NSG 120 EXAM 3 COMPREHENSIVE
ASSESSMENT QUESTIONS WITH
CORRECT ANSWERS (LATEST 2026 /
2027), (A+ GUARANTEE).
1. A nurse is caring for a client with a serum sodium level of 152 mEq/L. Which of the
following clinical manifestations should the nurse prioritize?
A. Muscle weakness and cardiac arrhythmias
B. Abdominal cramping and diarrhea
C. Agitation, confusion, and thirst
D. Hyperactive deep tendon reflexes
Answer: C
Conceptual Explanation: A sodium level of 152 mEq/L indicates hypernatremia. The
brain is most sensitive to changes in sodium; therefore, neurological symptoms like
agitation and confusion, along with thirst (the body’s compensatory mechanism), are
primary indicators.
2. When performing a sterile dressing change, which action by the nurse would violate the
principles of surgical asepsis?
A. Keeping the sterile field within the line of vision at all times
,B. Holding sterile gloved hands above the waist level
C. Turning the back to the sterile field to reach for additional supplies
D. Opening the outermost flap of the sterile kit away from the body
Answer: C
Conceptual Explanation: A sterile field is considered contaminated if it is out of the
nurse’s range of vision or if the nurse turns their back on it.
3. A client is receiving a continuous intravenous infusion of Heparin. The nurse notes the
client’s aPTT is 110 seconds (Control: 30-40 seconds). Which medication should the nurse
expect the provider to order?
A. Vitamin K
B. Naloxone
C. Calcium gluconate
D. Protamine sulfate
Answer: D
Conceptual Explanation: Protamine sulfate is the specific antidote for Heparin overdose.
An aPTT of 110 is significantly above the therapeutic range (usually 1.5 to 2.5 times the
control).
4. Which assessment finding is most characteristic of a stage 3 pressure injury?
A. Non-blanchable erythema of intact skin
, B. Partial-thickness loss of dermis presenting as a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness tissue loss with exposed bone or tendon
Answer: C
Conceptual Explanation: Stage 3 involves full-thickness skin loss where adipose (fat) is
visible in the ulcer, but bone, tendon, or muscle are not yet exposed.
5. The nurse is preparing to administer an intramuscular injection using the Z-track technique.
What is the primary purpose of this method?
A. To prevent the medication from leaking back into the needle track
B. To decrease the pain associated with the needle stick
C. To ensure the medication reaches the subcutaneous tissue
D. To speed up the absorption of the medication
Answer: A
Conceptual Explanation: The Z-track method seals the medication in the muscle tissue
and minimizes skin irritation by preventing the drug from tracking back through the
subcutaneous tissue.
6. A nurse is teaching a client about a low-purine diet. Which food choice indicates the client
understands the teaching?
A. Liver and onions
ASSESSMENT QUESTIONS WITH
CORRECT ANSWERS (LATEST 2026 /
2027), (A+ GUARANTEE).
1. A nurse is caring for a client with a serum sodium level of 152 mEq/L. Which of the
following clinical manifestations should the nurse prioritize?
A. Muscle weakness and cardiac arrhythmias
B. Abdominal cramping and diarrhea
C. Agitation, confusion, and thirst
D. Hyperactive deep tendon reflexes
Answer: C
Conceptual Explanation: A sodium level of 152 mEq/L indicates hypernatremia. The
brain is most sensitive to changes in sodium; therefore, neurological symptoms like
agitation and confusion, along with thirst (the body’s compensatory mechanism), are
primary indicators.
2. When performing a sterile dressing change, which action by the nurse would violate the
principles of surgical asepsis?
A. Keeping the sterile field within the line of vision at all times
,B. Holding sterile gloved hands above the waist level
C. Turning the back to the sterile field to reach for additional supplies
D. Opening the outermost flap of the sterile kit away from the body
Answer: C
Conceptual Explanation: A sterile field is considered contaminated if it is out of the
nurse’s range of vision or if the nurse turns their back on it.
3. A client is receiving a continuous intravenous infusion of Heparin. The nurse notes the
client’s aPTT is 110 seconds (Control: 30-40 seconds). Which medication should the nurse
expect the provider to order?
A. Vitamin K
B. Naloxone
C. Calcium gluconate
D. Protamine sulfate
Answer: D
Conceptual Explanation: Protamine sulfate is the specific antidote for Heparin overdose.
An aPTT of 110 is significantly above the therapeutic range (usually 1.5 to 2.5 times the
control).
4. Which assessment finding is most characteristic of a stage 3 pressure injury?
A. Non-blanchable erythema of intact skin
, B. Partial-thickness loss of dermis presenting as a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness tissue loss with exposed bone or tendon
Answer: C
Conceptual Explanation: Stage 3 involves full-thickness skin loss where adipose (fat) is
visible in the ulcer, but bone, tendon, or muscle are not yet exposed.
5. The nurse is preparing to administer an intramuscular injection using the Z-track technique.
What is the primary purpose of this method?
A. To prevent the medication from leaking back into the needle track
B. To decrease the pain associated with the needle stick
C. To ensure the medication reaches the subcutaneous tissue
D. To speed up the absorption of the medication
Answer: A
Conceptual Explanation: The Z-track method seals the medication in the muscle tissue
and minimizes skin irritation by preventing the drug from tracking back through the
subcutaneous tissue.
6. A nurse is teaching a client about a low-purine diet. Which food choice indicates the client
understands the teaching?
A. Liver and onions
