ATI Fundamentals of Nursing Questions
And Answers with rationale Verified
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:
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.
The nurse administers codeine sulfate 30 mg orally to a patient who underwent
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- 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 effective almost immediately;
however, codeine is not recommended for IV administration.
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)
And Answers with rationale Verified
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:
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.
The nurse administers codeine sulfate 30 mg orally to a patient who underwent
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- 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 effective almost immediately;
however, codeine is not recommended for IV administration.
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)
