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Nclex questions for Fundamentals of Nursing with rationale questions and answers correct and verified 100%
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Nclex questions for Fundamentals of Nursing with rationale questions and answers correct and verified 100%Nclex questions for Fundamentals of Nursing with rationale questions and answers correct and verified 100% A 73-year-old patient who sustained a right hip fracture in a fall requests pain ...

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  • September 3, 2024
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  • 2024/2025
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Nclex questions for Fundamentals of Nursi
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Ayt73-year-
oldytpatientytwhoytsustainedytaytrightythipytfractureytinytaytfallytrequestsytpainytmedicationytfromyttheytnurs
e.ytBasedytonythisytinjury,ytwhichyttypeytofytpainytisytthisytpatientytmostytlikelyytexperiencing?
yt1)ytPhantom

yt2)ytVisceral

yt3)ytDeepytsomatic

yt4)ytReferredyt-ytcorrectytanswers-Answer:

3)ytDeepytsomatic
yt

Rationale:
Deepytsomaticytpainytoriginatesytinytligaments,yttendons,ytnerves,ytbloodytvessels,ytandytbones.ytTherefor
e,ytaythipytfractureytcausesytdeepytsomaticytpain.ytPhantomytpainytisytpainytthatytisytperceivedyttoytoriginateyt
fromytaytpartytthatytwasytremovedytduringytsurgery.ytVisceralytpainytisytcausedytbyytdeepytinternalytpainytre
ceptorsytandytcommonlyytoccursytinyttheytabdominalytcavity,ytcranium,ytandytthorax.ytReferredytpainytocc
ursytinytanytareaytthatytisytdistantyttoyttheytoriginalytsite.
Whichytpainytmanagementyttaskytcanyttheytnurseytsafelyytdelegateyttoytnursingytassistiveytpersonnel?
yt1)ytAskingytaboutytpainytduringytvitalytsigns

yt2)ytEvaluatingyttheyteffectivenessytofytpainytmedication

yt3)ytDevelopingytaytplanytofytcareytinvolvingytnonpharmacologicytinterventions

yt4)ytAdministeringytover-the-counterytpainytmedicationsyt-ytcorrectytanswers-Answer:

1)ytAskingytaboutytpainytduringytvitalytsigns
yt

Rationale:
Theytnurseytcanytdelegateyttheyttaskytofytaskingytaboutytpainytwhenytnursingytassistiveytpersonnelyt(NAP)yt
obtainytvitalytsigns.ytTheytNAPytmustytbeytinstructedyttoytreportytfindingsyttoyttheytnurseytwithoutytdelay.yt
Theytnurseytshouldytevaluateyttheyteffectivenessytofytpainytmedicationsytandytdevelopyttheytplanytofytcare.yt
Administeringytover-the-
counterytandytprescriptionytmedicationsytisyttheytresponsibilityytofyttheytregisteredytnurseytorytlicensedytpr
acticalytnurse.
Whichytfactorytinyttheytpatient'sytpastytmedicalythistoryytdictatesytthatyttheytnurseytexerciseytcautionytwhen
ytadministeringytacetaminophenyt(Tylenol)?




1)ytHepatitisytB
2)ytOccasionalytalcoholytuse
3)ytAllergyyttoytaspirin
4)ytGastricytirritationytwithytbleedingyt-ytcorrectytanswers-Answer:
1)ytHepatitisytB
yt

,Rationale:
Evenytinytrecommendedytdoses,ytacetaminophenytcanytcauseytsevereythepatotoxicityytinytpatientsytwithytli
verytdisease,ytsuchytasythepatitisytB.ytPatientsytwhoytconsumeytalcoholytregularlyytshouldytalsoytuseytaceta
minophenytcautiously.ytThoseytallergicyttoytaspirinytorytotherytnonsteroidalytanti-
inflammatoryytdrugsyt(NSAIDs)ytcanytuseytacetaminophenytsafely.ytAcetaminophenytrarelyytcausesytgas
trointestinalyt(GI)ytproblems;yttherefore,ytitytcanytbeytusedytforytthoseytwithytaythistoryytofytgastricytirritatio
nytandytbleeding.
Whichytactionytshouldyttheytnurseyttakeytbeforeytadministeringytmorphineyt4.0ytmgytintravenouslyyttoytayt
patientytcomplainingytofytincisionalytpain?

1)ytAssessyttheytpatient'sytincision.
2)ytClarifyyttheytorderytwithyttheytprescriber.
3)ytAssessyttheytpatient'sytrespiratoryytstatus.
4)ytMonitoryttheytpatient'sytheartytrate.yt-ytcorrectytanswers-Answer:
3)ytAssessyttheytpatient'sytrespiratoryytstatus.
yt

Rationale:
Beforeytadministeringytanytopioidytanalgesic,ytsuchytasytmorphine,yttheytnurseytshouldytassessyttheytpatien
t'sytrespiratoryytstatusytbecauseytopioidytanalgesicsytcanytcauseytrespiratoryytdepression.ytItytisytnotytneces
saryyttoytclarifyyttheytorderytwithyttheytphysicianytbecauseytmorphineyt4ytmgytIVytisytanytappropriateytdose.y
tItytisytnotytnecessaryyttoytmonitoryttheytpatient'sytheartytrate.

Whichytactionytshouldyttheytnurseyttakeytwhenytpreparingytpatient-
controlledytanalgesiaytforytaytpostoperativeytpatient?

1)ytCautionyttheytpatientyttoytlimityttheytnumberytofyttimesytheytpressesyttheytdosingytbutton.
2)ytAskytanotherytnurseyttoytdouble-checkyttheytsetupytbeforeytpatientytuse.
3)ytInstructyttheytpatientyttoytadministerytaytdoseytonlyytwhenytexperiencingytpain.
4)ytProvideytclear,ytsimpleytinstructionsytforytdosingytifyttheytpatientytisytcognitivelyytimpaired.yt-
ytcorrectytanswers-Answer:

2)ytAskytanotherytnurseyttoytdouble-checkyttheytsetupytbeforeytpatientytuse.
yt

Rationale:
Asytaytsafeguardyttoytreduceyttheytriskytforytdosingyterrors,yttheytnurseytshouldytrequestytanotherytnurseyttoyt
double-
checkyttheytsetupytbeforeytpatientytuse.ytTheytnurseytshouldytreassureyttheytpatientytthatyttheytpumpythasytay
tlockoutytfeatureytthatytpreventsythimytfromytoverdosingytevenytifytheytcontinuesyttoytpushyttheytdoseytadmi

nistrationytbutton.ytTheytnurseytshouldytalsoytinstructyttheytpatientyttoytadministerytaytdoseytbeforeytpotent
iallyytpainfulytactivities,ytsuchytasytwalking.ytPatient-
controlledytanalgesiaytisytcontraindicatedytforytthoseytwhoytareytcognitivelyytimpaired.
Theytnurseytadministersytcodeineytsulfateyt30ytmgytorallyyttoytaytpatientytwhoytunderwentytcraniotomyyt3yt
daysytagoytforytaytbrainyttumor.ytHowytsoonytafterytadministrationytshouldyttheytnurseytreassessyttheytpatie
nt'sytpain?

1)ytImmediately
2)ytInyt10ytminutes

, 3)ytInyt15ytminutes
4)ytInyt60ytminutesyt-ytcorrectytanswers-Answer:
4)ytInyt60ytminutes
yt

Rationale:
Codeineytadministeredytbyyttheytoralytrouteytreachesytpeakytconcentrationytinyt60ytminutes;yttherefore,ytth
eytnurseytshouldytreassessyttheytpatient'sytpainyt60ytminutesytafterytadministration.ytTheytnurseytshouldytre
assessytpainytafteryt10ytminutesytwhenytadministeringytcodeineytbyyttheytintramuscularytorytsubcutaneous
ytroutes.ytDrugsytadministeredytbyyttheytintravenousyt(IV)ytrouteytareyteffectiveytalmostytimmediately;ytho

wever,ytcodeineytisytnotytrecommendedytforytIVytadministration.
Whichytnonsteroidalytanti-
inflammatoryytdrugytmightytbeytadministeredyttoytinhibitytplateletytaggregationytinytaytpatientytatytriskytfo
rytthrombophlebitis?

1)ytIbuprofenyt(Motrin)
2)ytCelecoxibyt(Celebrex)
3)ytAspirinyt(Ecotrin)
4)ytIndomethacinyt(Indocin)yt-ytcorrectytanswers-Answer:
3)ytAspirinyt(Ecotrin)
yt

Rationale:
AspirinytisytaytuniqueytNSAIDytthatytinhibitsytplateletytaggregation.ytLow-
doseytaspirinyttherapyytisytcommonlyytadministeredyttoytdecreaseyttheytriskytofytthrombophlebitis,ytmyoc
ardialytinfarction,ytandytstroke.ytIbuprofen,ytcelecoxib,ytandytindomethacinytareytNSAIDs,ytbutyttheyytdoyt
notytinhibitytplateletytaggregation.
Aytclientytwhoytisytreceivingytepiduralytanalgesiaytcomplainsytofytnauseaytandytlossytofytmotorytfunctionytin
ythisytlegs.ytTheytnurseytobtainsythisytbloodytpressureytandytnotesytaytdropytinythisytbloodytpressureytfromytth

eytpreviousytreading.ytWhichytcomplicationytisyttheytpatientytmostytlikelyytexperiencing?

1)ytInfectionytatyttheytcatheterytinsertionytsite
2)ytSideyteffectytofyttheytepiduralytanalgesic
3)ytEpiduralytcatheterytmigration
4)ytSpinalytcordytdamageyt-ytcorrectytanswers-Answer:
3)ytEpiduralytcatheterytmigration
yt

Rationale:
Theytpatientytisytexhibitingytsignsytofytepiduralytcatheterytmigration,ytwhichytincludeytnausea,ytaytdecrease
ytinytbloodytpressure,ytandytlossytofytmotorytfunctionytwithoutytanytidentifiableytcause.ytSignsytofytinfectionyt

atyttheytcatheterytsiteytincludeytredness,ytswelling,ytandytdrainage.ytLossytofytmotorytfunctionytisytnotytayttyp
icalytsideyteffectytassociatedytwithytepiduralytanalgesics.ytTheseytareytcommonytsignsytofytcatheterytmigrati
on,ytnotytspinalytcordytdamage.
Whichytofyttheytfollowingytclientsytisytexperiencingytanytabnormalytchangeytinytvitalytsigns?ytAytclientytwho
seyt(selectytallytthatytapply):

1)ytBloodytpressureyt(BP)ytwasyt132/80ytmmytHgytsittingytandytisyt120/60ytmmytHgytuponytstanding
2)ytRectalyttemperatureytisyt97.9°Fytinyttheytmorningytandyt99.2°Fytinyttheytevening

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