Nclex questions for Fundamentals of
Nursing with rationale
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 Correct answers
Answer:
3) Deep
somatic
Rational
e:
Deep somatic pain originates in ligaments, tendons, nerves, blood vessels,
and bones.a hip fracture causes deep somatic pain. Phantom pain is
Therefore,
pain that isto originate from a part that was removed during surgery.
perceived
Visceralby
caused pain
deep is internal pain receptors and commonly occurs in the
abdominal
cranium, cavity,
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 Correct answers
1)
Answer:
Asking about pain during vital
signs
Rational
e:
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 of care. Administering over-the-counter and prescription
develop the plan
medications
the is
responsibility of the registered nurse or licensed
practical nurse.
Which factor in the patient's past medical history dictates that the nurse
exercise
when caution
administering acetaminophen
(Tylenol)?
1) Hepatitis
B
2) Occasional alcohol
use
3) Allergy to
aspirin
4) Gastric irritation with bleeding Correct answers
Answer:
,1) Hepatitis
B
Rational
e:
Even in recommended doses, acetaminophen can cause severe
hepatotoxicity
patients in disease, such as hepatitis B. Patients who consume
with liver
alcohol also
should regularly
use acetaminophen cautiously. Those allergic to aspirin
or other
nonsteroidal anti-inflammatory drugs (NSAIDs) can use
acetaminophen safely.
Acetaminophen rarely causes gastrointestinal (GI) problems; therefore, it
canthose
for be usedwith a history of gastric irritation and
bleeding.
Which action should the nurse take before administering morphine 4.0 mg
intravenously
to a patient complaining of incisional
pain?
1) Assess the patient's
incision.
2) Clarify the order with the
prescriber.
3) Assess the patient's respiratory
status.
4) Monitor the patient's heart rate. Correct answers
Answer:
3) Assess the patient's respiratory
status.
Rational
e:
Before administering an opioid analgesic, such as morphine, the nurse
should
the assessrespiratory status because opioid analgesics can cause
patient's
respiratory
depression. It is not necessary to clarify the order with the physician
because
4 mg IV ismorphine
an appropriate dose. It is not necessary to monitor the patient's
heart rate.
Which action should the nurse take when preparing patient-controlled
analgesia for a
postoperative
patient?
1) Caution the patient to limit the number of times he presses the
dosing
2) button. nurse to double-check the setup before
Ask another
patient
3) Instruct
use.the patient to administer a dose only when
experiencing
4) pain.
Provide clear, simple instructions for dosing if the patient is
cognitively
Correct impaired.
answers
Answer:
2) Ask another nurse to double-check the setup before
patient use.
Rational
As a safeguard to reduce the risk for dosing errors, the nurse should
e:
request
nurse toanother
double-check the setup before patient use. The nurse should
reassurethat
patient thethe pump has a lockout feature that prevents him from
overdosingtoeven
continues pushifthe
he dose administration button. The nurse should also
instruct to
patient the
administer a dose before potentially painful activities, such
as walking.
Patient-controlled analgesia is contraindicated for those who are cognitively
impaired.
The nurse administers codeine sulfate 30 mg orally to a patient who
underwent
craniotomy 3 days ago for a brain tumor. How soon after administration
shouldreassess
nurse the the patient's
pain?
, 1)
Immediately
2) In 10
minutes
3) In 15
minutes
4) In 60 minutes Correct answers
Answer:
4) In 60
minutes
Rational
e:
Codeine administered by the oral route reaches peak concentration in
60 minutes;
therefore, the nurse should reassess the patient's pain 60 minutes after
administration.
The nurse should reassess pain after 10 minutes when administering
codeine by theor subcutaneous routes. Drugs administered by the
intramuscular
intravenous
are effective(IV) route
almost immediately; however, codeine is not
recommended for IV
administratio
n.
Which nonsteroidal anti-inflammatory drug might be administered to
inhibit platelet
aggregation in a patient at risk for
thrombophlebitis?
1) Ibuprofen
(Motrin)
2) Celecoxib
(Celebrex)
3) Aspirin
(Ecotrin)
4) Indomethacin (Indocin) Correct answers
Answer:
3) Aspirin
(Ecotrin)
Rational
e:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin
therapy is administered to decrease the risk of thrombophlebitis,
commonly
myocardial
and stroke. infarction,
Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do
not inhibit
platelet
aggregation.
A client who is receiving epidural analgesia complains of nausea and
loss of motor
function in his legs. The nurse obtains his blood pressure and notes a drop in
his blood from the previous reading. Which complication is the patient
pressure
most likely
experiencin
g?
1) Infection at the catheter
insertion
2) Side effect
site of the epidural
analgesic
3) Epidural catheter
migration
4) Spinal cord damage Correct answers
Answer:
3) Epidural catheter
migration
Rational
e:
The patient is exhibiting signs of epidural catheter migration, which include
nausea, ain blood pressure, and loss of motor function without an
decrease
identifiable
Signs cause.at the catheter site include redness, swelling, and
of infection
drainage. Loss of
Nursing with rationale
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 Correct answers
Answer:
3) Deep
somatic
Rational
e:
Deep somatic pain originates in ligaments, tendons, nerves, blood vessels,
and bones.a hip fracture causes deep somatic pain. Phantom pain is
Therefore,
pain that isto originate from a part that was removed during surgery.
perceived
Visceralby
caused pain
deep is internal pain receptors and commonly occurs in the
abdominal
cranium, cavity,
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 Correct answers
1)
Answer:
Asking about pain during vital
signs
Rational
e:
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 of care. Administering over-the-counter and prescription
develop the plan
medications
the is
responsibility of the registered nurse or licensed
practical nurse.
Which factor in the patient's past medical history dictates that the nurse
exercise
when caution
administering acetaminophen
(Tylenol)?
1) Hepatitis
B
2) Occasional alcohol
use
3) Allergy to
aspirin
4) Gastric irritation with bleeding Correct answers
Answer:
,1) Hepatitis
B
Rational
e:
Even in recommended doses, acetaminophen can cause severe
hepatotoxicity
patients in disease, such as hepatitis B. Patients who consume
with liver
alcohol also
should regularly
use acetaminophen cautiously. Those allergic to aspirin
or other
nonsteroidal anti-inflammatory drugs (NSAIDs) can use
acetaminophen safely.
Acetaminophen rarely causes gastrointestinal (GI) problems; therefore, it
canthose
for be usedwith a history of gastric irritation and
bleeding.
Which action should the nurse take before administering morphine 4.0 mg
intravenously
to a patient complaining of incisional
pain?
1) Assess the patient's
incision.
2) Clarify the order with the
prescriber.
3) Assess the patient's respiratory
status.
4) Monitor the patient's heart rate. Correct answers
Answer:
3) Assess the patient's respiratory
status.
Rational
e:
Before administering an opioid analgesic, such as morphine, the nurse
should
the assessrespiratory status because opioid analgesics can cause
patient's
respiratory
depression. It is not necessary to clarify the order with the physician
because
4 mg IV ismorphine
an appropriate dose. It is not necessary to monitor the patient's
heart rate.
Which action should the nurse take when preparing patient-controlled
analgesia for a
postoperative
patient?
1) Caution the patient to limit the number of times he presses the
dosing
2) button. nurse to double-check the setup before
Ask another
patient
3) Instruct
use.the patient to administer a dose only when
experiencing
4) pain.
Provide clear, simple instructions for dosing if the patient is
cognitively
Correct impaired.
answers
Answer:
2) Ask another nurse to double-check the setup before
patient use.
Rational
As a safeguard to reduce the risk for dosing errors, the nurse should
e:
request
nurse toanother
double-check the setup before patient use. The nurse should
reassurethat
patient thethe pump has a lockout feature that prevents him from
overdosingtoeven
continues pushifthe
he dose administration button. The nurse should also
instruct to
patient the
administer a dose before potentially painful activities, such
as walking.
Patient-controlled analgesia is contraindicated for those who are cognitively
impaired.
The nurse administers codeine sulfate 30 mg orally to a patient who
underwent
craniotomy 3 days ago for a brain tumor. How soon after administration
shouldreassess
nurse the the patient's
pain?
, 1)
Immediately
2) In 10
minutes
3) In 15
minutes
4) In 60 minutes Correct answers
Answer:
4) In 60
minutes
Rational
e:
Codeine administered by the oral route reaches peak concentration in
60 minutes;
therefore, the nurse should reassess the patient's pain 60 minutes after
administration.
The nurse should reassess pain after 10 minutes when administering
codeine by theor subcutaneous routes. Drugs administered by the
intramuscular
intravenous
are effective(IV) route
almost immediately; however, codeine is not
recommended for IV
administratio
n.
Which nonsteroidal anti-inflammatory drug might be administered to
inhibit platelet
aggregation in a patient at risk for
thrombophlebitis?
1) Ibuprofen
(Motrin)
2) Celecoxib
(Celebrex)
3) Aspirin
(Ecotrin)
4) Indomethacin (Indocin) Correct answers
Answer:
3) Aspirin
(Ecotrin)
Rational
e:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin
therapy is administered to decrease the risk of thrombophlebitis,
commonly
myocardial
and stroke. infarction,
Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do
not inhibit
platelet
aggregation.
A client who is receiving epidural analgesia complains of nausea and
loss of motor
function in his legs. The nurse obtains his blood pressure and notes a drop in
his blood from the previous reading. Which complication is the patient
pressure
most likely
experiencin
g?
1) Infection at the catheter
insertion
2) Side effect
site of the epidural
analgesic
3) Epidural catheter
migration
4) Spinal cord damage Correct answers
Answer:
3) Epidural catheter
migration
Rational
e:
The patient is exhibiting signs of epidural catheter migration, which include
nausea, ain blood pressure, and loss of motor function without an
decrease
identifiable
Signs cause.at the catheter site include redness, swelling, and
of infection
drainage. Loss of
