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NUR402 FINAL EXAM NCLEX QUESTIONS ANSWERS
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NUR 402 Final Exam NCLEX QuestionThe nurse is admitting a 68-year-old preoperative patient with a suspected abdominal
aortic aneurysm (AAA). The medication history reveals that the patient has been taking
warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission
diagnosis, the nurse should prepare to administer which medication?
A) Vitamin K
B) Cobalamin
C) Heparin sodium
D) Protamine sulfate -Answer- A) Vitamin K
Coumadin is a Vitamin K antagonist anticoagulant that could cause excessive bleeding
during surgery if clotting times are not corrected before surgery. For this reason, vitamin
K is given as the antidote for warfarin (Coumadin).
A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with
peripheral artery disease (PAD). The patient is a smoker and has a history of gout.
What should the nurse focus her teaching on to prevent complications for this patient?
A) Gender
B) Smoking
C) Ethnicity
D) Co-morbidities -Answer- B) Smoking
Smoking is the most significant factor for this patient. PAD is a marker of advanced
systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD
progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also
risk factors. Being male or Hispanic are not risk factors for PAD.
What medications should the nurse expect to include in the teaching plan to decrease
the risk of cardiovascular events and death for PAD patients (select all that apply)?
A) Ramipril (Altace)
B) Cilostazol (Pletal)
C) Simvastatin (Zocor)
D) Clopidogrel (Plavix)
E) Warfarin (Coumadin)
F) Aspirin (acetylsalicylic acid) -Answer- A) Ramipril (Altace)
C) Simvastatin (Zocor)
F) Aspirin (acetylsalicylic acid)
Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control
hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin
is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication,
but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the
,patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not
recommended to prevent CVD events in PAD patients.
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. -Answer- 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 -Answer- A) Buerger's disease
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. -Answer- D) He is bleeding into the abdomen.
, 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 -Answer- 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.
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 -Answer- 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 -Answer- D)
Teaching the patient the correct use of compression stockings
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