Nclex questions for Fundamentals of Nursing
with rationale
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Terms in this set (71)
A 73-year-old patient who Answer:
sustained a right hip fracture in a fall 3) Deep somatic
requests pain medication from the
nurse. Based on his injury, which Rationale:
type of pain is this patient most Deep somatic pain originates in ligaments,
likely experiencing? tendons, nerves, blood vessels, and bones.
1) Phantom Therefore, a hip fracture causes deep somatic
2) Visceral pain. Phantom pain is pain that is perceived to
3) Deep somatic originate from a part that was removed during
4) Referred 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 Answer:
the nurse safely delegate to nursing 1) Asking about pain during vital signs
assistive personnel?
1) Asking about pain during vital Rationale:
signs The nurse can delegate the task of asking about
2) Evaluating the effectiveness of pain when nursing assistive personnel (NAP)
pain medication obtain vital signs. The NAP must be instructed to
3) Developing a plan of care report findings to the nurse without delay. The
involving nonpharmacologic nurse should evaluate the effectiveness of pain
interventions medications and develop the plan of care.
4) Administering over-the-counter Administering over-the-counter and prescription
pain medications medications is the responsibility of the registered
nurse or licensed practical nurse.
Which factor in the patient's past Answer:
medical history dictates that the 1) Hepatitis B
nurse exercise caution when
administering acetaminophen Rationale:
(Tylenol)? Even in recommended doses, acetaminophen
can cause severe hepatotoxicity in patients with
1) Hepatitis B liver disease, such as hepatitis B. Patients who
2) Occasional alcohol use consume alcohol regularly should also use
3) Allergy to aspirin acetaminophen cautiously. Those allergic to
4) Gastric irritation with bleeding aspirin or other nonsteroidal anti-inflammatory
drugs (NSAIDs) can use acetaminophen safely.
Acetaminophen rarely causes gastrointestinal (GI)
problems; therefore, it can be used for those with
a history of gastric irritation and bleeding.
,Which action should the nurse take Answer:
before administering morphine 4.0 3) Assess the patient's respiratory status.
mg intravenously to a patient
complaining of incisional pain? Rationale:
Before administering an opioid analgesic, such as
1) Assess the patient's incision. morphine, the nurse should assess the patient's
2) Clarify the order with the respiratory status because opioid analgesics can
prescriber. cause respiratory depression. It is not necessary
3) Assess the patient's respiratory to clarify the order with the physician because
status. morphine 4 mg IV is an appropriate dose. It is not
4) Monitor the patient's heart rate. necessary to monitor the patient's heart rate.
Which action should the nurse take Answer:
when preparing patient-controlled 2) Ask another nurse to double-check the setup
analgesia for a postoperative before patient use.
patient?
Rationale:
1) Caution the patient to limit the As a safeguard to reduce the risk for dosing
number of times he presses the errors, the nurse should request another nurse to
dosing button. double-check the setup before patient use. The
2) Ask another nurse to double- nurse should reassure the patient that the pump
check the setup before patient use. has a lockout feature that prevents him from
3) Instruct the patient to administer overdosing even if he continues to push the dose
a dose only when experiencing administration button. The nurse should also
pain. instruct the patient to administer a dose before
4) Provide clear, simple instructions potentially painful activities, such as walking.
for dosing if the patient is Patient-controlled analgesia is contraindicated
cognitively impaired. for those who are cognitively impaired.
, The nurse administers codeine Answer:
sulfate 30 mg orally to a patient 4) In 60 minutes
who underwent craniotomy 3 days
ago for a brain tumor. How soon Rationale:
after administration should the Codeine administered by the oral route reaches
nurse reassess the patient's pain? peak concentration in 60 minutes; therefore, the
nurse should reassess the patient's pain 60
1) Immediately minutes after administration. The nurse should
2) In 10 minutes reassess pain after 10 minutes when administering
3) In 15 minutes codeine by the intramuscular or subcutaneous
4) In 60 minutes routes. Drugs administered by the intravenous
(IV) route are effective almost immediately;
however, codeine is not recommended for IV
administration.
Which nonsteroidal anti- Answer:
inflammatory drug might be 3) Aspirin (Ecotrin)
administered to inhibit platelet
aggregation in a patient at risk for Rationale:
thrombophlebitis? Aspirin is a unique NSAID that inhibits platelet
aggregation. Low-dose aspirin therapy is
1) Ibuprofen (Motrin) commonly administered to decrease the risk of
2) Celecoxib (Celebrex) thrombophlebitis, myocardial infarction, and
3) Aspirin (Ecotrin) stroke. Ibuprofen, celecoxib, and indomethacin
4) Indomethacin (Indocin) are NSAIDs, but they do not inhibit platelet
aggregation.
with rationale
Save
Terms in this set (71)
A 73-year-old patient who Answer:
sustained a right hip fracture in a fall 3) Deep somatic
requests pain medication from the
nurse. Based on his injury, which Rationale:
type of pain is this patient most Deep somatic pain originates in ligaments,
likely experiencing? tendons, nerves, blood vessels, and bones.
