NCLEX Med Surg- Questions #2 (with
rationales) All Answered Correctly
Updated.
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 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.
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 - Answer 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 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.
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 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.
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 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.
Which action should the nurse take when preparing patient-controlled analgesia 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
Answer:
2) Ask another nurse to double-check the setup before patient use.
Rationale:
rationales) All Answered Correctly
Updated.
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 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.
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 - Answer 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 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.
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 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.
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 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.
Which action should the nurse take when preparing patient-controlled analgesia 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
Answer:
2) Ask another nurse to double-check the setup before patient use.
Rationale:
