NCLEX QUESTIONS AND ANSWERS FOR FUNDAMENTALS OF

NCLEX QUESTIONS AND ANSWERS FOR FUNDAMENTALS OF

NURSING WITH RATIONALE 2023

A 73-year-old pa.ent who sustained a right hip fracture in a fall requests pain medica.on from the nurse. Based on his injury, which type of pain is this pa.ent most likely experiencing?1) Phantom 2) Visceral 3) Deep soma.c 4) Referred

Answer:

3) Deep soma.c

Ra.onale:

Deep soma.c pain originates in ligaments, tendons, nerves, blood vessels, and bones.Therefore, a hip fracture causes deep soma.c 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 assis.ve personnel?1) Asking about pain during vital signs 2) Evalua.ng the effec.veness of pain medica.on 3) Developing a plan of care involving nonpharmacologic interven.ons 4) Administering over-the-counter pain medica.ons

Answer:

1) Asking about pain during vital signs

Ra.onale:

The nurse can delegate the task of asking about pain when nursing assis.ve personnel (NAP) obtain vital signs. The NAP must be instructed to report findings to the nurse without delay.The nurse should evaluate the effec.veness of pain medica.ons and develop the plan of care. Administering over-the-counter and prescrip.on medica.ons is the responsibility of the registered nurse or licensed prac.cal nurse.

Which factor in the pa.ent's past medical history dictates that the nurse exercise cau.on when administering acetaminophen (Tylenol)?

1) Hepa..s B 2) Occasional alcohol use 3) Allergy to aspirin 4) Gastric irrita.on with bleeding

Answer:

1) Hepa..s B

Ra.onale:

Even in recommended doses, acetaminophen can cause severe hepatotoxicity in pa.ents with liver disease, such as hepa..s B. Pa.ents who consume alcohol regularly should also use acetaminophen cau.ously. Those allergic to aspirin or other nonsteroidal an.-

inflammatory drugs (NSAIDs) can use acetaminophen safely. Acetaminophen rarely causes gastrointes.nal (GI) problems; therefore, it can be used for those with a history of gastric irrita.on and bleeding.

Which ac.on should the nurse take before administering morphine 4.0 mg intravenously to a pa.ent complaining of incisional pain?

1) Assess the pa.ent's incision.2) Clarify the order with the prescriber.3) Assess the pa.ent's respiratory status.4) Monitor the pa.ent's heart rate.

Answer:

3) Assess the pa.ent's respiratory status.

Ra.onale:

Before administering an opioid analgesic, such as morphine, the nurse should assess the pa.ent'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 pa.ent's heart rate.

Which ac.on should the nurse take when preparing pa.ent-controlled analgesia for a postopera.ve pa.ent?

1) Cau.on the pa.ent to limit the number of .mes he presses the dosing bu_on.2) Ask another nurse to double-check the setup before pa.ent use.3) Instruct the pa.ent to administer a dose only when experiencing pain.4) Provide clear, simple instruc.ons for dosing if the pa.ent is cogni.vely impaired.

Answer:

2) Ask another nurse to double-check the setup before pa.ent use.

Ra.onale:

As a safeguard to reduce the risk for dosing errors, the nurse should request another nurse to double-check the setup before pa.ent use. The nurse should reassure the pa.ent that the pump has a lockout feature that prevents him from overdosing even if he con.nues to push the dose administra.on bu_on. The nurse should also instruct the pa.ent to administer a dose before poten.ally painful ac.vi.es, such as walking. Pa.ent-controlled analgesia is contraindicated for those who are cogni.vely impaired.

The nurse administers codeine sulfate 30 mg orally to a pa.ent who underwent craniotomy

• days ago for a brain tumor. How soon a`er administra.on should the nurse reassess the

pa.ent's pain?

1) Immediately 2) In 10 minutes 3) In 15 minutes 4) In 60 minutes

Answer:

4) In 60 minutes

Ra.onale:

Codeine administered by the oral route reaches peak concentra.on in 60 minutes; therefore, the nurse should reassess the pa.ent's pain 60 minutes a`er administra.on. The nurse should reassess pain a`er 10 minutes when administering codeine by the intramuscular or subcutaneous routes. Drugs administered by the intravenous (IV) route are effec.ve almost immediately; however, codeine is not recommended for IV administra.on.

Which nonsteroidal an.-inflammatory drug might be administered to inhibit platelet aggrega.on in a pa.ent at risk for thrombophlebi.s?

1) Ibuprofen (Motrin) 2) Celecoxib (Celebrex) 3) Aspirin (Ecotrin) 4) Indomethacin (Indocin)

Answer:

3) Aspirin (Ecotrin)

Ra.onale:

Aspirin is a unique NSAID that inhibits platelet aggrega.on. Low-dose aspirin therapy is commonly administered to decrease the risk of thrombophlebi.s, myocardial infarc.on, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggrega.on.

A client who is receiving epidural analgesia complains of nausea and loss of motor func.on in his legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complica.on is the pa.ent most likely experiencing?

1) Infec.on at the catheter inser.on site 2) Side effect of the epidural analgesic 3) Epidural catheter migra.on 4) Spinal cord damage

Answer:

3) Epidural catheter migra.on

Ra.onale:

The pa.ent is exhibi.ng signs of epidural catheter migra.on, which include nausea, a decrease in blood pressure, and loss of motor func.on without an iden.fiable cause. Signs of infec.on at the catheter site include redness, swelling, and drainage. Loss of motor func.on is not a typical side effect associated with epidural analgesics. These are common signs of catheter migra.on, not spinal cord damage.

Which of the following clients is experiencing an abnormal change in vital signs? A client

whose (select all that apply):

1) Blood pressure (BP) was 132/80 mm Hg sifng and is 120/60 mm Hg upon standing 2) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening 3) Heart rate was 76 before ea.ng and is 60 a`er ea.ng 4) Respiratory rate was 14 when standing and is 22 a`er walking

Answer:

1) Blood pressure (BP) was 132/80 mm Hg sifng and is 120/60 mm Hg upon standing 3) Heart rate was 76 before ea.ng and is 60 a`er ea.ng

Ra.onale:

The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension. The change in heart rate is abnormal; heart rate usually increases slightly a`er ea.ng rather than decreasing. The temperatures are within normal range for the rectal route, and temperature increases throughout the day. It is normal to have an increased respiratory rate a`er exercise.

The nurse assesses clients' breath sounds. Which one requires immediate medical a_en.on?

A client who has:

1) Crackles 2) Rhonchi 3) Stridor 4) Wheezes

Answer:

3) Stridor

Ra.onale:

Stridor is a sign of respiratory distress, possibly airway obstruc.on. Crackles and rhonchi indicate fluid in the lung; wheezes are caused by narrowing of the airway. Crackles, rhonchi, and wheezes indicate respiratory illness and are poten.ally serious but do not necessarily indicate respiratory distress that requires immediate medical a_en.on.

The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to

• Based on this assessment finding, it would be important for the nurse to also assess the:

1) Pulse deficit 2) Blood pressure 3) Apical pulse 4) Pulse pressure

Answer:

2) Blood pressure

Ra.onale:

If the leg pulses are weak, the nurse should assess the blood pressure in order to further explore the reason for the low pulse volume. If the blood pressure is low, then a low pulse volume would be expected. The pulse deficit is the difference between the apical and radial pulse. The apical pulse would not be helpful to assess peripheral circula.on. The pulse pressure is the difference between the systolic and diastolic pressures.

Which of the following clients has indica.ons of orthosta.c hypotension? A client whose

blood pressure is: