NUR 402 FINAL EXAM 2026-2027 NCLEX
QUESTIONS WITH VERIFIED ANSWERS
GRADED A+
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
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.
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
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
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
QUESTIONS WITH VERIFIED ANSWERS
GRADED A+
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
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.
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
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
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
