NCLEX QUESTIONS #2 MED SURG (WITH
RATIONALES) AND ANSWERS LATEST
VERSION VERIFIED RATIONALE GRADED A+
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 - ANS:
3) 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.
A client exhibits all of the following during a physical assessment. Which of these is considered
a primary defense against infection?
1) Fever
2) Intact skin
3) Inflammation
4) Lethargy - ANS:
2) Intact skin
Rationale:
, Intact skin is considered a primary defense against infection. Fever, the inflammatory response,
and phagocytosis (a process of killing pathogens) are considered secondary defenses against
infection.
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 - ANS:
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.
A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA)
cultured from the wound. Contact precautions are initiated. Which rule must be observed to
follow contact precautions?
1) A clean gown and gloves must be worn when in contact with the client.
2) Everyone who enters the room must wear a N-95 respirator mask.
3) All linen and trash must be marked as contaminated and send to biohazard waste.
4) Place the client in a room with a client with an upper respiratory infection. - ANS:
1) A clean gown and gloves must be worn when in contact with the client.
RATIONALES) AND ANSWERS LATEST
VERSION VERIFIED RATIONALE GRADED A+
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 - ANS:
3) 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.
A client exhibits all of the following during a physical assessment. Which of these is considered
a primary defense against infection?
1) Fever
2) Intact skin
3) Inflammation
4) Lethargy - ANS:
2) Intact skin
Rationale:
, Intact skin is considered a primary defense against infection. Fever, the inflammatory response,
and phagocytosis (a process of killing pathogens) are considered secondary defenses against
infection.
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 - ANS:
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.
A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA)
cultured from the wound. Contact precautions are initiated. Which rule must be observed to
follow contact precautions?
1) A clean gown and gloves must be worn when in contact with the client.
2) Everyone who enters the room must wear a N-95 respirator mask.
3) All linen and trash must be marked as contaminated and send to biohazard waste.
4) Place the client in a room with a client with an upper respiratory infection. - ANS:
1) A clean gown and gloves must be worn when in contact with the client.
