NCLEX QUESTIONS 2 MED SURG WITH
RATIONALES EXAM QUESTIONS WITH
CORRECT ANSWERS NEW UPDATE WITH
RATIONALES
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. ---Answer:
3) Assess the patient's respiratory status.
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 necessary 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.
,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 button.
2) Ask another nurse to double-check the setup before patient use.
3) Instruct the patient to administer a dose only when experiencing pain.
4) Provide clear, simple instructions for dosing if the patient is cognitively
impaired. ---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 if he continues to push the dose administration button. The
nurse should also instruct the patient to administer a dose before potentially
painful activities, such as walking. Patient-controlled analgesia is
contraindicated for those who are cognitively impaired.
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) ---Answer:
3) Aspirin (Ecotrin)
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin
therapy is commonly administered to decrease the risk of thrombophlebitis,
myocardial infarction, and stroke. 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 pressure from the previous reading. Which complication is the
patient most likely experiencing?
1) Infection at the catheter insertion site
2) Side effect of the epidural analgesic
3) Epidural catheter migration
4) Spinal cord damage ---Answer:
3) Epidural catheter migration
Rationale:
RATIONALES EXAM QUESTIONS WITH
CORRECT ANSWERS NEW UPDATE WITH
RATIONALES
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. ---Answer:
3) Assess the patient's respiratory status.
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 necessary 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.
,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 button.
2) Ask another nurse to double-check the setup before patient use.
3) Instruct the patient to administer a dose only when experiencing pain.
4) Provide clear, simple instructions for dosing if the patient is cognitively
impaired. ---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 if he continues to push the dose administration button. The
nurse should also instruct the patient to administer a dose before potentially
painful activities, such as walking. Patient-controlled analgesia is
contraindicated for those who are cognitively impaired.
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) ---Answer:
3) Aspirin (Ecotrin)
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin
therapy is commonly administered to decrease the risk of thrombophlebitis,
myocardial infarction, and stroke. 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 pressure from the previous reading. Which complication is the
patient most likely experiencing?
1) Infection at the catheter insertion site
2) Side effect of the epidural analgesic
3) Epidural catheter migration
4) Spinal cord damage ---Answer:
3) Epidural catheter migration
Rationale:
