Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
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?
Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
, Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
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.
Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
, Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
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.
Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
, Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
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.
Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
rationale 100% correct and verified
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?
Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
, Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
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.
Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
, Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
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.
Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
, Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
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.
Nclex questions with answers |Fundamentals of Nursing with
rationale 100% correct and verified
