Fundamentals of Nursing with rationale Nclex questions and Answers
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 - ansAnswer:
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.
A 75-year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with dehydration. A nursing
diagnosis of Risk for Impaired Skin Integrity is identified for this patient. Which factor places the client at Risk
for Impaired Skin Integrity? - ansAnswer:
Dehydration
Rationale:
Dehydration places the patient at risk for impaired skin integrity. Dehydration, caused by fluid volume deficit,
causes the skin to become dry and crack easily, impairing skin integrity. People who are very thin or very obese
are more likely to experience impaired skin integrity. This patient is of normal height and weight; therefore, his
body stature does not place him at risk. There is nothing to suggest that this patient has an impaired nutritional
status.
A client exhibits all of the following during a physical assessment. Which of these is considered a primary
defense against infection?
1) Fever
,2) Intact skin
3) Inflammation
4) Lethargy - ansAnswer:
2) Intact skin
Rationale:
Intact skin is considered a primary defense against infection. Fever, the inflammatory response, and
phagocytosis (a process of killing pathogens) are considered secondary defenses against infection.
A client requires protective isolation. Which client can be safely paired with this client in a client-care
assignment? One
1) admitted with unstable diabetes mellitus.
2) who underwent surgical repair of a perforated bowel.
3) with a stage 3 sacral pressure ulcer.
4) admitted with a urinary tract infection. - ansAnswer:
1) admitted with unstable diabetes mellitus.
Rationale:
The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is
free from infection. Perforation of the bowel exposes the client to infection requiring antibiotic therapy during
the postoperative period. Therefore, this client should not be paired with a client in protective isolation. A
client in protective isolation should not be paired with a client who has an open wound, such as a stage 3
pressure ulcer, or with a client who has a urinary tract infection.
A client who has experienced prolonged exposure to the cold is admitted to the hospital. Which method of
taking a temperature would be most appropriate for this client?
1) Axillary with an electronic thermometer
,2) Oral with a glass thermometer
3) Rectal with an electronic thermometer
4) Tympanic with an infrared thermometer - ansAnswer:
3) Rectal with an electronic thermometer
Rationale:
The rectal route is the most accurate for assessing core temperature, especially when it is critical to get an
accurate temperature. Therefore, in this situation it is preferred. Temperature is a particularly relevant data
point for this client with hypothermia as it indicates the patient's baseline status and response to treatment.
The electronic thermometer is safer than glass and is relatively accurate. Mercury thermometers are no longer
used in the hospital setting. The accuracy of tympanic thermometers is debatable.
A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The
nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which
complication is the patient most likely experiencing?
1) Infection at the catheter insertion site
2) Side effect of the epidural analgesic
3) Epidural catheter migration
4) Spinal cord damage - ansAnswer:
3) Epidural catheter migration
Rationale:
The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in blood
pressure, and loss of motor function without an identifiable cause. Signs of infection at the catheter site include
redness, swelling, and drainage. Loss of motor function is not a typical side effect associated with epidural
analgesics. These are common signs of catheter migration, not spinal cord damage.
A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the
wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions?
, 1) A clean gown and gloves must be worn when in contact with the client.
2) Everyone who enters the room must wear a N-95 respirator mask.
3) All linen and trash must be marked as contaminated and send to biohazard waste.
4) Place the client in a room with a client with an upper respiratory infection. - ansAnswer:
1) A clean gown and gloves must be worn when in contact with the client.
Rationale:
A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated
items in the room. A respirator mask is required only with airborne precautions, not contact precautions. All
linen must be double-bagged and clearly marked as contaminated. The client should be placed in a private
room or in a room with a client with an active infection caused by the same organism and no other infections.
A local church organizes a group for people who are having difficulty coping with the death of a loved one.
Which type of group has been organized?
1) Work-related social support group
2) Therapy group
3) Task group
4) Community committee - ansAnswer:
2) Therapy group
Rationale:
Therapy groups are designed to help individual members cope with issues, such as the death of a spouse,
divorce, or motherhood. Work-related social support groups help members of a profession cope with work-
associated stress. Task groups meet to accomplish a specified task. Community-based committees meet to
discuss community issues.
A mother comes to the emergency department after receiving a phone call informing her that her son was
involved in a motor vehicle accident. When she approaches the triage desk, she frantically asks, "How is my
son?" Which response by the nurse is best?
