NclexvnquestionsvnforvnFundamentalsvnofvnNursingvnwithvnrationale
Avn73-year-
oldvnpatientvnwhovnsustainedvnavnrightvnhipvnfracturevninvnavnfallvnrequestsvnpainv
nmedicationvnfromvnthevnnurse.vnBasedvnonvnhisvninjury,vnwhichvntypevnofvnpainv
nisvnthisvnpatientvnmostvnlikelyvnexperiencing?
1)vnPhantom
vn
2)vnVisceral
vn
3)vnDeepvnsomatic
vn
4)vnReferredvn-vncorrectvnanswer✔ ✔ Answer:
vn
3)vnDeepvnsomatic
vn
Rationale:
Deepvnsomaticvnpainvnoriginatesvninvnligaments,vntendons,vnnerves,vnbloodvnve
ssels,vnandvnbones.vnTherefore,vnavnhipvnfracturevncausesvndeepvnsomaticvnpain.
vnPhantomvnpainvnisvnpainvnthatvnisvnperceivedvntovnoriginatevnfromvnavnpartvnthat
vnwasvnremoved vnduringvnsurgery.vnVisceralvnpainvnisvncausedvnbyvndeepvninter
nalvnpainvnreceptorsvnandvncommonlyvnoccursvninvnthevnabdominalvncavity,vncr
anium,vnandvnthorax.vnReferredvnpainvnoccursvninvnanvnareavnthatvnisvndistantvnto
vnthevnoriginalvnsite.
Whichvnpainvnmanagementvntaskvncanvnthevnnursevnsafelyvndelegatevntovnnursi
ngvnassistivevnpersonnel?
1)vnAskingvnaboutvnpainvnduringvnvitalvnsigns
vn
, 2)vnEvaluatingvnthevneffectivenessvnofvnpainvnmedication
vn
3)vnDevelopingvnavnplanvnofvncarevninvolvingvnnonpharmacologicvninterventi
vn
ons
vn4)vnAdministeringvnover-the-countervnpainvnmedicationsvn-
vncorrectvnanswer✔ ✔ Answer:
1)vnAskingvnaboutvnpainvnduringvnvitalvnsigns
vn
Rationale:
Thevnnursevncanvndelegatevnthevntaskvnofvnaskingvnaboutvnpainvnwhenvnnursingvn
assistivevnpersonnelvn(NAP)vnobtainvnvitalvnsigns.vnThevnNAPvnmustvnbevninstr
uctedvntovnreportvnfindingsvntovnthevnnursevnwithoutvndelay.vnThevnnursevnshoul
dvnevaluatevnthevneffectivenessvnofvnpainvnmedicationsvnandvndevelopvnthevnpla
nvnofvncare.vnAdministeringvnover-the-
countervnandvnprescriptionvnmedicationsvnisvnthevnresponsibilityvnofvnthevnregi
steredvnnursevnorvnlicensedvnpracticalvnnurse.
Whichvnfactorvninvnthevnpatient'svnpastvnmedicalvnhistoryvndictatesvnthatvnthevnn
ursevnexercisevncautionvnwhenvnadministeringvnacetaminophenvn(Tylenol)?
1)vnHepatitisvnB
2)vnOccasionalvnalcoholvnuse
3)vnAllergyvntovnaspirin
4)vnGastricvnirritationvnwithvnbleedingvn-vncorrectvnanswer✔ ✔ Answer:
1)vnHepatitisvnB
,vn
Rationale:
Evenvninvnrecommendedvndoses,vnacetaminophenvncanvncausevnseverevnhepat
otoxicityvninvnpatientsvnwithvnlivervndisease,vnsuchvnasvnhepatitisvnB.vnPatientsvn
whovnconsumevnalcoholvnregularlyvnshouldvnalsovnusevnacetaminophenvncauti
ously.vnThosevnallergicvntovnaspirinvnorvnothervnnonsteroidalvnanti-
inflammatoryvndrugsvn(NSAIDs)vncanvnusevnacetaminophenvnsafely.vnAceta
minophenvnrarelyvncausesvngastrointestinalvn(GI)vnproblems;vntherefore,vnitvnc
anvnbevnusedvnforvnthosevnwithvnavnhistoryvnofvngastricvnirritationvnandvnbleeding
.
Whichvnactionvnshouldvnthevnnursevntakevnbeforevnadministeringvnmorphinevn4
.0vnmgvnintravenouslyvntovnavnpatientvncomplainingvnofvnincisionalvnpain?
1)vnAssessvnthevnpatient'svnincision.
2)vnClarifyvnthevnordervnwithvnthevnprescriber.
3)vnAssessvnthevnpatient'svnrespiratoryvnstatus.
4)vnMonitorvnthevnpatient'svnheartvnrate.vn-vncorrectvnanswer✔ ✔ Answer:
3)vnAssessvnthevnpatient'svnrespiratoryvnstatus.
vn
Rationale:
Beforevnadministeringvnanvnopioidvnanalgesic,vnsuchvnasvnmorphine,vnthevnnur
sevnshouldvnassessvnthevnpatient'svnrespiratoryvnstatusvnbecausevnopioidvnanalg
esicsvncanvncausevnrespiratoryvndepression.vnItvnisvnnotvnnecessaryvntovnclarifyvn
, thevnordervnwithvnthevnphysicianvnbecausevnmorphinevn4vnmgvnIVvnisvnanvnappro
priatevndose.vnItvnisvnnotvnnecessaryvntovnmonitorvnthevnpatient'svnheartvnrate.
Whichvnactionvnshouldvnthevnnursevntakevnwhenvnpreparingvnpatient-
controlledvnanalgesiavnforvnavnpostoperativevnpatient?
1)vnCautionvnthevnpatientvntovnlimitvnthevnnumbervnofvntimesvnhevnpressesvnthevnd
osingvnbutton.
2)vnAskvnanothervnnursevntovndouble-checkvnthevnsetupvnbeforevnpatientvnuse.
3)vnInstructvnthevnpatientvntovnadministervnavndosevnonlyvnwhenvnexperiencingvn
pain.
4)vnProvidevnclear,vnsimplevninstructionsvnforvndosingvnifvnthevnpatientvnisvncog
nitivelyvnimpaired.vn-vncorrectvnanswer✔ ✔ Answer:
2)vnAskvnanothervnnursevntovndouble-checkvnthevnsetupvnbeforevnpatientvnuse.
vn
Rationale:
Asvnavnsafeguardvntovnreducevnthevnriskvnforvndosingvnerrors,vnthevnnursevnshoul
dvnrequestvnanothervnnursevntovndouble-
checkvnthevnsetupvnbeforevnpatientvnuse.vnThevnnursevnshouldvnreassurevnthevnpa
tientvnthatvnthevnpumpvnhasvnavnlockoutvnfeaturevnthatvnpreventsvnhimvnfromvnov
erdosingvnevenvnifvnhevncontinuesvntovnpushvnthevndosevnadministrationvnbutton
.vnThevnnursevnshouldvnalsovninstructvnthevnpatientvntovnadministervnavndosevnbef
orevnpotentiallyvnpainfulvnactivities,vnsuchvnasvnwalking.vnPatient-
controlledvnanalgesiavnisvncontraindicatedvnforvnthosevnwhovnarevncognitivelyv
nimpaired.
Avn73-year-
oldvnpatientvnwhovnsustainedvnavnrightvnhipvnfracturevninvnavnfallvnrequestsvnpainv
nmedicationvnfromvnthevnnurse.vnBasedvnonvnhisvninjury,vnwhichvntypevnofvnpainv
nisvnthisvnpatientvnmostvnlikelyvnexperiencing?
1)vnPhantom
vn
2)vnVisceral
vn
3)vnDeepvnsomatic
vn
4)vnReferredvn-vncorrectvnanswer✔ ✔ Answer:
vn
3)vnDeepvnsomatic
vn
Rationale:
Deepvnsomaticvnpainvnoriginatesvninvnligaments,vntendons,vnnerves,vnbloodvnve
ssels,vnandvnbones.vnTherefore,vnavnhipvnfracturevncausesvndeepvnsomaticvnpain.
vnPhantomvnpainvnisvnpainvnthatvnisvnperceivedvntovnoriginatevnfromvnavnpartvnthat
vnwasvnremoved vnduringvnsurgery.vnVisceralvnpainvnisvncausedvnbyvndeepvninter
nalvnpainvnreceptorsvnandvncommonlyvnoccursvninvnthevnabdominalvncavity,vncr
anium,vnandvnthorax.vnReferredvnpainvnoccursvninvnanvnareavnthatvnisvndistantvnto
vnthevnoriginalvnsite.
Whichvnpainvnmanagementvntaskvncanvnthevnnursevnsafelyvndelegatevntovnnursi
ngvnassistivevnpersonnel?
1)vnAskingvnaboutvnpainvnduringvnvitalvnsigns
vn
, 2)vnEvaluatingvnthevneffectivenessvnofvnpainvnmedication
vn
3)vnDevelopingvnavnplanvnofvncarevninvolvingvnnonpharmacologicvninterventi
vn
ons
vn4)vnAdministeringvnover-the-countervnpainvnmedicationsvn-
vncorrectvnanswer✔ ✔ Answer:
1)vnAskingvnaboutvnpainvnduringvnvitalvnsigns
vn
Rationale:
Thevnnursevncanvndelegatevnthevntaskvnofvnaskingvnaboutvnpainvnwhenvnnursingvn
assistivevnpersonnelvn(NAP)vnobtainvnvitalvnsigns.vnThevnNAPvnmustvnbevninstr
uctedvntovnreportvnfindingsvntovnthevnnursevnwithoutvndelay.vnThevnnursevnshoul
dvnevaluatevnthevneffectivenessvnofvnpainvnmedicationsvnandvndevelopvnthevnpla
nvnofvncare.vnAdministeringvnover-the-
countervnandvnprescriptionvnmedicationsvnisvnthevnresponsibilityvnofvnthevnregi
steredvnnursevnorvnlicensedvnpracticalvnnurse.
Whichvnfactorvninvnthevnpatient'svnpastvnmedicalvnhistoryvndictatesvnthatvnthevnn
ursevnexercisevncautionvnwhenvnadministeringvnacetaminophenvn(Tylenol)?
1)vnHepatitisvnB
2)vnOccasionalvnalcoholvnuse
3)vnAllergyvntovnaspirin
4)vnGastricvnirritationvnwithvnbleedingvn-vncorrectvnanswer✔ ✔ Answer:
1)vnHepatitisvnB
,vn
Rationale:
Evenvninvnrecommendedvndoses,vnacetaminophenvncanvncausevnseverevnhepat
otoxicityvninvnpatientsvnwithvnlivervndisease,vnsuchvnasvnhepatitisvnB.vnPatientsvn
whovnconsumevnalcoholvnregularlyvnshouldvnalsovnusevnacetaminophenvncauti
ously.vnThosevnallergicvntovnaspirinvnorvnothervnnonsteroidalvnanti-
inflammatoryvndrugsvn(NSAIDs)vncanvnusevnacetaminophenvnsafely.vnAceta
minophenvnrarelyvncausesvngastrointestinalvn(GI)vnproblems;vntherefore,vnitvnc
anvnbevnusedvnforvnthosevnwithvnavnhistoryvnofvngastricvnirritationvnandvnbleeding
.
Whichvnactionvnshouldvnthevnnursevntakevnbeforevnadministeringvnmorphinevn4
.0vnmgvnintravenouslyvntovnavnpatientvncomplainingvnofvnincisionalvnpain?
1)vnAssessvnthevnpatient'svnincision.
2)vnClarifyvnthevnordervnwithvnthevnprescriber.
3)vnAssessvnthevnpatient'svnrespiratoryvnstatus.
4)vnMonitorvnthevnpatient'svnheartvnrate.vn-vncorrectvnanswer✔ ✔ Answer:
3)vnAssessvnthevnpatient'svnrespiratoryvnstatus.
vn
Rationale:
Beforevnadministeringvnanvnopioidvnanalgesic,vnsuchvnasvnmorphine,vnthevnnur
sevnshouldvnassessvnthevnpatient'svnrespiratoryvnstatusvnbecausevnopioidvnanalg
esicsvncanvncausevnrespiratoryvndepression.vnItvnisvnnotvnnecessaryvntovnclarifyvn
, thevnordervnwithvnthevnphysicianvnbecausevnmorphinevn4vnmgvnIVvnisvnanvnappro
priatevndose.vnItvnisvnnotvnnecessaryvntovnmonitorvnthevnpatient'svnheartvnrate.
Whichvnactionvnshouldvnthevnnursevntakevnwhenvnpreparingvnpatient-
controlledvnanalgesiavnforvnavnpostoperativevnpatient?
1)vnCautionvnthevnpatientvntovnlimitvnthevnnumbervnofvntimesvnhevnpressesvnthevnd
osingvnbutton.
2)vnAskvnanothervnnursevntovndouble-checkvnthevnsetupvnbeforevnpatientvnuse.
3)vnInstructvnthevnpatientvntovnadministervnavndosevnonlyvnwhenvnexperiencingvn
pain.
4)vnProvidevnclear,vnsimplevninstructionsvnforvndosingvnifvnthevnpatientvnisvncog
nitivelyvnimpaired.vn-vncorrectvnanswer✔ ✔ Answer:
2)vnAskvnanothervnnursevntovndouble-checkvnthevnsetupvnbeforevnpatientvnuse.
vn
Rationale:
Asvnavnsafeguardvntovnreducevnthevnriskvnforvndosingvnerrors,vnthevnnursevnshoul
dvnrequestvnanothervnnursevntovndouble-
checkvnthevnsetupvnbeforevnpatientvnuse.vnThevnnursevnshouldvnreassurevnthevnpa
tientvnthatvnthevnpumpvnhasvnavnlockoutvnfeaturevnthatvnpreventsvnhimvnfromvnov
erdosingvnevenvnifvnhevncontinuesvntovnpushvnthevndosevnadministrationvnbutton
.vnThevnnursevnshouldvnalsovninstructvnthevnpatientvntovnadministervnavndosevnbef
orevnpotentiallyvnpainfulvnactivities,vnsuchvnasvnwalking.vnPatient-
controlledvnanalgesiavnisvncontraindicatedvnforvnthosevnwhovnarevncognitivelyv
nimpaired.
