NUR 402 FINAL EXAM NCLEX QUESTIONS AND ANSWERS 2024/2025
ALL ANSWERS 100% CORRECT VERIFIED BEST SOLUTION RATED A+
A female patient with critical limb ischemia has had peripheral
artery bypass surgery to improve her circulation. What care
should the nurse provide on postoperative day 1?
A) Keep the patient on bed rest.
B) Assist the patient with walking several times.
C) Have the patient sit in the chair several times.
D) Place the patient on her side with knees flexed. - CORRECT
ANSWERS B) Assist the patient with walking several times.
To avoid blockage of the graft or stent, the patient should walk
several times on postoperative day 1 and subsequent days. Having
the patient's knees flexed for sitting in a chair or in bed increase
the risk of venous thrombosis and may place stress on the suture
lines.
A 40-year-old man tells the nurse he has a diagnosis for the color
and temperature changes of his limbs but can't remember the
name of it. He says he must stop smoking and avoid trauma and
exposure of his limbs to cold temperatures to get better. This
description should allow the nurse to ask the patient if he has
which diagnosis?
A) Buerger's disease
B) Venous thrombosis
C) Acute arterial ischemia
D) Raynaud's phenomenon - CORRECT ANSWERS A) Buerger's
disease
,NUR 402 FINAL EXAM NCLEX QUESTIONS AND ANSWERS 2024/2025
ALL ANSWERS 100% CORRECT VERIFIED BEST SOLUTION RATED A+
Buerger's disease is a nonatherosclerotic, segmental, recurrent
inflammatory disorder of small and medium-sized veins and
arteries of upper and lower extremities leading to color and
temperature changes of the limbs, intermittent claudication, rest
pain, and ischemic ulcerations. It primarily occurs in men younger
than 45 years old with a long history of tobacco and/or marijuana
use. Buerger's disease treatment includes smoking cessation,
trauma and cold temperature avoidance, and a walking program.
Venous thrombosis is the formation of a thrombus in association
with inflammation of the vein. Acute arterial ischemia is a sudden
interruption in arterial blood flow to a tissue caused by embolism,
thrombosis, or trauma. Raynaud's phenomenon is characterized
by vasospasm-induced color changes of the fingers, toes, ears, and
nose.
A male patient was admitted for a possible ruptured aortic
aneurysm, but had no back pain. Ten minutes later his assessment
includes the following: sinus tachycardia at 138, BP palpable at 65
mm Hg, increasing waist circumference, and no urine output. How
should the nurse interpret this assessment about the patient's
aneurysm?
A) Tamponade will soon occur.
B) The renal arteries are involved.
C) Perfusion to the legs is impaired.
D) He is bleeding into the abdomen. - CORRECT ANSWERS D) He
is bleeding into the abdomen.
,NUR 402 FINAL EXAM NCLEX QUESTIONS AND ANSWERS 2024/2025
ALL ANSWERS 100% CORRECT VERIFIED BEST SOLUTION RATED A+
The lack of back pain indicates the patient is most likely
exsanguinating into the abdominal space, and the bleeding is
likely to continue without surgical repair. A blockade of the blood
flow will not occur in the abdominal space as it would in the
retroperitoneal space where surrounding anatomic structures
may control the bleeding. The lack of urine output does not
indicate renal artery involvement, but that the bleeding is
occurring above the renal arteries, which decreases the blood
flow to the kidneys. There is no assessment data indicating
decreased perfusion to the legs.
The patient had aortic aneurysm repair. What priority nursing
action will the nurse use to maintain graft patency?
A) Assess output for renal dysfunction.
B) Use IV fluids to maintain adequate BP.
C) Use oral antihypertensives to maintain cardiac output.
D) Maintain a low BP to prevent pressure on surgical site -
CORRECT ANSWERS B) Use IV fluids to maintain adequate BP.
The priority is to maintain an adequate BP (determined by the
surgeon) to maintain graft patency. A prolonged low BP may
result in graft thrombosis, and hypertension may cause undue
stress on arterial anastomoses resulting in leakage of blood or
rupture at the suture lines, which is when IV antihypertensives
may be used. Renal output will be assessed when the aneurysm
repair is above the renal arteries to assess graft patency, not
maintain it.
, NUR 402 FINAL EXAM NCLEX QUESTIONS AND ANSWERS 2024/2025
ALL ANSWERS 100% CORRECT VERIFIED BEST SOLUTION RATED A+
The patient has CVI and a venous ulcer. The unlicensed assistive
personnel (UAP) decides to apply compression stockings because
that is what these patients always have ordered. What assessment
by the nurse would cause the application of compression
stockings to harm the patient?
A) Rest pain
B) High blood pressure
C) Elevated blood sugar
D) Dry, itchy, flaky skin - CORRECT ANSWERS A) Rest pain
Rest pain occurs as peripheral artery disease (PAD) progresses
and involves multiple arterial segments. Compression stockings
should not be used on patients with PAD. Elevated blood glucose,
possibly indicating uncontrolled diabetes mellitus, and
hypertension may or may not indicate arterial problems. Dry,
itchy, flaky skin indicates venous insufficiency. The RN should be
the one to obtain the order and instruct the UAP to apply
compression stockings if they are ordered.
What is a priority nursing intervention in the care of a patient
with a diagnosis of chronic venous insufficiency (CVI)?
A) Application of topical antibiotics to venous ulcers
B) Maintaining the patient's legs in a dependent position
C) Administration of oral and/or subcutaneous anticoagulants
D) Teaching the patient the correct use of compression stockings -
CORRECT ANSWERS D) Teaching the patient the correct use of
compression stockings
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