Advance Fundamentals Final Exam Questions
with Accurate Answers
A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at
120 mL/hr. Which of the following statements by the client should the alert the
nurse to suspect fluid overload? (Select all that apply)
a. "I feel lightheaded."
b. "I feel as though my heart is racing."
c. "I feel a little short of breath."
d. "The nurse technician told me that my blood pressure was 150 over 90."
e. "I think my ankles are less swollen." correct answer B, C, D
A nurse is collecting data from an older adult client as part of a neurologic
examination. Which of the following findings should the nurse expect as changes
associated with aging? (Select all that apply)
a. slower light touch sensation
b. some vision and hearing decline
c. slower fine finger movement
d. some short-term memory decline
e. decreased risk of depression correct answer A, B, C, D
A nurse is collection data from a client who is receiving IV therapy and reports
pain in the arm, chills, and "not feeling well." The nurse notes warmth, edema,
induration, and red streaking on the client's arm close to the IV insertion site.
Which of the following actions should the nurse plan to take first?
,a. Obtain a specimen for culture
b. apply a warm compress
c. administer analgesics
d. discontinue the infusion correct answer D. Discontinue the infusion
A nurse is demonstrating how to insert an IV catheter. Which of the following
statements by a nurse viewing the demonstration indicates understanding of the
procedure?
a. "I will thread the needle all the way into the vein until the hub rests against the
insertion site after I see a flashback of blood."
b. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees
with the bevel up."
c. "I will apply pressure approximately 1.2 inches below the insertion site prior to
removing the needle."
d. "I will choose a vein in the antecubital fossa for IV insertion due to its size and
easily accessible location." correct answer B. "I will insert the needle into the
client's skin at an angle of 10 to 30 degrees with the bevel up."
A nurse is performing a neurologic examination for a client. Which of the
following assessments should the nurse perform to test the client's balance?
(Select all that apply)
a. romberg test
b. hell-to-toe walk
c. snellen test
, d. spinal accessory function
e. rosenbaum test correct answer A, B
A nurse is performing an integumentary assessment for a group of clients. Which
of the following findings should the nurse recognize as requiring immediate
intervention?
a. pallor
b. cyanosis
c. jaundice
d. erythema correct answer B. cyanosis
A nurse is performing skin assessments on a group of clients. Which of the
following lesions should the nurse identify as vesicles? (Select all that apply)
a. acne
b. warts
c. psoriasis
d. herpes simplex
e. varicella correct answer D, E
A nurse is preparing to inject heparin SQ for a client who is postoperative. Which
of the following actions should the nurse take?
a. Use a 22-gauge needle
b. Select a site on the client's abdomen
with Accurate Answers
A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at
120 mL/hr. Which of the following statements by the client should the alert the
nurse to suspect fluid overload? (Select all that apply)
a. "I feel lightheaded."
b. "I feel as though my heart is racing."
c. "I feel a little short of breath."
d. "The nurse technician told me that my blood pressure was 150 over 90."
e. "I think my ankles are less swollen." correct answer B, C, D
A nurse is collecting data from an older adult client as part of a neurologic
examination. Which of the following findings should the nurse expect as changes
associated with aging? (Select all that apply)
a. slower light touch sensation
b. some vision and hearing decline
c. slower fine finger movement
d. some short-term memory decline
e. decreased risk of depression correct answer A, B, C, D
A nurse is collection data from a client who is receiving IV therapy and reports
pain in the arm, chills, and "not feeling well." The nurse notes warmth, edema,
induration, and red streaking on the client's arm close to the IV insertion site.
Which of the following actions should the nurse plan to take first?
,a. Obtain a specimen for culture
b. apply a warm compress
c. administer analgesics
d. discontinue the infusion correct answer D. Discontinue the infusion
A nurse is demonstrating how to insert an IV catheter. Which of the following
statements by a nurse viewing the demonstration indicates understanding of the
procedure?
a. "I will thread the needle all the way into the vein until the hub rests against the
insertion site after I see a flashback of blood."
b. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees
with the bevel up."
c. "I will apply pressure approximately 1.2 inches below the insertion site prior to
removing the needle."
d. "I will choose a vein in the antecubital fossa for IV insertion due to its size and
easily accessible location." correct answer B. "I will insert the needle into the
client's skin at an angle of 10 to 30 degrees with the bevel up."
A nurse is performing a neurologic examination for a client. Which of the
following assessments should the nurse perform to test the client's balance?
(Select all that apply)
a. romberg test
b. hell-to-toe walk
c. snellen test
, d. spinal accessory function
e. rosenbaum test correct answer A, B
A nurse is performing an integumentary assessment for a group of clients. Which
of the following findings should the nurse recognize as requiring immediate
intervention?
a. pallor
b. cyanosis
c. jaundice
d. erythema correct answer B. cyanosis
A nurse is performing skin assessments on a group of clients. Which of the
following lesions should the nurse identify as vesicles? (Select all that apply)
a. acne
b. warts
c. psoriasis
d. herpes simplex
e. varicella correct answer D, E
A nurse is preparing to inject heparin SQ for a client who is postoperative. Which
of the following actions should the nurse take?
a. Use a 22-gauge needle
b. Select a site on the client's abdomen
