NCLEX QUESTIONS #2 MED SURG (WITH
RATIONALES) AND ANSWERS LATEST VERSION
VERIFIED RATIONALE GRADED A+
A 73-year-old pa�ent who sustained a right hip fracture in a fall requests pain medica�on from the
nurse. Based on his injury, which type of pain is this pa�ent most likely experiencing?
1) Phantom
2) Visceral
3) Deep soma�c
4) Referred - ansAnswer:
3) Deep soma�c
Ra�onale:
Deep soma�c pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip
fracture causes deep soma�c 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 client exhibits all of the following during a physical assessment. Which of these is considered a primary
defense against infec�on?
1) Fever
2) Intact skin
3) Inflamma�on
4) Lethargy - ansAnswer:
2) Intact skin
Ra�onale:
Intact skin is considered a primary defense against infec�on. Fever, the inflammatory response, and
phagocytosis (a process of killing pathogens) are considered secondary defenses against infec�on.
, NCLEX QUESTIONS #2 MED SURG (WITH
RATIONALES) AND ANSWERS LATEST VERSION
VERIFIED RATIONALE GRADED A+
A client who is receiving epidural analgesia complains of nausea and loss of motor func�on in his legs.
The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading.
Which complica�on is the pa�ent most likely experiencing?
1) Infec�on at the catheter inser�on site
2) Side effect of the epidural analgesic
3) Epidural catheter migra�on
4) Spinal cord damage - ansAnswer:
3) Epidural catheter migra�on
Ra�onale:
The pa�ent is exhibi�ng signs of epidural catheter migra�on, which include nausea, a decrease in blood
pressure, and loss of motor func�on without an iden�fiable cause. Signs of infec�on at the catheter site
include redness, swelling, and drainage. Loss of motor func�on is not a typical side effect associated with
epidural analgesics. These are common signs of catheter migra�on, not spinal cord damage.
A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured
from the wound. Contact precau�ons are ini�ated. Which rule must be observed to follow contact
precau�ons?
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 infec�on. - ansAnswer:
1) A clean gown and gloves must be worn when in contact with the client.
Ra�onale:
RATIONALES) AND ANSWERS LATEST VERSION
VERIFIED RATIONALE GRADED A+
A 73-year-old pa�ent who sustained a right hip fracture in a fall requests pain medica�on from the
nurse. Based on his injury, which type of pain is this pa�ent most likely experiencing?
1) Phantom
2) Visceral
3) Deep soma�c
4) Referred - ansAnswer:
3) Deep soma�c
Ra�onale:
Deep soma�c pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip
fracture causes deep soma�c 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 client exhibits all of the following during a physical assessment. Which of these is considered a primary
defense against infec�on?
1) Fever
2) Intact skin
3) Inflamma�on
4) Lethargy - ansAnswer:
2) Intact skin
Ra�onale:
Intact skin is considered a primary defense against infec�on. Fever, the inflammatory response, and
phagocytosis (a process of killing pathogens) are considered secondary defenses against infec�on.
, NCLEX QUESTIONS #2 MED SURG (WITH
RATIONALES) AND ANSWERS LATEST VERSION
VERIFIED RATIONALE GRADED A+
A client who is receiving epidural analgesia complains of nausea and loss of motor func�on in his legs.
The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading.
Which complica�on is the pa�ent most likely experiencing?
1) Infec�on at the catheter inser�on site
2) Side effect of the epidural analgesic
3) Epidural catheter migra�on
4) Spinal cord damage - ansAnswer:
3) Epidural catheter migra�on
Ra�onale:
The pa�ent is exhibi�ng signs of epidural catheter migra�on, which include nausea, a decrease in blood
pressure, and loss of motor func�on without an iden�fiable cause. Signs of infec�on at the catheter site
include redness, swelling, and drainage. Loss of motor func�on is not a typical side effect associated with
epidural analgesics. These are common signs of catheter migra�on, not spinal cord damage.
A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured
from the wound. Contact precau�ons are ini�ated. Which rule must be observed to follow contact
precau�ons?
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 infec�on. - ansAnswer:
1) A clean gown and gloves must be worn when in contact with the client.
Ra�onale:
