NCLEX Questions for Fundamentals of
Nursing with Rationale Questions and
Answers
1.A 73-year-old patient who sustained a right hip fracture in a fall requests
pain medication from the nurse. Based on his injury, which type of pain is
this patient most likely experiencing?
1) Phantom
2) Visceral
3) Deep somatic
4) Referred
ANS
3) Deep somatic
Rationale:
Deep somatic pain originates in ligaments, tendons, nerves, blood
vessels, and bones. Therefore, a hip fracture causes deep somatic pain.
Phantom pain is pain that is perceived to originate from a part that was
removed during surgery. Visceral pain is caused by deep internal pain
receptors and commonly occurs in the abdominal cavity, cranium, and
thorax. Referred pain occurs in an area that is distant to the original
site.
2.Which pain management task can the nurse safely delegate to
nursing assistive personnel?
1) Asking about pain during vital signs
2) Evaluating the effectiveness of pain medication
3) Developing a plan of care involving nonpharmacologic interventions
4) Administering over-the-counter pain medications
ANS
1) Asking about pain during vital signs
,Rationale:
The nurse can delegate the task of asking about pain when nursing
assistive personnel (NAP) obtain vital signs. The NAP must be
instructed to report findings to the nurse without delay. The nurse
should evaluate the effectiveness of pain medications and develop the
plan of care. Administering over-the-counter and prescription
medications is the responsibility of the registered nurse or licensed
practical nurse.
3.Which factor in the patient's past medical history dictates that the
nurse exercise caution when administering acetaminophen (Tylenol)?
1) Hepatitis B
2) Occasional alcohol use
3) Allergy to aspirin
4) Gastric irritation with bleeding
ANS
1) Hepatitis B
Rationale:
Even in recommended doses, acetaminophen can cause severe
hepatotoxicity in patients with liver disease, such as hepatitis B.
Patients who consume alcohol regularly should also use acetaminophen
cautiously. Those allergic to aspirin or other nonsteroidal anti-
inflammatory drugs (NSAIDs) can use acetaminophen safely.
Acetaminophen rarely causes gastrointestinal (GI) problems; therefore,
it can be used for those with a history of gastric irritation and bleeding.
4.Which action should the nurse take before administering morphine 4.0
mg intravenously to a patient complaining of incisional pain?
1) Assess the patient's incision.
2) Clarify the order with the prescriber.
,3) Assess the patient's respiratory status.
4) Monitor the patient's heart rate.
ANS
3) Assess the patient's respiratory status.
Rationale:
Before administering an opioid analgesic, such as morphine, the nurse
should assess the patient's respiratory status because opioid analgesics
can cause respi- ratory depression. It is not necessary to clarify the orde
with the physician because morphine 4 mg IV is an appropriate dose. It i
not necessary to monitor the patient's heart rate.
5.Which action should the nurse take when preparing patient-controlled
anal- gesia for a postoperative patient?
1) Caution the patient to limit the number of times he presses the
dosing button.
2) Ask another nurse to double-check the setup before patient use.
3) Instruct the patient to administer a dose only when experiencing pain.
4) Provide clear, simple instructions for dosing if the patient is
cognitively impaired.
ANS
2) Ask another nurse to double-check the setup before patient use.
Rationale:
As a safeguard to reduce the risk for dosing errors, the nurse should
request another nurse to double-check the setup before patient use. The
nurse should reassure
the patient that the pump has a lockout feature that prevents him from
overdosing even if he continues to push the dose administration button.
The nurse should also
instruct the patient to administer a dose before potentially painful
activities, such as walking. Patient-controlled analgesia is
, contraindicated for those who are cognitively impaired.
6.The nurse administers codeine sulfate 30 mg orally to a patient who
under- went craniotomy 3 days ago for a brain tumor. How soon after
administration should the nurse reassess the patient's pain?
1) Immediately
2) In 10 minutes
3) In 15 minutes
4) In 60 minutes
ANS
4) In 60 minutes
Rationale:
Codeine administered by the oral route reaches peak concentration in
60 minutes; therefore, the nurse should reassess the patient's pain 60
minutes after administra- tion. The nurse should reassess pain after 10
minutes when administering codeine by the intramuscular or
subcutaneous routes. Drugs administered by the intravenous
(IV) route are effective almost immediately; however, codeine is not
recommended for IV administration.
7.Which nonsteroidal anti-inflammatory drug might be administered to
inhibit platelet aggregation in a patient at risk for thrombophlebitis?
1) Ibuprofen (Motrin)
2) Celecoxib (Celebrex)
3) Aspirin (Ecotrin)
4) Indomethacin (Indocin)
ANS
3) Aspirin (Ecotrin)
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose
Nursing with Rationale Questions and
Answers
1.A 73-year-old patient who sustained a right hip fracture in a fall requests
pain medication from the nurse. Based on his injury, which type of pain is
this patient most likely experiencing?
1) Phantom
2) Visceral
3) Deep somatic
4) Referred
ANS
3) Deep somatic
Rationale:
Deep somatic pain originates in ligaments, tendons, nerves, blood
vessels, and bones. Therefore, a hip fracture causes deep somatic pain.
Phantom pain is pain that is perceived to originate from a part that was
removed during surgery. Visceral pain is caused by deep internal pain
receptors and commonly occurs in the abdominal cavity, cranium, and
thorax. Referred pain occurs in an area that is distant to the original
site.
2.Which pain management task can the nurse safely delegate to
nursing assistive personnel?
1) Asking about pain during vital signs
2) Evaluating the effectiveness of pain medication
3) Developing a plan of care involving nonpharmacologic interventions
4) Administering over-the-counter pain medications
ANS
1) Asking about pain during vital signs
,Rationale:
The nurse can delegate the task of asking about pain when nursing
assistive personnel (NAP) obtain vital signs. The NAP must be
instructed to report findings to the nurse without delay. The nurse
should evaluate the effectiveness of pain medications and develop the
plan of care. Administering over-the-counter and prescription
medications is the responsibility of the registered nurse or licensed
practical nurse.
3.Which factor in the patient's past medical history dictates that the
nurse exercise caution when administering acetaminophen (Tylenol)?
1) Hepatitis B
2) Occasional alcohol use
3) Allergy to aspirin
4) Gastric irritation with bleeding
ANS
1) Hepatitis B
Rationale:
Even in recommended doses, acetaminophen can cause severe
hepatotoxicity in patients with liver disease, such as hepatitis B.
Patients who consume alcohol regularly should also use acetaminophen
cautiously. Those allergic to aspirin or other nonsteroidal anti-
inflammatory drugs (NSAIDs) can use acetaminophen safely.
Acetaminophen rarely causes gastrointestinal (GI) problems; therefore,
it can be used for those with a history of gastric irritation and bleeding.
4.Which action should the nurse take before administering morphine 4.0
mg intravenously to a patient complaining of incisional pain?
1) Assess the patient's incision.
2) Clarify the order with the prescriber.
,3) Assess the patient's respiratory status.
4) Monitor the patient's heart rate.
ANS
3) Assess the patient's respiratory status.
Rationale:
Before administering an opioid analgesic, such as morphine, the nurse
should assess the patient's respiratory status because opioid analgesics
can cause respi- ratory depression. It is not necessary to clarify the orde
with the physician because morphine 4 mg IV is an appropriate dose. It i
not necessary to monitor the patient's heart rate.
5.Which action should the nurse take when preparing patient-controlled
anal- gesia for a postoperative patient?
1) Caution the patient to limit the number of times he presses the
dosing button.
2) Ask another nurse to double-check the setup before patient use.
3) Instruct the patient to administer a dose only when experiencing pain.
4) Provide clear, simple instructions for dosing if the patient is
cognitively impaired.
ANS
2) Ask another nurse to double-check the setup before patient use.
Rationale:
As a safeguard to reduce the risk for dosing errors, the nurse should
request another nurse to double-check the setup before patient use. The
nurse should reassure
the patient that the pump has a lockout feature that prevents him from
overdosing even if he continues to push the dose administration button.
The nurse should also
instruct the patient to administer a dose before potentially painful
activities, such as walking. Patient-controlled analgesia is
, contraindicated for those who are cognitively impaired.
6.The nurse administers codeine sulfate 30 mg orally to a patient who
under- went craniotomy 3 days ago for a brain tumor. How soon after
administration should the nurse reassess the patient's pain?
1) Immediately
2) In 10 minutes
3) In 15 minutes
4) In 60 minutes
ANS
4) In 60 minutes
Rationale:
Codeine administered by the oral route reaches peak concentration in
60 minutes; therefore, the nurse should reassess the patient's pain 60
minutes after administra- tion. The nurse should reassess pain after 10
minutes when administering codeine by the intramuscular or
subcutaneous routes. Drugs administered by the intravenous
(IV) route are effective almost immediately; however, codeine is not
recommended for IV administration.
7.Which nonsteroidal anti-inflammatory drug might be administered to
inhibit platelet aggregation in a patient at risk for thrombophlebitis?
1) Ibuprofen (Motrin)
2) Celecoxib (Celebrex)
3) Aspirin (Ecotrin)
4) Indomethacin (Indocin)
ANS
3) Aspirin (Ecotrin)
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose
