[2022年03月15日] 最新NCLEX Certification NCLEX-RN実際の無料試験解答
NCLEX Certification NCLEX-RN問題集最新の練習テスト865独特な解答
質問 163
After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse's appropriate response is:
- A. "No vegetable exchanges are allowed."
- B. "Yes, but only one-half ear is allowed."
- C. "Corn and other starchy vegetables are considered to be bread exchanges."
- D. "Yes, you may exchange any vegetable for any other vegetable."
正解: C
解説:
Explanation
(A) Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. (B) The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. (C) Massaging the site of injectionfacilitates absorption of the insulin. (D) Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3-7 days.
質問 164
A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?
- A. Tuna on whole-wheat bread and iced tea
- B. Peanut butter and jelly sandwich and milk
- C. Oatmeal, whole-wheat toast, and milk
- D. Corn beef and cabbage and boiled potatoes
正解: D
解説:
Explanation/Reference:
Explanation:
(A, C, D) These foods are allowed with a colostomy. (B) Gasforming foods such as cabbage should be avoided.
質問 165
A 24-year-old woman who is gravida 1 reports, "I can't take iron pills because they make me sick." She continues, "My bowels aren't moving either." In counseling her based on these complaints, the nurse's most appropriate response would be, "It would be beneficial for you to eat . . .
- A. green leafy vegetables."
- B. red meat."
- C. eggs."
- D. prunes."
正解: D
解説:
(A) Prunes provide fiber to decrease constipation and are an excellent source of dietary iron, as the prenatal client is not taking her supplemental iron and iron-deficiency anemia is common during pregnancy. (B) Green leafy vegetables provide a source of fiber and iron; however, prunes are a better source of both. (C) Red meat is a good iron source but will not address the constipation problem. (D) Eggs are a good iron source but do not address the constipation problem.
質問 166
The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:
- A. Will bind calcium and therefore interfere with its metabolism
- B. Causes competition at iron-receptor sites between iron and vitamin B1
- C. Will cause more premenstrual cramping
- D. Interferes with iron absorption because the iron precipitates as an insoluble substance
正解: D
解説:
Explanation/Reference:
Explanation:
(A) Eating chalk is not related to calcium and its absorption. (B) Poor nutritional habits may result in increased discomfort during premenstrual days, but this is not a primary reason for the client to stop eating chalk. Premenstrual discomfort has not been mentioned. (C) Iron is rendered insoluble and is excreted through the gastrointestinal tract. (D) There is no competition between the two nutrients.
質問 167
One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication:
- A. On arising and no later than 6 PM
- B. With breakfast and at bedtime
- C. At evenly spaced intervals, such as 8 AM and 8 PM
- D. With at least one glass of water per pill
正解: A
解説:
Explanation
(A) This option provides adequate spacing of the medication and will limit the client's need to get up to go to the bathroom during the night hours, when he is especially at high risk for falls. (B) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls. This option also does not take into consideration the client's usual daily routine. (C) Taking this medication with at least one glass of water would not have an impact on the risk of falls. (D) This option would result in the need to get up during the night to urinate and would thus increase the risk of falls.
質問 168
A 7-year-old girl has been diagnosed with juvenile arthritis and has been placed on daily aspirin. Which statement made by the parent indicates a need for further teaching?
- A. "One sign of aspirin toxicity can be ringing in the ears."
- B. "My daughter takes her aspirin with her meals."
- C. "Her gums have been bleeding frequently. Maybe she is brushing too hard."
- D. "I give her aspirin on a regular schedule every day."
正解: C
解説:
Explanation
(A) Aspirin should not be given on an empty stomach because it is irritating to the mucosa. (B) Bleeding from decreased clotting capacity may be caused by aspirin toxicity. (C) A regular schedule of aspirin administration is important to maintain a satisfactory drug level in the body. (D) Aspirin toxicity may affect cranial nerve VIII, leading to tinnitus (ringing in the ears).
質問 169
A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of "not feeling well." At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
- A. Monitor him closely until dinner arrives
- B. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink
- C. Have him drink 4 oz of orange juice
- D. Ask him to dissolve three pieces of hard candy in his mouth
正解: C
解説:
Explanation
(A) The combination of sugar and juice will increase the blood sugar beyond the normal range. (B) Concentrated sweets are not absorbed as fast as juice; consequently, they elevate the blood sugar beyond the normal limit. (C) Four ounces of orange juice will act immediately to raise the blood sugar to a normal level and sustain it for 30 minutes until supper is served. (D) There is an increased potential for the client's blood sugar to decrease even further, resulting in diabetic coma.
質問 170
A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit?
- A. Numbness of extremities
- B. Dysrhythmias
- C. Headache
- D. Tetany
正解: B
解説:
Explanation
(A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency.
質問 171
A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?
- A. Fluctuating levels with a predawn increase
- B. A decreased blood sugar level
- C. A normal blood sugar level
- D. An increased blood sugar level
正解: D
解説:
Explanation/Reference:
Explanation:
(A) Blood sugar levels increase when the body responds to stress and illness. (B) Blood sugar levels increase when the body responds to stress and illness. (C) Hyperglycemia occurs because glucose is produced as the body responds to the stress and illness of cellulitis. (D) Blood sugar levels remain elevated as long as the body responds to stress and illness.
質問 172
A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?
- A. He enters a concert, but as the lights dim, he does not experience anxiety.
- B. He states that he no longer fears dark places.
- C. He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom.
- D. He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens.
正解: D
解説:
(A) This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. (B) The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. (C) The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy
prematurely. (D) Does he experience anxiety in the darkroom? He may have taken this job
to force himself to deal with the phobia directly.
質問 173
A client is experiencing muscle weakness and lethargy. His serum K+ is 3.2. What other symptoms might he exhibit?
- A. Numbness of extremities
- B. Dysrhythmias
- C. Headache
- D. Tetany
正解: B
解説:
Section: Questions Set B
Explanation:
(A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency.
質問 174
Which of the following findings would be abnormal in a postpartal woman?
- A. Chills shortly after delivery
- B. Pulse rate of 60 bpm in morning on first postdelivery day
- C. An oral temperature of 101F (38.3C) on the third day after delivery
- D. Urinary output of 3000 mL on the second day after delivery
正解: C
解説:
Explanation/Reference:
Explanation:
(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (12-24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000-3000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious process.
質問 175
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale.
When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
- A. Liver
- B. Superior vena cava
- C. Pulmonary system
- D. Left ventricle
正解: C
解説:
Explanation/Reference:
Explanation:
(A) The foramen ovale permits a percentage of the blood to shunt from the right atrium to the left atrium.
The blood then goes to the left ventricle, permitting systemic fetal circulation with blood containing a higher O2 saturation. (B) As the blood shunts from the right atrium to the left atrium, the pulmonary system is bypassed. The fetus receives O2 from the maternal circulation, thereby permitting the partial bypass of the pulmonary system. (C) The foramen ovale is locatedin the atrial septum of the heart and does not affect the liver. (D) The superior vena cava returns blood to the heart, bringing blood to the location of the foramen ovale.
質問 176
A 48-year-old client is in the surgical intensive care unit after having had three-vessel
coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician?
- A. Serum sodium is low. The nurse should change IV fluids to normal saline.
- B. Serum osmolality is elevated indicating hemoconcentration. The nurse should increase IV fluid rate.
- C. Serum potassium is low. The nurse should administer KCl as ordered.
- D. Blood urea nitrogen is subnormal. The nurse should increase the protein in the client's diet as soon as possible.
正解: C
解説:
(A)
An elevated serum osmolality poses no immediate danger and is not corrected rapidly.
(B)
A low serum sodium alone does not warrant changing IV fluids to normal saline. Other assessment parameters, such as hydration status, must be considered. (C) A low serum blood urea nitrogen is not necessarily indicative of protein deprivation. It may also be the result of overhydration. (D)A low serum potassium potentiates the effects of digitalis, predisposing the client to dangerous arrhythmias. It must be corrected immediately.
質問 177
Chorioamnionitis is a maternal infection that is usually associated with:
- A. Maternal dehydration
- B. Maternal pyelonephritis
- C. Prolonged rupture of membranes
- D. Postterm deliveries
正解: C
解説:
(A) Chorioamnionitis is an inflammation of the chorion and amnion that is generally associated with premature or prolonged rupture of membranes. (B) Postterm deliveries have not been shown to increase the risk of chorioamnionitis unless there has been prolonged rupture of membranes. (C) Pyelonephritis is a kidney infection that develops in 20%-40% of untreated maternal UTIs. (D) Maternal dehydration, though of great concern, is not related to chorioamnionitis.
質問 178
Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?
- A. She should be able to control evacuation of her bowels.
- B. She should be able to return to a regular diet.
- C. She should be able to manage her own care.
- D. She should be able to resume sexual activity.
正解: A
解説:
Explanation
(A) Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels.
The ileostomy will drain liquid stool continuously. (B) The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. (C) The client should be able to resume sexual activity. She will be able to wear a pouch. (D) The client has no other health or mental problems and should be able to manage her own ileostomy.
質問 179
Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities
- A. 0
- B. 1
- C. 2
- D. 3
正解: C
解説:
(A)
Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). (B) For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink.
(C)
For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. (D) For this infant to receive an Apgar
score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point.
質問 180
A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
- A. Document on fetal monitor strip and chart.
- B. Assess quantity of fluid.
- C. Assess fetal heart rate (FHR).
- D. Assess color and odor of fluid.
正解: C
解説:
Explanation/Reference:
Explanation:
(A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well-being, but it does not take priority over assessment of FHR. (B) Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.
質問 181
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
- A. Alteration in sensation secondary to third-degree burn
- B. Alteration in comfort secondary to alteration in skin integrity
- C. Fluid volume deficit secondary to alteration in skin integrity
- D. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
正解: D
解説:
Section: Questions Set D
Explanation:
(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48-72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
質問 182
A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:
- A. Swallow as tube passes
- B. Tilt her head backwards
- C. Cough as tube passes
- D. Hold breath as tube passes
正解: A
解説:
Explanation/Reference:
Explanation:
(A) Head should be tilted slightly forward to facilitate insertion. (B) Swallowing assists with insertion of tube and closes off airway. (C) Client should be swallowing as tube passes; holding the breath facilitates nothing. (D) Coughing may expel tube.
質問 183
Painless vaginal bleeding in the last trimester may be caused by:
- A. Polyhydramnios
- B. Abruptio placentae
- C. Menstruation
- D. Placenta previa
正解: D
解説:
(A) Menstruation should not occur during pregnancy. (B) Abruptio placentae is marked by painful vaginal bleeding following a premature placental detachment after 20th week of gestation. (C) A low-lying placenta separates from the uterine wall as the uterus contracts and cervix dilates. This separation causes painless bleeding in the 7th-8th month. (D) Polyhydramnios is excessive amniotic fluid.
質問 184
A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery:
- A. Has a greater risk of becoming reoccluded
- B. Is smaller in diameter
- C. Has too many valves
- D. Takes more time to remove
正解: D
解説:
Explanation
(A) It does take more time to remove the internal mammary artery, and this is one reason why some physicians do not use it. (B) There is not a greater risk of reocclusion. In fact, it may actually stay patent longer. (C) The internal mammary artery is actually larger in diameter than the saphenous vein. (D) The internal mammary artery does not have too many valves.
質問 185
Which of the following lab data is representative of a client with aplastic anemia?
- A. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000
- B. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000
- C. White blood cells 3000, hematocrit 27, red blood cells 2.8 million
- D. Hemoglobin 9.2, hematocrit 27, red blood cells 3.2 million
正解: B
解説:
Explanation
(A, B, C) Although all of the lab data are abnormal and although these values are decreased in aplastic anemia, the disorder is defined by severe deficits in red cell, white cell, and platelet counts. (D) Aplastic anemia is typically defined in terms of abnormalities of red blood cell count, usually <1 million, white cell count <2,000, and thrombocytes <20,000.
質問 186
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices."
- B. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway."
- C. "If I have any side effects from my medicines, I will take an extra dose of Cogentin."
- D. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now."
正解: A
解説:
Explanation/Reference:
Explanation:
(A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. (B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance.
質問 187
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