Galen College of Nursing-Louisville NUR 155
Nclex questions for Fundamentals of
Nursing with rationale exam with
question and answer 100% correct
Terms in this set (71)
A 73-year-old patient who sustained a right Answer:
hip fracture in a fall requests pain 3) Deep
somatic medication from the nurse. Based on his
injury, which type of pain is this patient most Rationale:
likely experiencing? Deep somatic pain originates in ligaments, tendons,
nerves,
1) Phantom blood vessels, and bones. Therefore, a
hip fracture causes
2)Visceral deep somatic pain. Phantom pain is pain that is
perceived to
3) Deep somatic originate from a part that was removed during surgery.
4) Referred 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.
,Which pain management task can the nurse Answer:
safely delegate to nursing assistive 1) Asking about pain during vital
signs personnel?
1) Asking about pain during vital signs Rationale:
2)Evaluating the effectiveness of pain The nurse can delegate the task of asking about
pain when medication nursing assistive personnel (NAP) obtain vital signs.
The NAP
3) Developing a plan of care involving must be instructed to report findings to the
nurse without nonpharmacologic interventions delay. The nurse should evaluate the
effectiveness of pain
4) Administering over-the-counter pain medications and develop the plan of care.
Administering medications over-the-counter and prescription medications
is the
responsibility of the registered nurse or licensed
practical nurse.
Which factor in the patient's past medical Answer:
history dictates that the nurse exercise 1) Hepatitis
B caution when administering acetaminophen
(Tylenol)? Rationale:
Even in recommended doses, acetaminophen can cause
1) Hepatitis B severe hepatotoxicity in patients with
liver disease, such as
2)Occasional alcohol use hepatitis B. Patients who consume alcohol regularly
should
3)Allergy to aspirin also use acetaminophen cautiously. Those allergic to
aspirin or
4) Gastric irritation with bleeding 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.
Which action should the nurse take before Answer:
administering morphine 4.0 mg 3) Assess the patient's respiratory
status. intravenously to a patient complaining of
incisional pain? Rationale:
Before administering an opioid analgesic, such as
morphine,
1) Assess the patient's incision. the nurse should
assess the patient's respiratory status
2)Clarify the order with the prescriber. because opioid analgesics can cause respiratory
depression.
3)Assess the patient's respiratory status. It is not necessary to clarify the order with the physician
4) Monitor the patient's heart rate. because morphine 4 mg IV is an appropriate dose. It is
not
necessary to monitor the patient's heart rate.
Which action should the nurse take when Answer:
preparing patient-controlled analgesia for a 2) Ask another nurse to double-check the
setup before patient postoperative patient? use.
1) Caution the patient to limit the number of Rationale:
times he presses the dosing button. As a safeguard to reduce the risk for dosing errors, the
nurse
2)Ask another nurse to double-check the should request another nurse to double-check the
setup setup before patient use. before patient use. The nurse should reassure the
patient that
3) Instruct the patient to administer a dose the pump has a lockout feature that prevents
him from only when experiencing pain. overdosing even if he continues to push the
, dose
4) Provide clear, simple instructions for administration button. The nurse should also
instruct the dosing if the patient is cognitively impaired. patient to administer a dose
before potentially painful
activities, such as walking. Patient-controlled analgesia is
contraindicated for those who are cognitively impaired.
Nclex questions for Fundamentals of
Nursing with rationale exam with
question and answer 100% correct
Terms in this set (71)
A 73-year-old patient who sustained a right Answer:
hip fracture in a fall requests pain 3) Deep
somatic medication from the nurse. Based on his
injury, which type of pain is this patient most Rationale:
likely experiencing? Deep somatic pain originates in ligaments, tendons,
nerves,
1) Phantom blood vessels, and bones. Therefore, a
hip fracture causes
2)Visceral deep somatic pain. Phantom pain is pain that is
perceived to
3) Deep somatic originate from a part that was removed during surgery.
4) Referred 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.
,Which pain management task can the nurse Answer:
safely delegate to nursing assistive 1) Asking about pain during vital
signs personnel?
1) Asking about pain during vital signs Rationale:
2)Evaluating the effectiveness of pain The nurse can delegate the task of asking about
pain when medication nursing assistive personnel (NAP) obtain vital signs.
The NAP
3) Developing a plan of care involving must be instructed to report findings to the
nurse without nonpharmacologic interventions delay. The nurse should evaluate the
effectiveness of pain
4) Administering over-the-counter pain medications and develop the plan of care.
Administering medications over-the-counter and prescription medications
is the
responsibility of the registered nurse or licensed
practical nurse.
Which factor in the patient's past medical Answer:
history dictates that the nurse exercise 1) Hepatitis
B caution when administering acetaminophen
(Tylenol)? Rationale:
Even in recommended doses, acetaminophen can cause
1) Hepatitis B severe hepatotoxicity in patients with
liver disease, such as
2)Occasional alcohol use hepatitis B. Patients who consume alcohol regularly
should
3)Allergy to aspirin also use acetaminophen cautiously. Those allergic to
aspirin or
4) Gastric irritation with bleeding 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.
Which action should the nurse take before Answer:
administering morphine 4.0 mg 3) Assess the patient's respiratory
status. intravenously to a patient complaining of
incisional pain? Rationale:
Before administering an opioid analgesic, such as
morphine,
1) Assess the patient's incision. the nurse should
assess the patient's respiratory status
2)Clarify the order with the prescriber. because opioid analgesics can cause respiratory
depression.
3)Assess the patient's respiratory status. It is not necessary to clarify the order with the physician
4) Monitor the patient's heart rate. because morphine 4 mg IV is an appropriate dose. It is
not
necessary to monitor the patient's heart rate.
Which action should the nurse take when Answer:
preparing patient-controlled analgesia for a 2) Ask another nurse to double-check the
setup before patient postoperative patient? use.
1) Caution the patient to limit the number of Rationale:
times he presses the dosing button. As a safeguard to reduce the risk for dosing errors, the
nurse
2)Ask another nurse to double-check the should request another nurse to double-check the
setup setup before patient use. before patient use. The nurse should reassure the
patient that
3) Instruct the patient to administer a dose the pump has a lockout feature that prevents
him from only when experiencing pain. overdosing even if he continues to push the
, dose
4) Provide clear, simple instructions for administration button. The nurse should also
instruct the dosing if the patient is cognitively impaired. patient to administer a dose
before potentially painful
activities, such as walking. Patient-controlled analgesia is
contraindicated for those who are cognitively impaired.
