NCLEX questions #2 Med Surg (with rationales)
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...
NCLEX questions #2 Med Surg (with rationales)
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:
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.
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
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 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.
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:
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