NCLEX questions #2 Med Surg (with
rationales) questions and correct
answers
A j73-year-old jpatient jwho jsustained ja jright jhip jfracture jin ja jfall jrequests jpain jmedication jfrom jthe
jnurse. jBased jon jhis jinjury, jwhich jtype jof jpain jis jthis jpatient jmost jlikely jexperiencing?
j1) jPhantom
j2) jVisceral
j3) jDeep jsomatic
j4) jReferred j- jAnswer j- jAnswer:
3) jDeep jsomatic
j
Rationale:
Deep jsomatic jpain joriginates jin jligaments, jtendons, jnerves, jblood jvessels, jand jbones. jTherefore, ja
jhip jfracture j causes jdeep jsomatic jpain. jPhantom jpain jis jpain jthat jis jperceived jto joriginate jfrom ja
jpart jthat jwas jremoved jduring jsurgery. jVisceral jpain jis jcaused jby jdeep jinternal jpain jreceptors jand
jcommonly joccurs jin j the jabdominal jcavity, jcranium, j and jthorax. jReferred jpain joccurs jin jan jarea j that
jis jdistant jto jthe j original jsite.
Which jpain jmanagement jtask jcan jthe jnurse jsafely jdelegate jto jnursing jassistive jpersonnel?
j1) jAsking jabout jpain jduring jvital jsigns
j2) j Evaluating jthe jeffectiveness jof jpain jmedication
j3) jDeveloping ja jplan jof j care jinvolving jnonpharmacologic jinterventions
j4) jAdministering jover-the-counter jpain jmedications j- jAnswer j- jAnswer:
1) jAsking jabout jpain jduring jvital jsigns
j
Rationale:
The jnurse jcan jdelegate jthe jtask jof jasking jabout jpain jwhen jnursing jassistive jpersonnel j(NAP) jobtain
jvital jsigns. jThe jNAP jmust jbe jinstructed jto jreport jfindings jto jthe j nurse jwithout jdelay. jThe jnurse
, jshould jevaluate jthe jeffectiveness jof jpain jmedications jand jdevelop jthe j plan jof j care. jAdministering
jover-the-counter jand jprescription jmedications jis jthe jresponsibility jof jthe jregistered jnurse jor
jlicensed jpractical jnurse.
Which jfactor jin jthe jpatient's jpast jmedical jhistory jdictates jthat jthe jnurse jexercise jcaution jwhen
jadministering jacetaminophen j(Tylenol)?
1) jHepatitis jB
2) jOccasional jalcohol juse
3) jAllergy jto jaspirin
4) jGastric jirritation jwith jbleeding j- jAnswer j- jAnswer:
1) jHepatitis jB
j
Rationale:
Even jin jrecommended jdoses, jacetaminophen jcan jcause jsevere jhepatotoxicity jin jpatients jwith jliver
jdisease, jsuch jas jhepatitis jB. jPatients jwho jconsume j alcohol jregularly jshould jalso juse jacetaminophen
jcautiously. jThose jallergic jto jaspirin jor jother jnonsteroidal janti-inflammatory jdrugs j(NSAIDs) jcan juse
jacetaminophen jsafely. jAcetaminophen jrarely jcauses jgastrointestinal j(GI) jproblems; jtherefore, jit j can
jbe jused jfor j those jwith ja jhistory jof jgastric jirritation j and jbleeding.
Which jaction jshould jthe jnurse jtake jbefore jadministering jmorphine j4.0 jmg jintravenously jto ja
jpatient jcomplaining jof jincisional jpain?
1) jAssess jthe jpatient's jincision.
2) jClarify jthe jorder jwith jthe jprescriber.
3) jAssess jthe jpatient's jrespiratory jstatus.
