Fundamentals of Nursing with rationale Nclex Study Guide 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
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
