[2023年12月] 問題集練習試験問題学習ガイドはNCLEX-RN試験合格させます
NCLEX-RN問題集には練習試験問題解答
NCLEX-RN試験は、米国で登録看護師になるための重要なステップです。試験に合格することは、国内のどの州でも看護師免許を取得するために必須です。試験では、看護知識、批判的思考、意思決定能力が評価されます。試験に合格するためには、最新の看護実践を熟読し、熱心な準備と学習が必要です。
NCLEX-RN試験に合格することは、アメリカ合衆国でライセンスを持つ登録看護師になるための重要なステップです。この試験は、挑戦的に設計されており、候補者は高い知識、技能、競争力を示さなければなりません。しかし、NCLEX-RN試験に合格することは、看護の充実したキャリアにつながる重要なステップであり、成功した候補者は患者を助け、地域社会での違いを作り出す充実したキャリアを楽しむことができます。
質問 # 164
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular
accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
- A. Potential for injury related to impaired mobility and seizures
- B. Impaired verbal communication related to aphasia
- C. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness
- D. Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow
正解：C
解説：
(A)
An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion.
(D)
Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
質問 # 165
At 32 weeks' gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, "How do I prepare for the test I am scheduled for?" The RN will most likely inform her of the following instructions to help prepare her for the test:
- A. "You will have to remain as still as you possibly can."
- B. "You will need to drink 6 to 8 glasses of water to fill your bladder."
- C. "Do not eat any food or drink any liquids before the test is started."
- D. "You need to know that an IV is always started before the test."
正解：A
解説：
Explanation
(A) An IV line is not started in a nonstress test, because this test is used as an indicator of fetal well-being.
This test measures fetal activity and heart rate acceleration. (B) The bladder does not have to be full prior to this test. It is not a sonogram test where a full bladder enables other structures to be scanned. (C) It has been proved that eating or drinking liquids prior to the test can assist in increasing fetal activity. (D) Any maternal activity will interfere with the results of the test.
質問 # 166
An 8-week-old infant has been diagnosed with gastroesophageal reflux. The nurse is teaching the infant's mother to care for the infant at home. Which one of the following statements by the nurse is appropriate regarding the infant's home care?
- A. "Antacids need to be given an hour before feeding."
- B. "Lay the infant flat on her left side after feeding."
- C. "Play activities should be carried out before instead of after feedings."
- D. "Feed the infant every 4 hours with half-strength formula."
正解：C
解説：
Explanation
(A) Elevating the child's head to a 30-degree angle is the recommended position for gastroesophageal reflux.
The supine position predisposes the child to aspiration. (B) Small, frequent feedings with thickened formula are recommended to minimize vomiting. (C) Antacids should be given at the same time as the feeding to improve their buffering action. (D) The infant should be kept still after feedings to reduce the risk of vomiting and aspiration. Vigorous activities should be carried out before feedings.
質問 # 167
A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?
- A. Peanut butter and jelly sandwich and milk
- B. Corn beef and cabbage and boiled potatoes
- C. Tuna on whole-wheat bread and iced tea
- D. Oatmeal, whole-wheat toast, and milk
正解：B
解説：
(A, C, D) These foods are allowed with a colostomy. (B) Gasforming foods such as cabbage should be avoided.
質問 # 168
A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?
- A. Uncomforted by touch, refuses bottle
- B. Responsive to touch, wants to be held
- C. Finicky eater, easily pacified, cuddly
- D. Maintains eye-to-eye contact
正解：A
解説：
(A) Normal infant attachment behaviors include responding to touch and wanting to be held. (B) Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. (C) Attachment behavior includes maintaining eye contact. (D) Maternal deprivation behaviors include displeasure with touch and physical contact.
質問 # 169
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in highsugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen.
The client answers the nurse, "It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?" The client's actions and response best demonstrate:
- A. Denial
- B. Depression
- C. Anger
- D. Bargaining
正解：A
解説：
Section: Questions Set E
Explanation:
(A) Depression may be an underlying feature, but it is not evident from limited data presented here. (B) Anger is not exhibited in his response. (C) Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. (D) There is no evidence of bargaining in the client's actions or verbal response.
質問 # 170
Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?
- A. Monitor renal function.
- B. Assess knowledge of respiratory isolation.
- C. Monitor compliance with drug therapy.
- D. Monitor liver function.
正解：C
解説：
Section: Questions Set D
Explanation:
(A) Monitoring liver function will not prevent the development of drug-resistant organisms. (B) Monitoring renal function will not prevent the development of drug-resistant organisms. (C) Knowledge of respiratory isolation will reduce transmission of tuberculosis but will not prevent development of drug-resistant organisms. (D) Noncompliance with prescribed antituberculosis drug regimen is the primary cause of drug-resistant organisms. Noncompliance permits the mutation of organisms.
質問 # 171
The nurse provides a male client with diet teaching so that he can help prevent constipation in the future.
Which food choices indicate that this teaching has been understood?
- A. Pancakes and syrup
- B. Bagel with cream cheese
- C. Omelette and hash browns
- D. Cooked oatmeal and grapefruit half
正解：D
解説：
Section: Questions Set B
Explanation:
(A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation.
(B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk.
質問 # 172
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
- A. Hypernatremia
- B. Hypovolemic shock
- C. Hyponatremia
- D. Hypokalemia
正解：C
解説：
(A) Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. (B) Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. (C) Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. (D) This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.
質問 # 173
Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client's history?
- A. Nulliparity
- B. Early menopause
- C. Maternal family history of breast cancer
- D. Menarche after age 13
正解：C
解説：
(A) Women who begin menarche late (after 13 years old) have a lower risk of developing breast cancer than women who have begun earlier. Average age for menarche is 12.5 years. (B) Women who have never been pregnant have an increased risk for breast cancer, but a positive family history poses an even greater risk. (C) A positive family history puts a woman at an increased risk of developing breast cancer. It is recommended that mammography screening begin 5 years before the age at which an immediate female relative was diagnosed with breast cancer. (D) Early menopause decreases the risk of developing breast cancer.
質問 # 174
A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will "beat out of her chest." The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
- A. Starting an 18-gauge IV infusion
- B. Transfusing the blood in a 2-hour time frame
- C. Administering the correct blood product to the correctclient
- D. Having the consent form on the chart
正解：C
解説：
Explanation/Reference:
Explanation:
(A) An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. (B) The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. (C) Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. (D) The blood administration should take place over the ordered time frame designated by the physician.
質問 # 175
The postpartum nurse should include which of the following instructions to breast-feeding mothers?
- A. Daily caloric intake should be increased by 500 cal.
- B. Breast milk is totally digestible by the baby because it contains lactose.
- C. Wash the nipples with soap and water before and after each feeding.
- D. Limit feeding times for several days to avoid nipple soreness.
正解：A
解説：
Section: Questions Set E
Explanation:
(A) Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. (B) Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. (C) For optimal milk production, an additional
500 kcal over maintenance levels are needed daily. (D) Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants.
質問 # 176
In an interview for suspected child abuse, the child's mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child's father states, "Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child." Based on this remark, the nurse would make the following nursing diagnosis:
- A. Altered family process related to physical abuse
- B. Ineffective coping
- C. Fear related to retaliation by the father
- D. Actual injury related to poor impulse control by the father
正解：A
解説：
Explanation/Reference:
Explanation:
(A) There is no evidence of fear as the child is unable to communicate. (B) There is actual injury, but the parents have not yet admitted causing the child's injuries. (C) This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. (D) Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.
質問 # 177
A 32-year-old female client is being treated for Guillain- Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?
- A. Loss of superficial and deep tendon reflexes
- B. Complaints of a headache
- C. Complaints of shortness of breath
- D. Facial paralysis
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Headaches are not associated with Guillain-Barré syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated.
Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. (D) Facial paralysis is expected and is not considered abnormal.
質問 # 178
Which stage of labor lasts from delivery of the baby to delivery of the placenta?
- A. Fifth
- B. Third
- C. Fourth
- D. Second
正解：B
解説：
Section: Questions Set G
Explanation:
(A) This stage is from complete dilatation of the cervix to delivery of the fetus. (B) This is the correct stage for the definition. (C) This stage lasts for about 2 hours after the delivery of the placenta. (D) There is no fifth stage of labor.
質問 # 179
When assessing a female child for Turner's syndrome, the nurse observes for which of the following symptoms?
- A. Secondary sex characteristics
- B. Tall stature
- C. Gynecomastia
- D. Amenorrhea
正解：D
解説：
Explanation
(A) This syndrome is caused by absence of one of the X chromosomes. These children are short in stature. (B) Amenorrhea is a symptom of Turner's syndrome, which appears at puberty. (C) Sexual infantilism is characteristic of this syndrome. (D) Gynecomastia is a symptom in Klinefelter's syndrome.
質問 # 180
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