NCLEX NCSBN LATEST ACTUAL EXAM WITH 250+ ACTUAL QUESTIONS AND CORRECT
ANSWERS RATED A+
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-Correct Answer: B
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.
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 - ANSWER-Correct
Answer: A
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
During an assessment of a patient's abdomen, a pulsating abdominal mass is noted by the
healthcare provider. Which of the following should be the healthcare provider's next action?
A. Assess femoral pulses
B. Obtain a bladder scan
C. Measure the abdominal circumference
D. Ask the patient to perform a Valsalva maneuver - ANSWER-A - assess femoral pulse
A patient sustains an amputation of the first and second digits in a chainsaw accident. Which
task should be delegated to the LPN/LVN?
A
Gently cleanse the amputated digits with Betadine solution.
B
Place the amputated digits directly into ice slurry.
C
Wrap the amputated digits in sterile gauze moistened with saline.
D
Store the amputated digits in a solution of sterile normal saline. - ANSWER-Question 14
Explanation: C
The only correct intervention is C. the digits should be gently cleansed with normal saline,
wrapped in sterile gauze moistened with saline, and placed in a plastic bag or container. The
container is then placed on ice.
Matt has PVD. The nurse shows an understanding of PVD when the nurse states:
,A. In PVD, skin temperature is not important.
B. Do not elevate lower limb positioning for arterial PVD
C. No hair on lower legs with venous PVD
D. Elevate lower limb positioning for venous PVD - ANSWER-B and D
**no elevation with arterial, can elevate with venous, but not above level of the heart.
**no hair on legs for arterial PVD
Amy is being assessed for PVD. Upon her assessment, the nurse finds that Amy has ulceration
around her hips, her legs show no edema, she has severe pain, and has no pedal pulse. What
would the nurse take away from this assessment?
1. Venous PVD
2. Arterial PVD - ANSWER-2 - Arterial PVD
Barry is being assessed for PVD. He complains of aching pain. His skin feels warm and there is
edema present. He has a pedal pulse. His skin feels thick and dry. What would his s/s indicate?
1. Acute venous PVD
2. Chronic arterial PVD
3. Chronic venous PVD
4. Acute arterial PVD - ANSWER-3 - chronic venous PVD
PVD often affects the blood flow usually where?
, A. Arms
B. Legs
C. Heart
D. Kidney - ANSWER-B. legs
**venous ulcers will appear on legs, arterial ulcers on toes
A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants are
covered with blood. He and his hysterical friends are yelling and trying to explain that that they
were goofing around and he got poked in the abdomen with a stick. Which of the following
comments should be given first consideration?
A
"There was a lot of blood and we used three bandages."
B
"He pulled the stick out, just now, because it was hurting him."
C
"The stick was really dirty and covered with mud."
D
"He's a diabetic, so he needs attention right away." - ANSWER-Question 20 Explanation: B
An impaled object may be providing a tamponade effect, and removal can precipitate sudden
hemodynamic decompensation. Additional history including a more definitive description of the
blood loss, depth of penetration, and medical history should be obtained. Other information,
such as the dirt on the stick or history of diabetes, is important in the overall treatment plan,
but can be addressed later.
PVD can be most modified by:
ANSWERS RATED A+
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-Correct Answer: B
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.
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 - ANSWER-Correct
Answer: A
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
During an assessment of a patient's abdomen, a pulsating abdominal mass is noted by the
healthcare provider. Which of the following should be the healthcare provider's next action?
A. Assess femoral pulses
B. Obtain a bladder scan
C. Measure the abdominal circumference
D. Ask the patient to perform a Valsalva maneuver - ANSWER-A - assess femoral pulse
A patient sustains an amputation of the first and second digits in a chainsaw accident. Which
task should be delegated to the LPN/LVN?
A
Gently cleanse the amputated digits with Betadine solution.
B
Place the amputated digits directly into ice slurry.
C
Wrap the amputated digits in sterile gauze moistened with saline.
D
Store the amputated digits in a solution of sterile normal saline. - ANSWER-Question 14
Explanation: C
The only correct intervention is C. the digits should be gently cleansed with normal saline,
wrapped in sterile gauze moistened with saline, and placed in a plastic bag or container. The
container is then placed on ice.
Matt has PVD. The nurse shows an understanding of PVD when the nurse states:
,A. In PVD, skin temperature is not important.
B. Do not elevate lower limb positioning for arterial PVD
C. No hair on lower legs with venous PVD
D. Elevate lower limb positioning for venous PVD - ANSWER-B and D
**no elevation with arterial, can elevate with venous, but not above level of the heart.
**no hair on legs for arterial PVD
Amy is being assessed for PVD. Upon her assessment, the nurse finds that Amy has ulceration
around her hips, her legs show no edema, she has severe pain, and has no pedal pulse. What
would the nurse take away from this assessment?
1. Venous PVD
2. Arterial PVD - ANSWER-2 - Arterial PVD
Barry is being assessed for PVD. He complains of aching pain. His skin feels warm and there is
edema present. He has a pedal pulse. His skin feels thick and dry. What would his s/s indicate?
1. Acute venous PVD
2. Chronic arterial PVD
3. Chronic venous PVD
4. Acute arterial PVD - ANSWER-3 - chronic venous PVD
PVD often affects the blood flow usually where?
, A. Arms
B. Legs
C. Heart
D. Kidney - ANSWER-B. legs
**venous ulcers will appear on legs, arterial ulcers on toes
A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants are
covered with blood. He and his hysterical friends are yelling and trying to explain that that they
were goofing around and he got poked in the abdomen with a stick. Which of the following
comments should be given first consideration?
A
"There was a lot of blood and we used three bandages."
B
"He pulled the stick out, just now, because it was hurting him."
C
"The stick was really dirty and covered with mud."
D
"He's a diabetic, so he needs attention right away." - ANSWER-Question 20 Explanation: B
An impaled object may be providing a tamponade effect, and removal can precipitate sudden
hemodynamic decompensation. Additional history including a more definitive description of the
blood loss, depth of penetration, and medical history should be obtained. Other information,
such as the dirt on the stick or history of diabetes, is important in the overall treatment plan,
but can be addressed later.
PVD can be most modified by:
