NCLEX QUESTIONS 2 MED SURG (WITH RATIONALES)
QUESTIONS AND CORRECT ANSWERS GRADED A+
LATEST UPDATE.
/. 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
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.
/.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
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.
/.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
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.
/.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.
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.
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)
Rationale:
QUESTIONS AND CORRECT ANSWERS GRADED A+
LATEST UPDATE.
/. 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
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.
/.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
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.
/.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
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.
/.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.
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.
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)
Rationale:
