Nclex questions for Fundamentals of Nursing
with rationale Exam 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 - -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:
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:
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:
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:
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:
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)
4) Indomethacin (Indocin) - -Answer:
3) Aspirin (Ecotrin)
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin
therapy is commonly administered to decrease the risk of thrombophlebitis,
myocardial infarction, and stroke. Ibuprofen, celecoxib, and indomethacin
are NSAIDs, but they do not inhibit platelet aggregation.
-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 - -Answer:
3) Epidural catheter migration
Rationale:
with rationale Exam 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 - -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:
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:
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:
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:
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:
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)
4) Indomethacin (Indocin) - -Answer:
3) Aspirin (Ecotrin)
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin
therapy is commonly administered to decrease the risk of thrombophlebitis,
myocardial infarction, and stroke. Ibuprofen, celecoxib, and indomethacin
are NSAIDs, but they do not inhibit platelet aggregation.
-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 - -Answer:
3) Epidural catheter migration
Rationale:
