Nclex questions for Fundamentals of
Nursing with rationale
A 73-year-vintage affected person who sustained a proper hip fracture in a fall requests ache
medicine from the nurse. Based on his harm, which type of ache is that this patient
maximum probable experiencing?
1) Phantom
2) Visceral
3) Deep somatic
4) Referred - ANSAnswer:
three) Deep somatic
Rationale:
Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones.
Therefore, a hip fracture reasons deep somatic pain. Phantom ache is ache this is appeared
to originate from a element that became eliminated in the course of surgical treatment.
Visceral pain is because of deep inner pain receptors and generally happens within the
abdominal cavity, skull, and thorax. Referred ache occurs in an area that is distant to the
unique website.
Which ache management task can the nurse adequately delegate to nursing assistive
employees?
1) Asking about pain throughout crucial signs and symptoms
2) Evaluating the effectiveness of ache medication
3) Developing a plan of care related to nonpharmacologic interventions
4) Administering over the counter pain medicines - ANSAnswer:
1) Asking approximately ache at some stage in vital symptoms
Rationale:
The nurse can delegate the challenge of asking about ache whilst nursing assistive
personnel (NAP) acquire important signs. The NAP need to be instructed to record findings
to the nurse immediately. The nurse have to compare the effectiveness of pain medicinal
drugs and broaden the plan of care. Administering over-the-counter and prescription
medications is the duty of the registered nurse or certified sensible nurse.
Which thing inside the patient's beyond medical records dictates that the nurse exercise
warning when administering acetaminophen (Tylenol)?
1) Hepatitis B
2) Occasional alcohol use
3) Allergy to aspirin
4) Gastric inflammation with bleeding - ANSAnswer:
1) Hepatitis B
,Rationale:
Even in endorsed doses, acetaminophen can motive extreme hepatotoxicity in patients with
liver sickness, such as hepatitis B. Patients who eat alcohol regularly have to additionally
use acetaminophen carefully. Those allergic to aspirin or other nonsteroidal
anti-inflammatory pills (NSAIDs) can use acetaminophen thoroughly. Acetaminophen hardly
ever causes gastrointestinal (GI) problems; consequently, it is able to be used for those with
a history of gastric inflammation and bleeding.
Which action need to the nurse take before administering morphine four.Zero mg
intravenously to a affected person complaining of incisional ache?
1) Assess the patient's incision.
2) Clarify the order with the prescriber.
3) Assess the patient's respiration fame.
Four) Monitor the patient's heart charge. - ANSAnswer:
three) Assess the affected person's breathing reputation.
Rationale:
Before administering an opioid analgesic, including morphine, the nurse need to check the
affected person's breathing repute due to the fact opioid analgesics can motive breathing
melancholy. It isn't necessary to clarify the order with the health practitioner due to the fact
morphine four mg IV is the proper dose. It isn't always necessary to screen the patient's
coronary heart rate.
Which action need to the nurse take while getting ready affected person-managed analgesia
for a postoperative affected person?
1) Caution the affected person to restriction the wide variety of instances he presses the
dosing button.
2) Ask any other nurse to double-check the setup before patient use.
Three) Instruct the patient to manage a dose handiest when experiencing pain.
4) Provide clear, easy instructions for dosing if the patient is cognitively impaired. -
ANSAnswer:
2) Ask every other nurse to double-take a look at the setup earlier than patient use.
Rationale:
As a safeguard to reduce the danger for dosing errors, the nurse need to request every other
nurse to double-take a look at the setup before patient use. The nurse ought to reassure the
affected person that the pump has a lockout characteristic that forestalls him from
overdosing although he continues to push the dose administration button. The nurse ought
to additionally teach the patient to administer a dose before doubtlessly painful sports,
consisting of on foot. Patient-managed analgesia is contraindicated for people who are
cognitively impaired.
The nurse administers codeine sulfate 30 mg orally to a affected person who underwent
craniotomy 3 days ago for a mind tumor. How soon after management have to the nurse
reconsider the patient's ache?
, 1) Immediately
2) In 10 mins
3) In 15 minutes
four) In 60 mins - ANSAnswer:
4) In 60 mins
Rationale:
Codeine administered by the oral route reaches top concentration in 60 minutes; therefore,
the nurse need to reassess the affected person's pain 60 minutes after administration. The
nurse should think again pain after 10 minutes whilst administering codeine via the
intramuscular or subcutaneous routes. Drugs administered via the intravenous (IV) path are
powerful nearly straight away; however, codeine is not encouraged for IV administration.
Which nonsteroidal anti inflammatory drug might be administered to inhibit platelet
aggregation in a affected person at threat for thrombophlebitis?
Rationale:
Aspirin is a completely unique NSAID that inhibits platelet aggregation. Low-dose aspirin
remedy is normally administered to decrease the threat of thrombophlebitis, myocardial
infarction, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do now
not inhibit platelet aggregation.
A client who is receiving epidural analgesia complains of nausea and loss of motor
characteristic in his legs. The nurse obtains his blood pressure and notes a drop in his blood
strain from the preceding reading. Which problem is the patient maximum probable
experiencing?
1) Infection on the catheter insertion web site
2) Side effect of the epidural analgesic
three) Epidural catheter migration
4) Spinal twine harm - ANSAnswer:
three) Epidural catheter migration
Rationale:
The affected person is displaying symptoms of epidural catheter migration, which include
nausea, a lower in blood pressure, and loss of motor characteristic without an identifiable
cause. Signs of infection on the catheter website consist of redness, swelling, and drainage.
Loss of motor function isn't always a standard facet effect related to epidural analgesics.
These are not unusual signs and symptoms of catheter migration, no longer spinal twine
damage.
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