1) Phantom Therefore, a hip fracture causes deep somatic
2) Visceral pain. Phantom pain is pain that is perceived to
3) Deep somatic originate from a part that was removed during
4) Referred 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 Answer:
the nurse safely delegate to nursing 1) Asking about pain during vital signs
assistive personnel?
1) Asking about pain during vital Rationale:
signs The nurse can delegate the task of asking about
2) Evaluating the effectiveness of pain when nursing assistive personnel (NAP)
pain medication obtain vital signs. The NAP must be instructed to
3) Developing a plan of care report findings to the nurse without delay. The
involving nonpharmacologic nurse should evaluate the effectiveness of pain
interventions medications and develop the plan of care.
4) Administering over-the-counter Administering over-the-counter and prescription
pain medications medications is the responsibility of the registered
nurse or licensed practical nurse.
Which factor in the patient's past Answer:
medical history dictates that the 1) Hepatitis B
nurse exercise caution when
administering acetaminophen Rationale:
(Tylenol)? Even in recommended doses, acetaminophen
can cause severe hepatotoxicity in patients with
1) Hepatitis B liver disease, such as hepatitis B. Patients who
2) Occasional alcohol use consume alcohol regularly should also use
3) Allergy to aspirin acetaminophen cautiously. Those allergic to
4) Gastric irritation with bleeding aspirin or other nonsteroidal anti-inflammatory
drugs (NSAIDs) can use acetaminophen safely.
Acetaminophen rarely causes gastrointestinal (GI)
problems; therefore, it can be used for those with
a history of gastric irritation and bleeding.
,Which action should the nurse take Answer:
before administering morphine 4.0 3) Assess the patient's respiratory status.
mg intravenously to a patient
complaining of incisional pain? Rationale:
Before administering an opioid analgesic, such as
1) Assess the patient's incision. morphine, the nurse should assess the patient's
2) Clarify the order with the respiratory status because opioid analgesics can
prescriber. cause respiratory depression. It is not necessary
3) Assess the patient's respiratory to clarify the order with the physician because
status. morphine 4 mg IV is an appropriate dose. It is not
4) Monitor the patient's heart rate. necessary to monitor the patient's heart rate.
Which action should the nurse take Answer:
when preparing patient-controlled 2) Ask another nurse to double-check the setup
analgesia for a postoperative before patient use.
patient?
Rationale:
1) Caution the patient to limit the As a safeguard to reduce the risk for dosing
number of times he presses the errors, the nurse should request another nurse to
dosing button. double-check the setup before patient use. The
2) Ask another nurse to double- nurse should reassure the patient that the pump
check the setup before patient use. has a lockout feature that prevents him from
3) Instruct the patient to administer overdosing even if he continues to push the dose
a dose only when experiencing administration button. The nurse should also
pain. instruct the patient to administer a dose before
4) Provide clear, simple instructions potentially painful activities, such as walking.
for dosing if the patient is Patient-controlled analgesia is contraindicated
cognitively impaired. for those who are cognitively impaired.
, The nurse administers codeine Answer:
sulfate 30 mg orally to a patient 4) In 60 minutes
who underwent craniotomy 3 days
ago for a brain tumor. How soon Rationale:
after administration should the Codeine administered by the oral route reaches
nurse reassess the patient's pain? peak concentration in 60 minutes; therefore, the
nurse should reassess the patient's pain 60
1) Immediately minutes after administration. The nurse should
2) In 10 minutes reassess pain after 10 minutes when administering
3) In 15 minutes codeine by the intramuscular or subcutaneous
4) In 60 minutes routes. Drugs administered by the intravenous
(IV) route are effective almost immediately;
however, codeine is not recommended for IV
administration.
Which nonsteroidal anti- Answer:
inflammatory drug might be 3) Aspirin (Ecotrin)
administered to inhibit platelet
aggregation in a patient at risk for Rationale:
thrombophlebitis? Aspirin is a unique NSAID that inhibits platelet
aggregation. Low-dose aspirin therapy is
1) Ibuprofen (Motrin) commonly administered to decrease the risk of
2) Celecoxib (Celebrex) thrombophlebitis, myocardial infarction, and
3) Aspirin (Ecotrin) stroke. Ibuprofen, celecoxib, and indomethacin
4) Indomethacin (Indocin) are NSAIDs, but they do not inhibit platelet
aggregation.
