NCLEX questions 2 Med Surg with rationales

NCLEX questions #2 Med Surg (with rationales) 4.3 (6 reviews) Terms in this set (23) Science MedicineNursing Save 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 4) Administering over-the-counter pain medications

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:

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:

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.

Which nonsteroidal anti- inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis?1) Ibuprofen (Motrin) 2) Celecoxib (Celebrex) 3) Aspirin (Ecotrin) 4) Indomethacin (Indocin)

Answer:

3) Aspirin (Ecotrin)

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 2) Side effect of the epidural analgesic 3) Epidural catheter migration 4) Spinal cord damage

Answer:

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.