NCLEX Exam Questions for Fundamentals of Nursing with
Rationale.
1. A 73-year-old patient
Answer:
who sustained a right hip
3) Deep somatic
fracture 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? 3. Which factor in the patient's past
1)Phantom medical history dictates that the
2) Visceral nurse exercise cau- tion when
3)Deep somatic administering ac- etaminophen
4)Referred (Tylenol)?
2. Which pain management
task can the nurse safely
delegate to nursing
assistive personnel?
1)Asking about pain
during vital signs
2)Evaluating the
effective- ness of pain
medication
3)Developing a plan of
care involving
nonpharmacologic
interventions
4)Administering
over-the-counter pain
med- ications
1/
69
, NCLEX Exam Questions for Fundamentals of Nursing with
Rationale.
somatic pain. Phantom pain is pain that is acetaminophen can cause se-
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.
Answer:
1) Asking about pain during vital signs
Rationale:
The nurse can delegate the task of asking
about pain when nurs- ing 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.
Answer:
1) Hepatitis B
Rationale:
Even in recommended doses,
2/
69
, NCLEX Exam Questions for Fundamentals of Nursing with
Rationale.
vere hepatotoxicity in patients with liver disease, such
1)Hepatitis B
as he- patitis B. Patients who consume alcohol
2)Occasional alcohol
regularly should also use acetaminophen cautiously.
use
Those allergic to aspirin or other nonsteroidal anti-
3)Allergy to aspirin
inflammatory drugs (NSAIDs) can use aceta- minophen
4)Gastric irritation
safely. Acetaminophen rarely causes gastrointestinal
with bleeding
(GI) problems; therefore, it can be used for those with a
history of gastric irritation and bleeding.
4. Which action should Answer:
the nurse take before 3) Assess the patient's respiratory status.
adminis- tering
morphine 4.0 mg in-
travenously to a patient com- Rationale:
plaining of incisional lim- it the number of times he
pain? presses the dosing button.
2) Ask another nurse to dou-
1)Assess the patient's
inci- sion.
2)Clarify the order with
the prescriber.
3)Assess the patient's
respi- ratory status.
4)Monitor the patient's
heart rate.
5. Which action should
the nurse take when
preparing patient-
controlled analgesia for a
postoperative patient?
1)Caution the patient to
3/
69
, NCLEX Exam Questions for Fundamentals of Nursing with
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 nec- essary
to 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.
Answer:
2) Ask another nurse to double-check
the setup before patient use.
Rationale:
As a safeguard to reduce the risk for
dosing errors, the nurse should request
another nurse to double-check the setup
before patient use. The nurse should
reassure the patient that the pump has a
lockout feature that prevents him from
overdosing even
4/
69
Rationale.
1. A 73-year-old patient
Answer:
who sustained a right hip
3) Deep somatic
fracture 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? 3. Which factor in the patient's past
1)Phantom medical history dictates that the
2) Visceral nurse exercise cau- tion when
3)Deep somatic administering ac- etaminophen
4)Referred (Tylenol)?
2. Which pain management
task can the nurse safely
delegate to nursing
assistive personnel?
1)Asking about pain
during vital signs
2)Evaluating the
effective- ness of pain
medication
3)Developing a plan of
care involving
nonpharmacologic
interventions
4)Administering
over-the-counter pain
med- ications
1/
69
, NCLEX Exam Questions for Fundamentals of Nursing with
Rationale.
somatic pain. Phantom pain is pain that is acetaminophen can cause se-
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.
Answer:
1) Asking about pain during vital signs
Rationale:
The nurse can delegate the task of asking
about pain when nurs- ing 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.
Answer:
1) Hepatitis B
Rationale:
Even in recommended doses,
2/
69
, NCLEX Exam Questions for Fundamentals of Nursing with
Rationale.
vere hepatotoxicity in patients with liver disease, such
1)Hepatitis B
as he- patitis B. Patients who consume alcohol
2)Occasional alcohol
regularly should also use acetaminophen cautiously.
use
Those allergic to aspirin or other nonsteroidal anti-
3)Allergy to aspirin
inflammatory drugs (NSAIDs) can use aceta- minophen
4)Gastric irritation
safely. Acetaminophen rarely causes gastrointestinal
with bleeding
(GI) problems; therefore, it can be used for those with a
history of gastric irritation and bleeding.
4. Which action should Answer:
the nurse take before 3) Assess the patient's respiratory status.
adminis- tering
morphine 4.0 mg in-
travenously to a patient com- Rationale:
plaining of incisional lim- it the number of times he
pain? presses the dosing button.
2) Ask another nurse to dou-
1)Assess the patient's
inci- sion.
2)Clarify the order with
the prescriber.
3)Assess the patient's
respi- ratory status.
4)Monitor the patient's
heart rate.
5. Which action should
the nurse take when
preparing patient-
controlled analgesia for a
postoperative patient?
1)Caution the patient to
3/
69
, NCLEX Exam Questions for Fundamentals of Nursing with
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 nec- essary
to 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.
Answer:
2) Ask another nurse to double-check
the setup before patient use.
Rationale:
As a safeguard to reduce the risk for
dosing errors, the nurse should request
another nurse to double-check the setup
before patient use. The nurse should
reassure the patient that the pump has a
lockout feature that prevents him from
overdosing even
4/
69
