Nclex questions for Fundamentals of Nursing with rationale
Study online at https://quizlet.com/_jmg9sm
1. A 73-year-old patient who Answer:
sustained a right hip fracture 3) Deep somatic
in a fall requests pain med-
ication from the nurse. Based Rationale:
on his injury, which type of Deep somatic pain originates in ligaments, tendons, nerves,
pain is this patient most likely blood vessels, and bones. Therefore, a hip fracture causes deep
experiencing? somatic pain. Phantom pain is pain that is perceived to originate
1) Phantom from a part that was removed during surgery. Visceral pain is
2) Visceral caused by deep internal pain receptors and commonly occurs in
3) Deep somatic the abdominal cavity, cranium, and thorax. Referred pain occurs
4) Referred in an area that is distant to the original site.
2. Which pain management Answer:
task can the nurse safely 1) Asking about pain during vital signs
delegate to nursing assistive
personnel? Rationale:
1) Asking about pain during The nurse can delegate the task of asking about pain when nurs-
vital signs ing assistive personnel (NAP) obtain vital signs. The NAP must
2) Evaluating the effective- be instructed to report findings to the nurse without delay. The
ness of pain medication nurse should evaluate the effectiveness of pain medications and
3) Developing a plan of care develop the plan of care. Administering over-the-counter and
involving nonpharmacologic prescription medications is the responsibility of the registered
interventions nurse or licensed practical nurse.
4) Administering
over-the-counter pain med-
ications
3. Which factor in the patient's Answer:
past medical history dictates 1) Hepatitis B
that the nurse exercise cau-
tion when administering ac- Rationale:
etaminophen (Tylenol)? Even in recommended doses, acetaminophen can cause se-
, Nclex questions for Fundamentals of Nursing with rationale
Study online at https://quizlet.com/_jmg9sm
vere hepatotoxicity in patients with liver disease, such as he-
1) Hepatitis B patitis B. Patients who consume alcohol regularly should also
2) Occasional alcohol use use acetaminophen cautiously. Those allergic to aspirin or other
3) Allergy to aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can use aceta-
4) Gastric irritation with minophen safely. Acetaminophen rarely causes gastrointestinal
bleeding (GI) problems; therefore, it can be used for those with a history
of gastric irritation and bleeding.
4. Which action should the Answer:
nurse take before adminis- 3) Assess the patient's respiratory status.
tering morphine 4.0 mg in-
travenously to a patient com- Rationale:
plaining of incisional pain? Before administering an opioid analgesic, such as morphine,
the nurse should assess the patient's respiratory status because
1) Assess the patient's inci- opioid analgesics can cause respiratory depression. It is not nec-
sion. essary to clarify the order with the physician because morphine
2) Clarify the order with the 4 mg IV is an appropriate dose. It is not necessary to monitor the
prescriber. patient's heart rate.
3) Assess the patient's respi-
ratory status.
4) Monitor the patient's heart
rate.
5. Which action should the Answer:
nurse take when preparing 2) Ask another nurse to double-check the setup before patient
patient-controlled analgesia use.
for a postoperative patient?
Rationale:
1) Caution the patient to lim- As a safeguard to reduce the risk for dosing errors, the nurse
it the number of times he should request another nurse to double-check the setup before
presses the dosing button. patient use. The nurse should reassure the patient that the pump
2) Ask another nurse to dou- has a lockout feature that prevents him from overdosing even
, Nclex questions for Fundamentals of Nursing with rationale
Study online at https://quizlet.com/_jmg9sm
ble-check the setup before if he continues to push the dose administration button. The
patient use. nurse should also instruct the patient to administer a dose before
3) Instruct the patient to ad- potentially painful activities, such as walking. Patient-controlled
minister a dose only when ex- analgesia is contraindicated for those who are cognitively im-
periencing pain. paired.
4) Provide clear, simple in-
structions for dosing if the
patient is cognitively im-
paired.
6. The nurse administers Answer:
codeine sulfate 30 mg orally 4) In 60 minutes
to a patient who underwent
craniotomy 3 days ago for Rationale:
a brain tumor. How soon af- Codeine administered by the oral route reaches peak concen-
ter administration should the tration in 60 minutes; therefore, the nurse should reassess the
nurse reassess the patient's patient's pain 60 minutes after administration. The nurse should
pain? reassess pain after 10 minutes when administering codeine by
the intramuscular or subcutaneous routes. Drugs administered
1) Immediately by the intravenous (IV) route are effective almost immediately;
2) In 10 minutes however, codeine is not recommended for IV administration.
