NCLEX questions for Fundamentals of Nursing with rationale *Q&A* [verified]

NCLEX questions for Fundamentals of Nursing with rationale *Q&A* [verified] A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing? 1) Phantom 2) Visceral 3) Deep somatic 4) Referred *Ans* Answer: 3) Deep somatic Rationale: Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic 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. Which pain management task can the nurse safely delegate to nursing assistive personnel? 1) Asking about pain during vital signs 2) Evaluating the effectiveness of pain medication 3) Developing a plan of care involving nonpharmacologic interventions 4) Administering over-the-counter pain medications *Ans* Answer: 1) Asking about pain during vital signs Rationale: The nurse can delegate the task of asking about pain when nursing assistive personnel (NAP) obtain vital signs. The NAP must be instructed to report findings to the nurse without delay. The nurse should evaluate the effectiveness 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. Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)? 1) Hepatitis B 2) Occasional alcohol use 3) Allergy to aspirin 4) Gastric irritation with bleeding *Ans* Answer: 1) Hepatitis B Rationale: Even in recommended doses, acetaminophen can cause severe hepatotoxicity in patients with liver disease, such as hepatitis B. Patients who consume alcohol regularly should also use acetaminophen cautiously. Those allergic to aspirin or other nonsteroidal anti-inflammatory