Nclex Questions For Fundamentals Of Nursing With Rationale
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 Which factor in the patient's past medical history
is this patient most likely experiencing? dictates that the nurse exercise caution when
1) Phantom administering acetaminophen (Tylenol)?
2) Visceral
3) Deep somatic 1) Hepatitis B
4) Referred - ANSWER -Answer: 2) Occasional alcohol use
3) Deep somatic 3) Allergy to aspirin
4) Gastric irritation with bleeding -
Rationale: ANSWER -Answer:
Deep somatic pain originates in ligaments, 1) Hepatitis B
tendons, nerves, blood vessels, and bones.
Therefore, a hip fracture causes deep somatic Rationale:
pain. Phantom pain is pain that is perceived to Even in recommended doses, acetaminophen
originate from a part that was removed during can cause severe hepatotoxicity in patients with
surgery. Visceral pain is caused by deep internal liver disease, such as hepatitis B. Patients who
pain receptors and commonly occurs in the consume alcohol regularly should also use
abdominal cavity, cranium, and thorax. Referred acetaminophen cautiously. Those allergic to
pain occurs in an area that is distant to the aspirin or other nonsteroidal anti-inflammatory
original site. 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 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 Which action should the nurse take before
medication administering morphine 4.0 mg intravenously to a
3) Developing a plan of care involving patient complaining of incisional pain?
nonpharmacologic interventions
4) Administering over-the-counter pain 1) Assess the patient's incision.
medications - ANSWER -Answer: 2) Clarify the order with the prescriber.
1) Asking about pain during vital signs 3) Assess the patient's respiratory status.
4) Monitor the patient's heart rate. -
Rationale: ANSWER -Answer:
The nurse can delegate the task of asking about 3) Assess the patient's respiratory status.
pain when nursing assistive personnel (NAP)
obtain vital signs. The NAP must be instructed to Rationale:
report findings to the nurse without delay. The Before administering an opioid analgesic, such
nurse should evaluate the effectiveness of pain as morphine, the nurse should assess the
medications and develop the plan of care. patient's respiratory status because opioid
Administering over-the-counter and prescription analgesics can cause respiratory depression. It is
medications is the responsibility of the registered not necessary to clarify the order with the
nurse or licensed practical nurse. physician because morphine 4 mg IV is an
appropriate dose. It is not necessary to monitor
,Nclex Questions For Fundamentals Of Nursing With Rationale
the patient's heart rate.
Rationale:
Codeine administered by the oral route reaches
peak concentration in 60 minutes; therefore, the
Which action should the nurse take when nurse should reassess the patient's pain 60
preparing patient-controlled analgesia for a minutes after administration. The nurse should
postoperative patient? reassess pain after 10 minutes when
administering codeine by the intramuscular or
1) Caution the patient to limit the number of times subcutaneous routes. Drugs administered by the
he presses the dosing button. intravenous (IV) route are effective almost
2) Ask another nurse to double-check the setup immediately; however, codeine is not
before patient use. recommended for IV administration.
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. - Which nonsteroidal anti-inflammatory drug might
ANSWER -Answer: be administered to inhibit platelet aggregation in
2) Ask another nurse to double-check the setup a patient at risk for thrombophlebitis?
before patient use.
1) Ibuprofen (Motrin)
Rationale: 2) Celecoxib (Celebrex)
As a safeguard to reduce the risk for dosing 3) Aspirin (Ecotrin)
errors, the nurse should request another nurse to 4) Indomethacin (Indocin) - ANSWER -
double-check the setup before patient use. The Answer:
nurse should reassure the patient that the pump 3) Aspirin (Ecotrin)
has a lockout feature that prevents him from
overdosing even if he continues to push the dose Rationale:
administration button. The nurse should also Aspirin is a unique NSAID that inhibits platelet
instruct the patient to administer a dose before aggregation. Low-dose aspirin therapy is
potentially painful activities, such as walking. commonly administered to decrease the risk of
Patient-controlled analgesia is contraindicated thrombophlebitis, myocardial infarction, and
for those who are cognitively impaired. stroke. Ibuprofen, celecoxib, and indomethacin
are NSAIDs, but they do not inhibit platelet
aggregation.
The nurse administers codeine sulfate 30 mg
orally to a patient who underwent craniotomy 3
days ago for a brain tumor. How soon after A client who is receiving epidural analgesia
administration should the nurse reassess the complains of nausea and loss of motor function in
patient's pain? his legs. The nurse obtains his blood pressure
and notes a drop in his blood pressure from the
1) Immediately previous reading. Which complication is the
2) In 10 minutes patient most likely experiencing?
3) In 15 minutes
4) In 60 minutes - ANSWER -Answer: 1) Infection at the catheter insertion site
4) In 60 minutes 2) Side effect of the epidural analgesic
, Nclex Questions For Fundamentals Of Nursing With Rationale
3) Epidural catheter migration
4) Spinal cord damage - ANSWER -
Answer: The nurse assesses clients' breath sounds.
3) Epidural catheter migration Which one requires immediate medical attention?
A client who has:
Rationale:
The patient is exhibiting signs of epidural 1) Crackles
catheter migration, which include nausea, a 2) Rhonchi
decrease in blood pressure, and loss of motor 3) Stridor
function without an identifiable cause. Signs of 4) Wheezes - ANSWER -Answer:
infection at the catheter site include redness, 3) Stridor
swelling, and drainage. Loss of motor function is
not a typical side effect associated with epidural Rationale:
analgesics. These are common signs of catheter Stridor is a sign of respiratory distress, possibly
migration, not spinal cord damage. airway obstruction. Crackles and rhonchi indicate
fluid in the lung; wheezes are caused by
narrowing of the airway. Crackles, rhonchi, and
wheezes indicate respiratory illness and are
Which of the following clients is experiencing an potentially serious but do not necessarily indicate
abnormal change in vital signs? A client whose respiratory distress that requires immediate
(select all that apply): medical attention.
1) Blood pressure (BP) was 132/80 mm Hg
sitting and is 120/60 mm Hg upon standing
2) Rectal temperature is 97.9°F in the morning The nurse assesses the client's pedal pulses as
and 99.2°F in the evening having a pulse volume of 1 on a scale of 0 to 3.
3) Heart rate was 76 before eating and is 60 after Based on this assessment finding, it would be
eating important for the nurse to also assess the:
4) Respiratory rate was 14 when standing and is
22 after walking - ANSWER -Answer: 1) Pulse deficit
1) Blood pressure (BP) was 132/80 mm Hg 2) Blood pressure
sitting and is 120/60 mm Hg upon standing 3) Apical pulse
3) Heart rate was 76 before eating and is 60 after 4) Pulse pressure - ANSWER -Answer:
eating 2) Blood pressure
Rationale: Rationale:
The BP change is abnormal; a BP change If the leg pulses are weak, the nurse should
greater than 10 mm Hg may indicate postural assess the blood pressure in order to further
hypotension. The change in heart rate is explore the reason for the low pulse volume. If
abnormal; heart rate usually increases slightly the blood pressure is low, then a low pulse
after eating rather than decreasing. The volume would be expected. The pulse deficit is
temperatures are within normal range for the the difference between the apical and radial
rectal route, and temperature increases pulse. The apical pulse would not be helpful to
throughout the day. It is normal to have an assess peripheral circulation. The pulse pressure
increased respiratory rate after exercise. is the difference between the systolic and
diastolic pressures.
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 Which factor in the patient's past medical history
is this patient most likely experiencing? dictates that the nurse exercise caution when
1) Phantom administering acetaminophen (Tylenol)?
2) Visceral
3) Deep somatic 1) Hepatitis B
4) Referred - ANSWER -Answer: 2) Occasional alcohol use
3) Deep somatic 3) Allergy to aspirin
4) Gastric irritation with bleeding -
Rationale: ANSWER -Answer:
Deep somatic pain originates in ligaments, 1) Hepatitis B
tendons, nerves, blood vessels, and bones.
Therefore, a hip fracture causes deep somatic Rationale:
pain. Phantom pain is pain that is perceived to Even in recommended doses, acetaminophen
originate from a part that was removed during can cause severe hepatotoxicity in patients with
surgery. Visceral pain is caused by deep internal liver disease, such as hepatitis B. Patients who
pain receptors and commonly occurs in the consume alcohol regularly should also use
abdominal cavity, cranium, and thorax. Referred acetaminophen cautiously. Those allergic to
pain occurs in an area that is distant to the aspirin or other nonsteroidal anti-inflammatory
original site. 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 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 Which action should the nurse take before
medication administering morphine 4.0 mg intravenously to a
3) Developing a plan of care involving patient complaining of incisional pain?
nonpharmacologic interventions
4) Administering over-the-counter pain 1) Assess the patient's incision.
medications - ANSWER -Answer: 2) Clarify the order with the prescriber.
1) Asking about pain during vital signs 3) Assess the patient's respiratory status.
4) Monitor the patient's heart rate. -
Rationale: ANSWER -Answer:
The nurse can delegate the task of asking about 3) Assess the patient's respiratory status.
pain when nursing assistive personnel (NAP)
obtain vital signs. The NAP must be instructed to Rationale:
report findings to the nurse without delay. The Before administering an opioid analgesic, such
nurse should evaluate the effectiveness of pain as morphine, the nurse should assess the
medications and develop the plan of care. patient's respiratory status because opioid
Administering over-the-counter and prescription analgesics can cause respiratory depression. It is
medications is the responsibility of the registered not necessary to clarify the order with the
nurse or licensed practical nurse. physician because morphine 4 mg IV is an
appropriate dose. It is not necessary to monitor
,Nclex Questions For Fundamentals Of Nursing With Rationale
the patient's heart rate.
Rationale:
Codeine administered by the oral route reaches
peak concentration in 60 minutes; therefore, the
Which action should the nurse take when nurse should reassess the patient's pain 60
preparing patient-controlled analgesia for a minutes after administration. The nurse should
postoperative patient? reassess pain after 10 minutes when
administering codeine by the intramuscular or
1) Caution the patient to limit the number of times subcutaneous routes. Drugs administered by the
he presses the dosing button. intravenous (IV) route are effective almost
2) Ask another nurse to double-check the setup immediately; however, codeine is not
before patient use. recommended for IV administration.
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. - Which nonsteroidal anti-inflammatory drug might
ANSWER -Answer: be administered to inhibit platelet aggregation in
2) Ask another nurse to double-check the setup a patient at risk for thrombophlebitis?
before patient use.
1) Ibuprofen (Motrin)
Rationale: 2) Celecoxib (Celebrex)
As a safeguard to reduce the risk for dosing 3) Aspirin (Ecotrin)
errors, the nurse should request another nurse to 4) Indomethacin (Indocin) - ANSWER -
double-check the setup before patient use. The Answer:
nurse should reassure the patient that the pump 3) Aspirin (Ecotrin)
has a lockout feature that prevents him from
overdosing even if he continues to push the dose Rationale:
administration button. The nurse should also Aspirin is a unique NSAID that inhibits platelet
instruct the patient to administer a dose before aggregation. Low-dose aspirin therapy is
potentially painful activities, such as walking. commonly administered to decrease the risk of
Patient-controlled analgesia is contraindicated thrombophlebitis, myocardial infarction, and
for those who are cognitively impaired. stroke. Ibuprofen, celecoxib, and indomethacin
are NSAIDs, but they do not inhibit platelet
aggregation.
The nurse administers codeine sulfate 30 mg
orally to a patient who underwent craniotomy 3
days ago for a brain tumor. How soon after A client who is receiving epidural analgesia
administration should the nurse reassess the complains of nausea and loss of motor function in
patient's pain? his legs. The nurse obtains his blood pressure
and notes a drop in his blood pressure from the
1) Immediately previous reading. Which complication is the
2) In 10 minutes patient most likely experiencing?
3) In 15 minutes
4) In 60 minutes - ANSWER -Answer: 1) Infection at the catheter insertion site
4) In 60 minutes 2) Side effect of the epidural analgesic
, Nclex Questions For Fundamentals Of Nursing With Rationale
3) Epidural catheter migration
4) Spinal cord damage - ANSWER -
Answer: The nurse assesses clients' breath sounds.
3) Epidural catheter migration Which one requires immediate medical attention?
A client who has:
Rationale:
The patient is exhibiting signs of epidural 1) Crackles
catheter migration, which include nausea, a 2) Rhonchi
decrease in blood pressure, and loss of motor 3) Stridor
function without an identifiable cause. Signs of 4) Wheezes - ANSWER -Answer:
infection at the catheter site include redness, 3) Stridor
swelling, and drainage. Loss of motor function is
not a typical side effect associated with epidural Rationale:
analgesics. These are common signs of catheter Stridor is a sign of respiratory distress, possibly
migration, not spinal cord damage. airway obstruction. Crackles and rhonchi indicate
fluid in the lung; wheezes are caused by
narrowing of the airway. Crackles, rhonchi, and
wheezes indicate respiratory illness and are
Which of the following clients is experiencing an potentially serious but do not necessarily indicate
abnormal change in vital signs? A client whose respiratory distress that requires immediate
(select all that apply): medical attention.
1) Blood pressure (BP) was 132/80 mm Hg
sitting and is 120/60 mm Hg upon standing
2) Rectal temperature is 97.9°F in the morning The nurse assesses the client's pedal pulses as
and 99.2°F in the evening having a pulse volume of 1 on a scale of 0 to 3.
3) Heart rate was 76 before eating and is 60 after Based on this assessment finding, it would be
eating important for the nurse to also assess the:
4) Respiratory rate was 14 when standing and is
22 after walking - ANSWER -Answer: 1) Pulse deficit
1) Blood pressure (BP) was 132/80 mm Hg 2) Blood pressure
sitting and is 120/60 mm Hg upon standing 3) Apical pulse
3) Heart rate was 76 before eating and is 60 after 4) Pulse pressure - ANSWER -Answer:
eating 2) Blood pressure
Rationale: Rationale:
The BP change is abnormal; a BP change If the leg pulses are weak, the nurse should
greater than 10 mm Hg may indicate postural assess the blood pressure in order to further
hypotension. The change in heart rate is explore the reason for the low pulse volume. If
abnormal; heart rate usually increases slightly the blood pressure is low, then a low pulse
after eating rather than decreasing. The volume would be expected. The pulse deficit is
temperatures are within normal range for the the difference between the apical and radial
rectal route, and temperature increases pulse. The apical pulse would not be helpful to
throughout the day. It is normal to have an assess peripheral circulation. The pulse pressure
increased respiratory rate after exercise. is the difference between the systolic and
diastolic pressures.