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 - ansAnswer:
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.
A 75-year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with dehydration. A nursing
diagnosis of Risk for Impaired Skin Integrity is identified for this patient. Which factor places the client at Risk
for Impaired Skin Integrity? - ansAnswer:
Dehydration
Rationale:
Dehydration places the patient at risk for impaired skin integrity. Dehydration, caused by fluid volume deficit,
causes the skin to become dry and crack easily, impairing skin integrity. People who are very thin or very obese
are more likely to experience impaired skin integrity. This patient is of normal height and weight; therefore, his
body stature does not place him at risk. There is nothing to suggest that this patient has an impaired nutritional
status.
A client exhibits all of the following during a physical assessment. Which of these is considered a primary
defense against infection?
1) Fever
,2) Intact skin
3) Inflammation
4) Lethargy - ansAnswer:
2) Intact skin
Rationale:
Intact skin is considered a primary defense against infection. Fever, the inflammatory response, and
phagocytosis (a process of killing pathogens) are considered secondary defenses against infection.
A client requires protective isolation. Which client can be safely paired with this client in a client-care
assignment? One
1) admitted with unstable diabetes mellitus.
2) who underwent surgical repair of a perforated bowel.
3) with a stage 3 sacral pressure ulcer.
4) admitted with a urinary tract infection. - ansAnswer:
1) admitted with unstable diabetes mellitus.
Rationale:
The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is
free from infection. Perforation of the bowel exposes the client to infection requiring antibiotic therapy during
the postoperative period. Therefore, this client should not be paired with a client in protective isolation. A
client in protective isolation should not be paired with a client who has an open wound, such as a stage 3
pressure ulcer, or with a client who has a urinary tract infection.
A client who has experienced prolonged exposure to the cold is admitted to the hospital. Which method of
taking a temperature would be most appropriate for this client?
1) Axillary with an electronic thermometer
,2) Oral with a glass thermometer
3) Rectal with an electronic thermometer
4) Tympanic with an infrared thermometer - ansAnswer:
3) Rectal with an electronic thermometer
Rationale:
The rectal route is the most accurate for assessing core temperature, especially when it is critical to get an
accurate temperature. Therefore, in this situation it is preferred. Temperature is a particularly relevant data
point for this client with hypothermia as it indicates the patient's baseline status and response to treatment.
The electronic thermometer is safer than glass and is relatively accurate. Mercury thermometers are no longer
used in the hospital setting. The accuracy of tympanic thermometers is debatable.
A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The
nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which
complication is the patient most likely experiencing?
1) Infection at the catheter insertion site
2) Side effect of the epidural analgesic
3) Epidural catheter migration
4) Spinal cord damage - ansAnswer:
3) Epidural catheter migration
Rationale:
The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in blood
pressure, and loss of motor function without an identifiable cause. Signs of infection at the catheter site include
redness, swelling, and drainage. Loss of motor function is not a typical side effect associated with epidural
analgesics. These are common signs of catheter migration, not spinal cord damage.
A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the
wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions?
, 1) A clean gown and gloves must be worn when in contact with the client.
2) Everyone who enters the room must wear a N-95 respirator mask.
3) All linen and trash must be marked as contaminated and send to biohazard waste.
4) Place the client in a room with a client with an upper respiratory infection. - ansAnswer:
1) A clean gown and gloves must be worn when in contact with the client.
Rationale:
A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated
items in the room. A respirator mask is required only with airborne precautions, not contact precautions. All
linen must be double-bagged and clearly marked as contaminated. The client should be placed in a private
room or in a room with a client with an active infection caused by the same organism and no other infections.
A local church organizes a group for people who are having difficulty coping with the death of a loved one.
Which type of group has been organized?
1) Work-related social support group
2) Therapy group
3) Task group
4) Community committee - ansAnswer:
2) Therapy group
Rationale:
Therapy groups are designed to help individual members cope with issues, such as the death of a spouse,
divorce, or motherhood. Work-related social support groups help members of a profession cope with work-
associated stress. Task groups meet to accomplish a specified task. Community-based committees meet to
discuss community issues.
A mother comes to the emergency department after receiving a phone call informing her that her son was
involved in a motor vehicle accident. When she approaches the triage desk, she frantically asks, "How is my
son?" Which response by the nurse is best?
