NCLEX QUESTIONS FOR FUNDAMENTALS OF NURSING
WITH RATIONALE
1. 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
Answer:
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.
2. 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
Answer:
a. 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.
,3. 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
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 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.
4. 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.
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 should the nurse reassess the patient's pain?
1) Immediately
2) In 10 minutes
3) In 15 minutes
4) In 60 minutes
Answer:
4) In 60 minutes
Rationale:
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 the intramuscular or subcutaneous routes.
Drugs administered by the intravenous (IV) route are effective almost immediately; however,
codeine is not recommended for IV administration.
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:
The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in
blood pressure, and loss of motor function without an identifiable cause. Signs of infection at the
catheter site include redness, swelling, and drainage. Loss of motor function is not a typical side
effect associated with epidural analgesics. These are common signs of catheter migration, not spinal
cord damage.
Which of the following clients is experiencing an abnormal change in vital signs? A client whose
(select all that apply):
1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
2) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening
3) Heart rate was 76 before eating and is 60 after eating
4) Respiratory rate was 14 when standing and is 22 after walking
Answer:
1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
3) Heart rate was 76 before eating and is 60 after eating
Rationale:
The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension.
The change in heart rate is abnormal; heart rate usually increases slightly after eating rather than
WITH RATIONALE
1. 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
Answer:
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.
2. 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
Answer:
a. 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.
,3. 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
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 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.
4. 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.
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 should the nurse reassess the patient's pain?
1) Immediately
2) In 10 minutes
3) In 15 minutes
4) In 60 minutes
Answer:
4) In 60 minutes
Rationale:
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 the intramuscular or subcutaneous routes.
Drugs administered by the intravenous (IV) route are effective almost immediately; however,
codeine is not recommended for IV administration.
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:
The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in
blood pressure, and loss of motor function without an identifiable cause. Signs of infection at the
catheter site include redness, swelling, and drainage. Loss of motor function is not a typical side
effect associated with epidural analgesics. These are common signs of catheter migration, not spinal
cord damage.
Which of the following clients is experiencing an abnormal change in vital signs? A client whose
(select all that apply):
1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
2) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening
3) Heart rate was 76 before eating and is 60 after eating
4) Respiratory rate was 14 when standing and is 22 after walking
Answer:
1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
3) Heart rate was 76 before eating and is 60 after eating
Rationale:
The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension.
The change in heart rate is abnormal; heart rate usually increases slightly after eating rather than
