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NCLEX-RN試験は、コンピューター適応型テスト（CAT）であり、質問の難易度がテスト受験者のパフォーマンスに基づいて調整されます。試験は75から265問まで構成され、合格するには最低75問に回答する必要があります。試験は、薬理学、急性および慢性疾患を持つ患者の看護ケア、看護実践における倫理的および法的考慮事項を含む幅広いトピックをカバーしています。
NCLEX-RN試験は、十分な準備が必要な厳しい試験です。受験者は、テストの内容を確認し理解し、コンピュータベースのフォーマットに慣れ、タイムドセッティングで問題に回答する練習をする必要があります。レビューコース、学習ガイド、模擬試験、オンラインリソースなど、NCLEX-RN試験に備えるためのいくつかのリソースがあります。十分な準備と試験内容の徹底的な理解により、RNはNCLEX-RN試験に合格し、アメリカで看護実践のライセンスを取得することができます。
NCLEX-RNは、アメリカ合衆国での看護師の資格取得の重要なコンポーネントです。この試験は、候補者の看護実践、クライアントのニーズ、看護プロセスに関する知識と技能を評価します。この試験に合格することは、看護師としてのライセンスの取得に重要なステップであり、資格のある個人のみが看護活動を行うことを保証します。
質問 # 467
A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is
130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
- A. Previous birth of an infant weighing>9 lb
- B. Maternal weight
- C. Family history of heart disease
- D. Age>25 years
正解：A
解説：
Explanation
(A) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. (B) The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. (C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. (D) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy.
質問 # 468
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
- A. Headache and facial flushing
- B. Pallor and itching of the face and neck
- C. Circumoral pallor and lightheadedness
- D. Dizziness and tachypnea
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms.
質問 # 469
A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:
- A. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through the nose. Repeat 4-5 times to complete the series
- B. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20-24 times/min
- C. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more times to complete the series every 1-2 hours while awake
- D. Purse the lips and take quick, short breaths approximately 18-20 times/min
正解：C
解説：
(A) This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. (B) Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. (C) Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. (D) Inhaling and exhaling at a rate of 20-24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.
質問 # 470
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
- A. Explain that he will be kept NPO for 24 hours before the exam
- B. Practice with him so he will be able to hold his breath for 1 minute
- C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
- D. Explain that his vital signs will be checked frequently after the test
正解：D
解説：
Explanation
(A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5-10 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock.
質問 # 471
A female client is admitted to the emergency department complaining of severe right-sided abdominal pain and vaginal spotting. She states that her last menstrual period was about 2 months ago. A positive pregnancy test result and ultrasonography confirm an ectopic pregnancy. The nurse could best explain to the client that her condition is caused by:
- A. A congenital abnormality of the tube
- B. Abnormal development of the embryo
- C. A distended or ruptured fallopian tube
- D. A malfunctioning of the placenta
正解：C
解説：
Explanation
(A) The embryo itself may develop normally in the first several weeks of an ectopic pregnancy. (B) An ectopic pregnancy in the fallopian tube causes severe pain owing to the size of the growing embryo within the narrow lumen of the tube, causing distention and finally rupture within the first 12 weeks of pregnancy. (C) The Fallopian tube may either be normal or contain adhesions caused by a history of pelvic inflammatory disease or tubal surgeries, neither of which are congenital causes. (D) An ectopic pregnancy does not involve a dysfunctional placenta, but the implantation of the blastocyst outside the uterus.
質問 # 472
Which of the following statements relevant to a suicidal client is correct?
- A. Nurses who care for a client who has attempted suicide should not make any reference to the word
"suicide" in order to protect the client's ego. - B. A client who threatens suicide is just seeking attention and is not likely to attempt suicide.
- C. The more specific a client's plan, the more likely he or she is to attempt suicide.
- D. A client who is unsuccessful at a first suicide attempt is not likely to make future attempts.
正解：C
解説：
Explanation
(A) This is a high-risk factor for potential suicide. (B) A previous suicide attempt is a definite risk factor for subsequent attempts. (C) Every threat of suicide should be taken seriously. (D) The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions.
質問 # 473
A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to:
- A. Encourage her to eat in moderation, choose foods that she likes, and avoid foods that she dislikes
- B. Praise her for eating everything
- C. Allow her privacy at mealtimes
- D. Observe behavior for 1-2 hours after meals to prevent vomiting
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Eating alone is not recommended for anorexic clients because they tend to hoard food instead of eating it. (B) The client should be praised for whatever she eats, which is usually a small portion or percentage of what is served. Praise should not be withheld until she eats everything. (C) The client should be observed eyeto- eye for at least 1 hour following meals to prevent discarding food stashed in her clothing at mealtime or engaging in selfinduced vomiting. (D) If offered these choices, the client would choose low-caloric foods, not a nutritious diet.
質問 # 474
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self- mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:
- A. Placing her in seclusion until the behavior is under control
- B. Confronting the client, letting her know the consequences for getting angry and disrupting the unit
- C. Walking up to the client and touching her on the arm to get her attention
- D. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area
正解：D
解説：
Section: Questions Set B
Explanation:
(A) Threatening a client with punitive action is violating a client's rights and could escalate the client's anger.
(B) Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. (C) Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. (D) Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.
質問 # 475
A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes:
- A. Alternate successive administrations
- B. According to the client's preference
- C. Bronchodilator followed by the glucocorticoid
- D. Glucocorticoid followed by the bronchodilator
正解：C
解説：
Explanation/Reference:
Explanation:
(A) The client would not receive therapeutic effects of the glucocorticoid when it is inhaled through constricted airways. (B) Bronchodilating the airways first allows for the glucocorticoid to be inhaled through open airways and increases the penetration of the steroid for maximum effectiveness of the drug. (C) Inac- Inaccurate use of the inhalers will lead to decreased effectiveness of the treatment. (D) Client teaching regarding the use and effects of inhalers will promote client understanding and compliance.
質問 # 476
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, "What is the greatest risk to my baby if it is born prematurely?" The RN's answer should be:
- A. Hypoglycemia
- B. Lack of development of the intestines
- C. Hyperglycemia
- D. Lack of development of the lungs
正解：D
解説：
Explanation
(A) Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. (B) Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. (C) Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to the premature infant. (D) Infants born before 37 weeks' gestation are at greatest risk for an insufficient amount of surfactant in the alveoli system of the lungs.
Surfactant helps to prevent lung collapse and ensures stability of the respiratory system so that the infant can maintain his own respirations once the umbilical cord is severed at birth.
質問 # 477
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?
- A. Tube feedings with nutritional supplements
- B. Small, frequent feedings of foods that can be carried
- C. Giving him a quiet place where he can sit down to eat meals
- D. Allowing him to eat when and what he wants
正解：B
解説：
Explanation
(A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when other methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of client may forget to eat. (D) The manic client is unable to sit down to eat full meals.
質問 # 478
A schizophrenic is admitted to the psychiatric unit. What affect would the nurse expect to observe?
- A. Apathy and flatness
- B. Smiling
- C. Hostility
- D. Anger
正解：A
解説：
Explanation
(A) Anger is an emotion that is not necessarily present in schizophrenia. (B) Lack of response to or involvement with environment and distancing are characteristic of schizophrenia. (C) Euphoria is more characteristic of manic-depressive disorder (bipolar disorder). (D) Hostility is an emotion that is not necessarily present in schizophrenia.
質問 # 479
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
- A. The client aspirated tube feeding.
- B. The nurse has placed the suction catheter in the esophagus.
- C. This is a normal finding.
- D. The feeding is infusing into the trachea.
正解：A
解説：
Explanation
(A) Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding. (B) Because the trachea provides direct access to a client's airway, it would not be possible to place the catheter in the esophagus. (C) Blue-colored sputum is never considered a normal finding and should be reported and documented. (D) The nurse confirmed placement of the feeding tube in the stomach prior to initiating the tube feeding; therefore, it is highly unlikely that the feeding tube would be located in the trachea.
質問 # 480
A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely.
The first intervention the RN should initiate is to:
- A. Assess the client to see if she is having vaginal bleeding
- B. Place the examining table in the Trendelenburg position
- C. Obtain the client's vital signs immediately
- D. Help the client to a sitting position
正解：D
解説：
Explanation
(A) This position would cause the gravid uterus to bear the increased pressure of the vena cava, which could lead to maternal hypotension, in turn causing the client to continue to have pallor and to feel light-headed. (B) This would not be the first intervention the RN should initiate. TheRN should understand the supine position and its effect on the gravid uterus and vena cava. (C) The RN's first intervention should be one that helps to alleviate the client's symptoms. Obtaining her vital signs will not alleviate her symptoms. (D) This would move the gravid uterus off of the client's vena cava, which would alleviate the maternal hypotension that is the cause of her symptoms.
質問 # 481
A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:
- A. Relax during contractions
- B. Hyperventilate during contractions
- C. Push during contractions
- D. Walk between contractions
正解：C
解説：
Section: Questions Set C
Explanation:
(A) The second stage of labor is characterized by uterine contractions, which cause the client to bear down. (B) Slow, deep, rhythmic breathing facilitates the laboring process. Hyperventilation is abnormal breathing resulting from loss of pain control. (C) The client should remain on bed rest during labor. (D) Contractions result in discomfort.
質問 # 482
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