Nclex Exam Questions With All Answers Correct
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: Answer:
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 assis-
tive 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: Answer:
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 ettectiveness 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: Answer:
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.: Answer:
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 respiratory depression. It is not necessary to clarify the order with the physician
because morphine 4 mg IV is an appropriate dose. It is 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.: Answer:
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: Answer:
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 administration. 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 ettective
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): Answer:
3) Aspirin (Ecotrin)
Rationale:
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: Answer:
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 assis-
tive 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: Answer:
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 ettectiveness 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: Answer:
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.: Answer:
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 respiratory depression. It is not necessary to clarify the order with the physician
because morphine 4 mg IV is an appropriate dose. It is 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.: Answer:
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: Answer:
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 administration. 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 ettective
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): Answer:
3) Aspirin (Ecotrin)
Rationale:
