suggests critical airway obstruction and inadequate movement of air through the respiratory tract.

🍊 Bluish discoloration around the mouth indicates significant hypoxemia, making airway management the immediate priority.

🍊 Using the ABC priority framework, maintaining a patent airway takes precedence over establishing IV access or obtaining additional allergy information.

🍊 Endotracheal intubation may be required urgently because progressive laryngeal edema can rapidly make intubation extremely difficult or impossible.

🍊 The nurse should immediately prepare the necessary airway and intubation equipment while activating emergency assistance.

🍊 Intramuscular epinephrine is the first-line medication for anaphylaxis and should be administered promptly when prescribed or according to emergency protocol, although it is not listed among the choices.

🍊 Early definitive airway management is essential because untreated anaphylaxis can progress rapidly to complete airway obstruction, respiratory arrest, and cardiac arrest.

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Answer 6

Correct Answers:

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

Rationale :

🌸 A comprehensive pain assessment is the priority when caring for a child experiencing chronic pain.

🌸 The nurse should first determine the pain's history, onset, intensity, duration, and location to establish a clear baseline.

🌸 Assessing these characteristics helps determine the nature and pattern of the pain and guides appropriate interventions.

🌸 Pain intensity should be measured using an age- and developmentally appropriate pain assessment tool whenever possible.

🌸 Information about onset and duration helps identify whether the pain is continuous, intermittent, worsening, or associated with particular activities.

🌸 Determining the location can provide important information about the possible underlying source and whether the pain radiates to another area.

🌸 A detailed baseline assessment also allows the nurse to evaluate whether subsequent pharmacologic and nonpharmacologic interventions are effective.

🌸 After assessing the pain itself, the nurse can evaluate its broader emotional, psychological, functional, and family effects.

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Answer 7

Correct Answers:

Hemorrhage

Rationale :

🌻 Hemorrhage causes a significant reduction in circulating blood volume, which stimulates the release of antidiuretic hormone (ADH).

🌻 ADH, also called vasopressin, is synthesized in the hypothalamus and stored and released by the posterior pituitary gland.

🌻 A decrease in circulating volume and blood pressure is detected by pressure-sensitive receptors, which promote increased ADH secretion.

🌻 ADH acts primarily on the collecting ducts of the kidneys, increasing their permeability to water.

🌻 Increased water reabsorption reduces urine output and helps conserve fluid during significant blood loss.

🌻 At higher concentrations, ADH also produces vasoconstriction, which can help support blood pressure during severe hypovolemia.

🌻 These compensatory responses help preserve circulating volume and tissue perfusion until the underlying blood loss is corrected.

🌻 Therefore, hemorrhage is the pathologic condition listed that directly stimulates ADH release as part of the body's response to hypovolemia.

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Answer 8

Correct Answers:

Language delay

Rationale :

🌼 Language delay is the most sensitive indicator listed because language development depends heavily on a child's cognitive and intellectual abilities.

🌼 Children with intellectual disability commonly demonstrate delays in acquiring, understanding, and appropriately using language.

🌼 Delayed receptive language may appear as difficulty understanding words, instructions, or age-appropriate concepts.

🌼 Delayed expressive language can manifest as limited vocabulary, delayed sentence formation, or difficulty communicating thoughts.

🌼 Developmental assessment considers language together with cognitive, social, motor, and adaptive functioning when intellectual disability is suspected.

🌼 A significant language delay should therefore prompt further evaluation of the child's overall developmental milestones and intellectual functioning.

🌼 Formal diagnosis requires evidence of deficits in intellectual functioning and adaptive functioning, rather than language delay alone.

🌼 Among the findings provided, language delay has the strongest direct relationship with impaired cognitive development and is therefore the most sensitive indicator.

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Answer 9

Correct Answers:

Scarlet fever

Rationale :

🏵️ Scarlet fever is the condition least likely to produce wheezing because it primarily results from infection with group A Streptococcus (GAS) that produces erythrogenic toxins.

🏵️ Typical manifestations include fever, sore throat, a red “strawberry” tongue, and a characteristic sandpaper-like rash.

🏵️ Scarlet fever primarily involves the pharynx and skin rather than causing obstruction or narrowing of the lower airways.

🏵️ Wheezing is a high-pitched musical sound produced when air passes through narrowed or obstructed lower airways.

🏵️ Respiratory disorders involving bronchospasm, airway inflammation, mucus, or small-airway obstruction are therefore more commonly associated with wheezing.

🏵️ The presence of wheezing in a child should prompt assessment for conditions affecting the bronchi and bronchioles rather than uncomplicated scarlet fever.

🏵️ Additional respiratory assessment should include respiratory rate, work of breathing, oxygen saturation, retractions, breath sounds, and signs of hypoxemia.

🏵️ Therefore, scarlet fever has the weakest association with wheezing among the conditions presented.

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Answer 10

Correct Answers:

The patient's insulin levels are inadequate

Rationale :

♠️ Positive urine ketones in a client with type 1 diabetes mellitus usually indicate that the body does not have enough effective insulin available.

♠️ Without adequate insulin, glucose cannot enter cells efficiently to be used as an energy source.

♠️ The body then begins breaking down fat stores to produce energy.

♠️ Fat metabolism produces ketone bodies, which accumulate in the blood and eventually appear in the urine.

♠️ The presence of ketones can indicate worsening hyperglycemia and increases concern for development of diabetic ketoacidosis (DKA).

♠️ Clients with type 1 diabetes should generally continue insulin, even during illness, because withholding insulin can worsen ketone production.

♠️ The nurse should assess blood glucose, ketone levels, hydration status, and symptoms of DKA such as nausea, vomiting, abdominal pain, and deep respirations.

♠️ Therefore, the most likely conclusion is that the client's insulin level is inadequate for current metabolic needs.

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NSG 120HCC 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?

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NSG 120HCC 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?