4) jMonitor jthe jpatient's jheart jrate. j- jAnswer j- jAnswer:
3) jAssess jthe jpatient's jrespiratory jstatus.
j
Rationale:
Before jadministering jan jopioid janalgesic, jsuch jas jmorphine, jthe jnurse jshould jassess jthe jpatient's
jrespiratory jstatus jbecause jopioid janalgesics jcan jcause jrespiratory jdepression. jIt jis jnot jnecessary j to
rationales) questions and correct
answers
A j73-year-old jpatient jwho jsustained ja jright jhip jfracture jin ja jfall jrequests jpain jmedication jfrom jthe
jnurse. jBased jon jhis jinjury, jwhich jtype jof jpain jis jthis jpatient jmost jlikely jexperiencing?
j1) jPhantom
j2) jVisceral
j3) jDeep jsomatic
j4) jReferred j- jAnswer j- jAnswer:
3) jDeep jsomatic
j
Rationale:
Deep jsomatic jpain joriginates jin jligaments, jtendons, jnerves, jblood jvessels, jand jbones. jTherefore, ja
jhip jfracture j causes jdeep jsomatic jpain. jPhantom jpain jis jpain jthat jis jperceived jto joriginate jfrom ja
jpart jthat jwas jremoved jduring jsurgery. jVisceral jpain jis jcaused jby jdeep jinternal jpain jreceptors jand
jcommonly joccurs jin j the jabdominal jcavity, jcranium, j and jthorax. jReferred jpain joccurs jin jan jarea j that
jis jdistant jto jthe j original jsite.
Which jpain jmanagement jtask jcan jthe jnurse jsafely jdelegate jto jnursing jassistive jpersonnel?
j1) jAsking jabout jpain jduring jvital jsigns
j2) j Evaluating jthe jeffectiveness jof jpain jmedication
j3) jDeveloping ja jplan jof j care jinvolving jnonpharmacologic jinterventions
j4) jAdministering jover-the-counter jpain jmedications j- jAnswer j- jAnswer:
1) jAsking jabout jpain jduring jvital jsigns
j
Rationale:
The jnurse jcan jdelegate jthe jtask jof jasking jabout jpain jwhen jnursing jassistive jpersonnel j(NAP) jobtain
jvital jsigns. jThe jNAP jmust jbe jinstructed jto jreport jfindings jto jthe j nurse jwithout jdelay. jThe jnurse
, jshould jevaluate jthe jeffectiveness jof jpain jmedications jand jdevelop jthe j plan jof j care. jAdministering
jover-the-counter jand jprescription jmedications jis jthe jresponsibility jof jthe jregistered jnurse jor
jlicensed jpractical jnurse.
Which jfactor jin jthe jpatient's jpast jmedical jhistory jdictates jthat jthe jnurse jexercise jcaution jwhen
jadministering jacetaminophen j(Tylenol)?
1) jHepatitis jB
2) jOccasional jalcohol juse
3) jAllergy jto jaspirin
4) jGastric jirritation jwith jbleeding j- jAnswer j- jAnswer:
1) jHepatitis jB
j
Rationale:
Even jin jrecommended jdoses, jacetaminophen jcan jcause jsevere jhepatotoxicity jin jpatients jwith jliver
jdisease, jsuch jas jhepatitis jB. jPatients jwho jconsume j alcohol jregularly jshould jalso juse jacetaminophen
jcautiously. jThose jallergic jto jaspirin jor jother jnonsteroidal janti-inflammatory jdrugs j(NSAIDs) jcan juse
jacetaminophen jsafely. jAcetaminophen jrarely jcauses jgastrointestinal j(GI) jproblems; jtherefore, jit j can
jbe jused jfor j those jwith ja jhistory jof jgastric jirritation j and jbleeding.
Which jaction jshould jthe jnurse jtake jbefore jadministering jmorphine j4.0 jmg jintravenously jto ja
jpatient jcomplaining jof jincisional jpain?
1) jAssess jthe jpatient's jincision.
2) jClarify jthe jorder jwith jthe jprescriber.
3) jAssess jthe jpatient's jrespiratory jstatus.
4) jMonitor jthe jpatient's jheart jrate. j- jAnswer j- jAnswer:
3) jAssess jthe jpatient's jrespiratory jstatus.
j
Rationale:
Before jadministering jan jopioid janalgesic, jsuch jas jmorphine, jthe jnurse jshould jassess jthe jpatient's
jrespiratory jstatus jbecause jopioid janalgesics jcan jcause jrespiratory jdepression. jIt jis jnot jnecessary j to
