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NUR 402
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NUR 402 FINAL EXAM NCLEX QUESTIONS AND ANSWERS ALL ANSWERS 100% CORRECT VERIFIED BEST SOLUTION RATED A+
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NUR 402 FINAL EXAM NCLEX QUESTIONS AND ANSWERS 2024/2025ALL 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
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?
,NUR 402 FINAL EXAM NCLEX QUESTIONS AND ANSWERS 2024/2025
ALL ANSWERS 100% CORRECT VERIFIED BEST SOLUTION RATED A+
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.
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.
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
, NUR 402 FINAL EXAM NCLEX QUESTIONS AND ANSWERS 2024/2025
ALL ANSWERS 100% CORRECT VERIFIED BEST SOLUTION RATED A+
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
CVI requires conscientious and consistent application of compression stockings.
Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or
IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent
position.
Which person should the nurse identify as having the highest risk for abdominal aortic
aneurysm?
A) A 70-year-old male, with high cholesterol and hypertension
B) A 40-year-old female with obesity and metabolic syndrome
C) A 60-year-old male with renal insufficiency who is physically inactive
D) A 65-year-old female with hyperhomocysteinemia and substance abuse - CORRECT
ANSWERS A) A 70-year-old male, with high cholesterol and hypertension
The most common etiology of descending abdominal aortic aneurysm (AAA) is
atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk
factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary
or peripheral artery disease, high blood pressure, and high cholesterol.
A 67-year-old man with peripheral artery disease is seen in the primary care clinic. Which
symptom reported by the patient would indicate to the nurse that the patient is
experiencing intermittent claudication?
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