3) In 15 minutes
4) In 60 minutes
7. Which nonsteroidal anti-in- Answer:
flammatory drug might 3) Aspirin (Ecotrin)
be administered to inhib-
it platelet aggregation in a Rationale:
patient at risk for throm- Aspirin is a unique NSAID that inhibits platelet aggregation.
bophlebitis? Low-dose aspirin therapy is commonly administered to decrease
the risk of thrombophlebitis, myocardial infarction, and stroke.
1) Ibuprofen (Motrin)
, Nclex questions for Fundamentals of Nursing with rationale
Study online at https://quizlet.com/_jmg9sm
2) Celecoxib (Celebrex) Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do
3) Aspirin (Ecotrin) not inhibit platelet aggregation.
4) Indomethacin (Indocin)
8. A client who is receiving Answer:
epidural analgesia complains 3) Epidural catheter migration
of nausea and loss of motor
function in his legs. The nurse Rationale:
obtains his blood pressure The patient is exhibiting signs of epidural catheter migration,
and notes a drop in his blood which include nausea, a decrease in blood pressure, and loss of
pressure from the previous motor function without an identifiable cause. Signs of infection at
reading. Which complication the catheter site include redness, swelling, and drainage. Loss of
is the patient most likely ex- motor function is not a typical side effect associated with epidural
periencing? analgesics. These are common signs of catheter migration, not
spinal cord damage.
1) Infection at the catheter in-
sertion site
2) Side effect of the epidural
analgesic
3) Epidural catheter migra-
tion
4) Spinal cord damage
9. Which of the following clients Answer:
is experiencing an abnormal 1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60
change in vital signs? A client mm Hg upon standing
whose (select all that apply): 3) Heart rate was 76 before eating and is 60 after eating
1) Blood pressure (BP) was Rationale:
132/80 mm Hg sitting and is The BP change is abnormal; a BP change greater than 10 mm Hg
120/60 mm Hg upon stand- may indicate postural hypotension. The change in heart rate is
ing abnormal; heart rate usually increases slightly after eating rather
Study online at https://quizlet.com/_jmg9sm
1. A 73-year-old patient who Answer:
sustained a right hip fracture 3) Deep somatic
in a fall requests pain med-
ication from the nurse. Based Rationale:
on his injury, which type of Deep somatic pain originates in ligaments, tendons, nerves,
pain is this patient most likely blood vessels, and bones. Therefore, a hip fracture causes deep
experiencing? somatic pain. Phantom pain is pain that is perceived to originate
1) Phantom from a part that was removed during surgery. Visceral pain is
2) Visceral caused by deep internal pain receptors and commonly occurs in
3) Deep somatic the abdominal cavity, cranium, and thorax. Referred pain occurs
4) Referred in an area that is distant to the original site.
2. Which pain management Answer:
task can the nurse safely 1) Asking about pain during vital signs
delegate to nursing assistive
personnel? Rationale:
1) Asking about pain during The nurse can delegate the task of asking about pain when nurs-
vital signs ing assistive personnel (NAP) obtain vital signs. The NAP must
2) Evaluating the effective- be instructed to report findings to the nurse without delay. The
ness of pain medication nurse should evaluate the effectiveness of pain medications and
3) Developing a plan of care develop the plan of care. Administering over-the-counter and
involving nonpharmacologic prescription medications is the responsibility of the registered
interventions nurse or licensed practical nurse.
4) Administering
over-the-counter pain med-
ications
3. Which factor in the patient's Answer:
past medical history dictates 1) Hepatitis B
that the nurse exercise cau-
tion when administering ac- Rationale:
etaminophen (Tylenol)? Even in recommended doses, acetaminophen can cause se-
, Nclex questions for Fundamentals of Nursing with rationale
Study online at https://quizlet.com/_jmg9sm
vere hepatotoxicity in patients with liver disease, such as he-
1) Hepatitis B patitis B. Patients who consume alcohol regularly should also
2) Occasional alcohol use use acetaminophen cautiously. Those allergic to aspirin or other
3) Allergy to aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can use aceta-
4) Gastric irritation with minophen safely. Acetaminophen rarely causes gastrointestinal
bleeding (GI) problems; therefore, it can be used for those with a history
of gastric irritation and bleeding.
4. Which action should the Answer:
nurse take before adminis- 3) Assess the patient's respiratory status.
tering morphine 4.0 mg in-
travenously to a patient com- Rationale:
plaining of incisional pain? Before administering an opioid analgesic, such as morphine,
the nurse should assess the patient's respiratory status because
1) Assess the patient's inci- opioid analgesics can cause respiratory depression. It is not nec-
sion. essary to clarify the order with the physician because morphine
2) Clarify the order with the 4 mg IV is an appropriate dose. It is not necessary to monitor the
prescriber. patient's heart rate.
3) Assess the patient's respi-
ratory status.
4) Monitor the patient's heart
rate.
5. Which action should the Answer:
nurse take when preparing 2) Ask another nurse to double-check the setup before patient
patient-controlled analgesia use.
for a postoperative patient?
Rationale:
1) Caution the patient to lim- As a safeguard to reduce the risk for dosing errors, the nurse
it the number of times he should request another nurse to double-check the setup before
presses the dosing button. patient use. The nurse should reassure the patient that the pump
2) Ask another nurse to dou- has a lockout feature that prevents him from overdosing even
, Nclex questions for Fundamentals of Nursing with rationale
Study online at https://quizlet.com/_jmg9sm
ble-check the setup before if he continues to push the dose administration button. The
patient use. nurse should also instruct the patient to administer a dose before
3) Instruct the patient to ad- potentially painful activities, such as walking. Patient-controlled
minister a dose only when ex- analgesia is contraindicated for those who are cognitively im-
periencing pain. paired.
4) Provide clear, simple in-
structions for dosing if the
patient is cognitively im-
paired.
6. The nurse administers Answer:
codeine sulfate 30 mg orally 4) In 60 minutes
to a patient who underwent
craniotomy 3 days ago for Rationale:
a brain tumor. How soon af- Codeine administered by the oral route reaches peak concen-
ter administration should the tration in 60 minutes; therefore, the nurse should reassess the
nurse reassess the patient's patient's pain 60 minutes after administration. The nurse should
pain? reassess pain after 10 minutes when administering codeine by
the intramuscular or subcutaneous routes. Drugs administered
1) Immediately by the intravenous (IV) route are effective almost immediately;
2) In 10 minutes however, codeine is not recommended for IV administration.
3) In 15 minutes
4) In 60 minutes
7. Which nonsteroidal anti-in- Answer:
flammatory drug might 3) Aspirin (Ecotrin)
be administered to inhib-
it platelet aggregation in a Rationale:
patient at risk for throm- Aspirin is a unique NSAID that inhibits platelet aggregation.
bophlebitis? Low-dose aspirin therapy is commonly administered to decrease
the risk of thrombophlebitis, myocardial infarction, and stroke.
1) Ibuprofen (Motrin)
, Nclex questions for Fundamentals of Nursing with rationale
Study online at https://quizlet.com/_jmg9sm
2) Celecoxib (Celebrex) Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do
3) Aspirin (Ecotrin) not inhibit platelet aggregation.
4) Indomethacin (Indocin)
8. A client who is receiving Answer:
epidural analgesia complains 3) Epidural catheter migration
of nausea and loss of motor
function in his legs. The nurse Rationale:
obtains his blood pressure The patient is exhibiting signs of epidural catheter migration,
and notes a drop in his blood which include nausea, a decrease in blood pressure, and loss of
pressure from the previous motor function without an identifiable cause. Signs of infection at
reading. Which complication the catheter site include redness, swelling, and drainage. Loss of
is the patient most likely ex- motor function is not a typical side effect associated with epidural
periencing? analgesics. These are common signs of catheter migration, not
spinal cord damage.
1) Infection at the catheter in-
sertion site
2) Side effect of the epidural
analgesic
3) Epidural catheter migra-
tion
4) Spinal cord damage
9. Which of the following clients Answer:
is experiencing an abnormal 1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60
change in vital signs? A client mm Hg upon standing
whose (select all that apply): 3) Heart rate was 76 before eating and is 60 after eating
1) Blood pressure (BP) was Rationale:
132/80 mm Hg sitting and is The BP change is abnormal; a BP change greater than 10 mm Hg
120/60 mm Hg upon stand- may indicate postural hypotension. The change in heart rate is
ing abnormal; heart rate usually increases slightly after eating rather
