Chapter 46 My Nursing Test Banks
Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 46
Question 1
Type: MCSA
The nurse is caring for an 8-month-old infant. What is the best tool the nurse should use for evaluating pain in this
infant?
1. FLACC scale
2. Wong-Baker FACES
3. Visual analog scale
4. Numeric rating scale
Correct Answer: 1
Rationale 1: The FLACC scale has been validated in children from 2 months to 7 years old.
Rationale 2: This pain scale would not be appropriate for a client of this age.
Rationale 3: This pain scale would not be appropriate for a client of this age.
Rationale 4: This pain scale would not be appropriate for a client of this age.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual,
socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and
culturally appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and
interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Identify subjective and objective data to collect and analyze when assessing pain.
MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain.
Page Number: 1097
Question 2
Type: MCSA
The nurse is preparing to discharge a client home with a prescription for ibuprofen (Motrin). What should the nurse
instruct as a common side effect of this medication?
,1. Gastrointestinal (GI) distress
2. Shakiness
3. Tremors
4. Rash
Correct Answer: 1
Rationale 1: The most common side effect of NSAIDs, including ibuprofen, is gastrointestinal distress, such as heartburn
or indigestion.
Rationale 2: Shakiness is not a common side effect of NSAIDs.
Rationale 3: Tremors are not a common side effect of NSAIDs.
Rationale 4: A rash is not a common side effect of NSAIDs.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age,
culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and
interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10. Describe pharmacologic interventions for pain.
MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain.
Page Number: 1107
Question 3
Type: MCSA
Which of the following objective assessment data will the nurse obtain before administering a prescribed opioid
medication to a client?
1. Pain level as stated by client
2. Any nausea the client may be feeling
3. Respiratory rate
4. Color of skin
Correct Answer: 3
Rationale 1: This is an example of subjective data.
,Rationale 2: This is an example of subjective data.
Rationale 3: Opioids may depress the respiratory system, so the nurse should assess the respiratory rate before
administering opioids.
Rationale 4: This is not applicable to assess prior to administering an opioid medication to a client.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual,
socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and
culturally appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and
interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Identify subjective and objective data to collect and analyze when assessing pain.
MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain.
Page Number: 1110
Question 4
Type: MCSA
The nurse provides an oral opiate to a client with pain. In how many hours should the nurse expect the client to need
another dose of the medication?
1. 2 hours
2. 4 hours
3. 6 hours
4. 8 hours
Correct Answer: 2
Rationale 1: The duration of action for most opiates is 4 hours.
Rationale 2: The duration of action for most opiates is 4 hours.
Rationale 3: The duration of action for most opiates is 4 hours.
Rationale 4: The duration of action for most opiates is 4 hours.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
, Client Need Sub: Pharmacological and Parenteral Therapies
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the
acute and chronic care of patients and promoting health across the lifespan
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and
interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10. Describe pharmacologic interventions for pain.
MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain.
Page Number: 1111
Question 5
Type: MCSA
The nurse is to administer acetaminophen (Tylenol) prn to a client for a headache; however, the client has been
vomiting all day. Which route should the nurse use to administer the medication?
1. Oral
2. Vaginal
3. Rectal
4. Intravenous
Correct Answer: 3
Rationale 1: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an
acetaminophen suppository to the client.
Rationale 2: This medication is not available as a vaginal suppository.
Rationale 3: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an
acetaminophen suppository to the client.
Rationale 4: There is not an intravenous form of this medication.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the
acute and chronic care of patients and promoting health across the lifespan
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and
interventions
Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 46
Question 1
Type: MCSA
The nurse is caring for an 8-month-old infant. What is the best tool the nurse should use for evaluating pain in this
infant?
1. FLACC scale
2. Wong-Baker FACES
3. Visual analog scale
4. Numeric rating scale
Correct Answer: 1
Rationale 1: The FLACC scale has been validated in children from 2 months to 7 years old.
Rationale 2: This pain scale would not be appropriate for a client of this age.
Rationale 3: This pain scale would not be appropriate for a client of this age.
Rationale 4: This pain scale would not be appropriate for a client of this age.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual,
socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and
culturally appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and
interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Identify subjective and objective data to collect and analyze when assessing pain.
MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain.
Page Number: 1097
Question 2
Type: MCSA
The nurse is preparing to discharge a client home with a prescription for ibuprofen (Motrin). What should the nurse
instruct as a common side effect of this medication?
,1. Gastrointestinal (GI) distress
2. Shakiness
3. Tremors
4. Rash
Correct Answer: 1
Rationale 1: The most common side effect of NSAIDs, including ibuprofen, is gastrointestinal distress, such as heartburn
or indigestion.
Rationale 2: Shakiness is not a common side effect of NSAIDs.
Rationale 3: Tremors are not a common side effect of NSAIDs.
Rationale 4: A rash is not a common side effect of NSAIDs.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age,
culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and
interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10. Describe pharmacologic interventions for pain.
MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain.
Page Number: 1107
Question 3
Type: MCSA
Which of the following objective assessment data will the nurse obtain before administering a prescribed opioid
medication to a client?
1. Pain level as stated by client
2. Any nausea the client may be feeling
3. Respiratory rate
4. Color of skin
Correct Answer: 3
Rationale 1: This is an example of subjective data.
,Rationale 2: This is an example of subjective data.
Rationale 3: Opioids may depress the respiratory system, so the nurse should assess the respiratory rate before
administering opioids.
Rationale 4: This is not applicable to assess prior to administering an opioid medication to a client.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual,
socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and
culturally appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and
interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Identify subjective and objective data to collect and analyze when assessing pain.
MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain.
Page Number: 1110
Question 4
Type: MCSA
The nurse provides an oral opiate to a client with pain. In how many hours should the nurse expect the client to need
another dose of the medication?
1. 2 hours
2. 4 hours
3. 6 hours
4. 8 hours
Correct Answer: 2
Rationale 1: The duration of action for most opiates is 4 hours.
Rationale 2: The duration of action for most opiates is 4 hours.
Rationale 3: The duration of action for most opiates is 4 hours.
Rationale 4: The duration of action for most opiates is 4 hours.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
, Client Need Sub: Pharmacological and Parenteral Therapies
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the
acute and chronic care of patients and promoting health across the lifespan
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and
interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10. Describe pharmacologic interventions for pain.
MNL Learning Outcome: 4.11.4. Implement the nursing process in the care of the client experiencing pain.
Page Number: 1111
Question 5
Type: MCSA
The nurse is to administer acetaminophen (Tylenol) prn to a client for a headache; however, the client has been
vomiting all day. Which route should the nurse use to administer the medication?
1. Oral
2. Vaginal
3. Rectal
4. Intravenous
Correct Answer: 3
Rationale 1: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an
acetaminophen suppository to the client.
Rationale 2: This medication is not available as a vaginal suppository.
Rationale 3: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an
acetaminophen suppository to the client.
Rationale 4: There is not an intravenous form of this medication.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the
acute and chronic care of patients and promoting health across the lifespan
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and
interventions
