NCLEX Questions for Fundamentals of Nursing with Rationales: Comprehensive Questions and Answers

NCLEX QUESTIONS FOR FUNDAMENTALS OF
NURSING WITH RATIONALE QUESTIONS AND
ANSWERS
1. 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.
2. 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



,NCLEX QUESTIONS FOR FUNDAMENTALS OF
NURSING WITH RATIONALE QUESTIONS AND
ANSWERS
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 ettectiveness 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.
3. 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






, NCLEX QUESTIONS FOR FUNDAMENTALS OF
NURSING WITH RATIONALE QUESTIONS AND
ANSWERS
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.
4. 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


, NCLEX QUESTIONS FOR FUNDAMENTALS OF
NURSING WITH RATIONALE QUESTIONS AND
ANSWERS
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.
5. Which action should the nurse take when preparing patient-
controlled anal-gesia 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: