Nclex questions for Fundamentals of Nursing with rationale. Exam Questions And Answers 100% Pass
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Nclex questions for Fundamentals of Nursing
with rationale. Exam Questions And Answers
100% Pass
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) Phan...
Nclex questions for Fundamentals of Nursing
with rationale. Exam Questions And Answers
100% Pass
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✔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
4) Administering over-the-counter pain medications - answer✔Answer:
1) Asking about pain during vital signs
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 - answer✔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✔Answer:
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✔Answer:
2) Ask another nurse to double-check the setup before patient use.
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.
The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3
days ago for a brain tumor. How soon after administration should the nurse reassess the patient's
pain?
4) In 60 minutes - answer✔Answer:
4) In 60 minutes
Rationale:
Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore, the
nurse should reassess the patient's pain 60 minutes after administration. The nurse should
reassess pain after 10 minutes when administering codeine by the intramuscular or subcutaneous
routes. Drugs administered by the intravenous (IV) route are effective almost immediately;
however, codeine is not recommended for IV administration.
Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation
in a patient at risk for thrombophlebitis?
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is
commonly administered to decrease the risk of thrombophlebitis, myocardial infarction, and
stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet
aggregation.
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
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