NUR 402 FINAL EXAM WITH NCLEX QUESTIONS LATEST
2024-2025 ACTUAL TEST REAL QUESTIONS WITH WELL
ELABORATED ANSWERS WITH RATIONALES (100%
CORRECT VERIFIED ANSWERS) A NEW UPDATED VERSION
|ALREADY GRADED 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.
Answer- B) Assist the patient with walking several times.
Rationale: 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
Rationale: 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.
Rationale: 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.
Rationale: 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
2024-2025 ACTUAL TEST REAL QUESTIONS WITH WELL
ELABORATED ANSWERS WITH RATIONALES (100%
CORRECT VERIFIED ANSWERS) A NEW UPDATED VERSION
|ALREADY GRADED 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.
Answer- B) Assist the patient with walking several times.
Rationale: 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
Rationale: 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.
Rationale: 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.
Rationale: 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
