NCLEX QUESTIONS #2 MED SURG (WITH
RATIONALES) AND ANSWERS LATEST VERSION
VERIFIED RATIONALE GRADED A+
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 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.
, NCLEX QUESTIONS #2 MED SURG (WITH
RATIONALES) AND ANSWERS LATEST VERSION
VERIFIED RATIONALE GRADED A+
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:
RATIONALES) AND ANSWERS LATEST VERSION
VERIFIED RATIONALE GRADED A+
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 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.
, NCLEX QUESTIONS #2 MED SURG (WITH
RATIONALES) AND ANSWERS LATEST VERSION
VERIFIED RATIONALE GRADED A+
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:
