NCLEX-RN試験問題集を使って一日でNCLEX Certification試験合格目指す（最新の865解答)
NCLEX-RN試験正確な問題集、学習ノートと理論
質問 # 91
A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant's developmental progression?
- A. She stands while holding onto furniture.
- B. She creeps and crawls.
- C. She pulls herself to her feet with help.
- D. She sits briefly alone with assistance.
正解：D
解説：
(A) The 9-month-old infant can sit alone for long periods. By the age of 6 months, many infants can pull themselves to a sitting position. (B, C, D) This skill represents normal development.
質問 # 92
Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:
- A. Diminished or absent femoral pulses
- B. A diastolic murmur
- C. A third heart sound
- D. Pulse pressure difference between the upper extremities
正解：A
解説：
Explanation/Reference:
Explanation:
(A) S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. (B) Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. (C) Pulse pressure differences of>20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate- sized cuffs. (D) Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta.
質問 # 93
A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:
- A. Nitroglycerin (Nitrol) 1 inch topically every 4 hours
- B. Digoxin (Lanoxin) 0.25 mg po every day
- C. Furosemide (Lasix) 40 mg po every morning
- D. O22 L/min via nasal cannula
正解：B
解説：
Section: Questions Set C
Explanation:
(A) Digoxin is a cardiac glycoside given to clients in heart failure to improve their myocardial contractility. (B) Furosemide is a loop diuretic given to clients in heart failure to promote diuresis. (C) O2is given to clients in heart failure to increase oxygenation and to prevent or treat hypoxemia. (D) Nitroglycerin is a nitrate given to clients in heart failure to increase their cardiac output by decreasing the peripheral resistance that the left ventricle must pump against.
質問 # 94
A 32-year-old female client is being treated for Guillain- Barre 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. Complaints of a headache
- B. Loss of superficial and deep tendon reflexes
- C. Facial paralysis
- D. Complaints of shortness of breath
正解：D
解説：
Explanation
(A) Headaches are not associated with Guillain-Barre 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 # 95
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
- A. Foods such as aged cheese, yogurt, soy sauce, and bananas should not be eaten with this drug.
- B. Because fluoxetine is a tricyclic antidepressant, it may precipitate a hypertensive crisis.
- C. The therapeutic effect of the drug occurs 2-4 weeks after treatment is begun.
- D. Fluoxetine may be administered safely in combination with monoamine oxidase (MAO) inhibitors.
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. (B) This statement is true.
(C) These foods are high in tyramine and should be avoided when the client is taking MAO inhibitors.
Fluoxetine is not an MAO inhibitor. (D) Fatal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors.
質問 # 96
A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?
- A. The delirious client is capable of returning to his previous level of functioning.
- B. The delirious client is incapable of returning to his previous level of functioning.
- C. Delirium is an insidious process.
- D. Delirium entails progressive intellectual and behavioral deterioration.
正解：A
解説：
Section: Questions Set D
Explanation:
(A) This answer is correct. If the cause is removed, the delirious client will recover completely. (B) This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. (C) This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. (D) This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.
質問 # 97
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. Anger
- B. Denial
- C. Bargaining
- D. Depression
正解：B
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 # 98
The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include:
- A. Eye discharge and hemoptysis
- B. Blurred vision and dizziness
- C. Eye pain and itching
- D. Feeling of eye pressure and headache
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage.
(B) Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not.
質問 # 99
Which of the following lab data is representative of a client with aplastic anemia?
- A. White blood cells 3000, hematocrit 27, red blood cells 2.8 million
- B. Red blood cells 1 million, white blood cells 1500, thrombocytes 16,000
- C. Hemoglobin 9.2, hematocrit 27, red blood cells 3.2 million
- D. White blood cells 4000, erythrocytes 2.5 million, thrombocytes 100,000
正解：B
解説：
Section: Questions Set G
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 # 100
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:
- A. Maintain O2at <40%
- B. Maintain on 100% O2
- C. Maintain O2at>40%
- D. Give moist O2at>40%
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Retrolental fibroplasia is the result of prolonged exposure to high levels of O2in premature infants.
Complications are hemorrhage and retinal detachment. (B, C, D) O2concentration is too high.
質問 # 101
The primary reason that an increase in heart rate (100 bpm) detrimental to the client with a myocardial infarction (MI) is that:
- A. Decreased coronary artery perfusion due to decreased diastolic filling time will occur, which will increase ischemic damage to the myocardium
- B. Systolic ejection time will decrease, thereby decreasing cardiac output
- C. Decreased contractile strength will occur due to decreased filling time
- D. Stroke volume and blood pressure will drop proportionately
正解：A
解説：
(A) Decreased stroke volume and blood pressure will occur secondary to decreased diastolic filling. (B) Tachycardia primarily decreases diastole; systolic time changes very little. (C) Contractility decreases owing to the decreased filling time and decreased time for fiber lengthening. (D) Decreased O2 supply due to decreased time for filling of the coronary arteriesincreases ischemia and infarct size. Tachycardia primarily robs the heart of diastolic
time, which is the primary time for coronary artery filling.
質問 # 102
The nurse is caring for a client with pancreatitis. Which of the following IV medications would the nurse expect the physician to prescribe for control of pain in this client?
- A. Morphine sulfate
- B. Meperidine (Demerol)
- C. Kerolac tromethamine (Toradol)
- D. Promethazine (Phenergan)
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Morphine sulfate is contraindicated in clients with pancreatitis because it may cause spasms of the sphincter of Oddi and increase pancreatic pain. (B) Ketorolac tromethamine is currently not approved by the Food and Drug Administration for IV use. (C) Promethazine is a medication that has no analgesic properties. (D) Meperidine is the drug of choice for clients with pancreatitis. It will not cause spasms at the sphincter of Oddi, which can lead to increased pancreatic pain.
質問 # 103
A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?
- A. "I will not drive but ride in the front seat of the car with a seat belt on for my first doctor's appointment."
- B. "When I bathe tomorrow morning, I will be very careful not to get soap on my incision."
- C. "I am allowed to exercise by walking for short periods."
- D. "Teach my husband about the diet. He'll be doing all the cooking now."
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt. (B) Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. (C) Activity instructions include: avoid sitting for long periods and get exercise by walking. Lifting more than 5 lb of weight is also prohibited. (D) The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization.A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations.
質問 # 104
A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes?
- A. IV
- B. Oral
- C. Aerosol
- D. IM
正解：C
解説：
(A) Ribavirin is not supplied in an oral form. (B) Ribavirin is administered by aerosol in order to decrease the duration of viral shedding within the infected tissue. (C) Ribavirin is not approved for IV use to treat respiratory syncytial virus. (D) Ribavirin is a synthetic antiviral agent supplied as a crystalline powder that is reconstituted with sterile water. A Small Aerosol Particle Generator unit aerosolizes the medication for delivery by oxygen hood, croup tent, or aerosol mask.
質問 # 105
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate
(MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
- A. MgSO4serum levels are>15 mg/dL
- B. Urine output is 20 mL/hr
- C. Respirations are>16 breaths/min
- D. Deep tendon reflexes are absent
正解：C
解説：
(A) MgSO4is a central nervous system depressant. Loss of reflexes is often the first sign of developing toxicity. (B) Urinary output at <25 mL/hr or 100 mL in 4 hours may result in the accumulation of toxic levels of magnesium. (C) The therapeutic serum range for MgSO4is 6-8 mg/dL. Higher levels indicate toxicity. (D) Respirations of>16 breaths/min indicate that toxic levels of magnesium have not been reached. Medication administration would be safe.
質問 # 106
A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:
- A. Secondary infection resulting from poor oral hygiene
- B. Drooling
- C. Loss of ability to speak and communicate effectively
- D. Aspiration and weight loss
正解：D
解説：
Explanation
(A) Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. (B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. (C) A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. (D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.
質問 # 107
Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder?
- A. Playing cards with other clients
- B. Playing tennis with a staff member
- C. Sewing beads on a leather belt
- D. Working crossword puzzles
正解：B
解説：
Section: Questions Set A
Explanation:
(A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B) During mania, the client's attention span is too short to accomplish this task. (C) This activity uses gross motor skills, eases tension, and expands excess energy. A staff member is better equipped to interact therapeutically with clients. (D) This activity requires the use of fine motor skills and is very tedious.
質問 # 108
A female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include:
- A. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be brought to the morgue.
- B. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms.
- C. Tell the family that they may conduct their ceremony in the client's room; however, the nurse must attend.
- D. Respect the client's family's wishes.
正解：D
解説：
Explanation/Reference:
Explanation:
(A) It is rare that a hospital has a specific policy addressing this particular issue. If the statement is true, the nurse should show evidence of the policy to the family and suggest alternatives, such as the hospital chapel. (B) Refusal to leave the room demonstrates a lack of understanding related to the family's need to grieve in their own manner. (C) The nurse should leave the room and allow the family privacy in their grief.
(D) The family's wish to conduct a religious ceremony in the client's room is part of the grief process. The request is based on specific cultural and religious differences dictating social customs.
質問 # 109
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. Confronting the client, letting her know the consequences for getting angry and disrupting the unit
- B. Placing her in seclusion until the behavior is under control
- C. Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area
- D. Walking up to the client and touching her on the arm to get her attention
正解：C
解説：
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 # 110
The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:
- A. Ergonovine maleate
- B. Oxytocin (Pitocin)
- C. Vasopressin (Pitressin)
- D. Progesterone
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Oxytocin is a hormone secreted by the neurohypophysis during suckling and parturition that produces strong uterine contractions. (B) Progesterone has a quiescence effect on the uterus. (C) Vasopressin is an antidiuretic hormone that promotes water reabsorption by the renal tubules. (D) Ergonovine produces dystocia as a result of sustained uterine contractions.
質問 # 111
Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to observe during postpartum care of the client?
- A. Hematuria, ecchymosis, and epistaxis
- B. Dysuria
- C. Vertigo, hematuria, ecchymosis
- D. Epistaxis, hematuria, dysuria
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Dysuria is not a common symptom of heparin overdose. (B) Although epistaxis and hematuria are common symptoms of heparin overdose, dysuria is not. (C) Vertigo is not a common symptom of heparin overdose. (D) Hematuria, ecchymosis, and epistaxis are the most common signs and symptoms of a heparin overdose. Others are thrombocytopenia, elevated liver enzymes, and local injection site complications.
質問 # 112
Signs and symptoms of an allergy attack include which of the following?
- A. Increased respiratory rate
- B. Prolonged expiration
- C. Circumoral cyanosis
- D. Wheezing on inspiration
正解：B
解説：
Explanation
(A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial lumina. (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis is not an early sign of hypoxia. (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs.
質問 # 113
A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?
- A. Strabismus
- B. Papilledema
- C. Hearing test
- D. Gait
正解：A
解説：
Explanation
(A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or ambylopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision screening. It is part of neurological assessment.
質問 # 114
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
- A. Apply strong sacral pressure during the contraction
- B. Place her in knee-chest position during the contraction
- C. Have her push with each contraction
- D. Use effleurage during the contraction
正解：A
解説：
(A) This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. (B) Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. (C) Sacral pressure will counteract the pressure created by the position of the fetal head. (D) The client is not completely dilated. Pushing is contraindicated until the second stage of labor.
質問 # 115
In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:
- A. Explain the side effects of the medication
- B. Discuss the danger of overmedication
- C. Explore the client's perception regarding medication therapy
- D. Distribute written material to supplement verbal instructions
正解：C
解説：
Section: Questions Set D
Explanation:
(A, B, C) The nurse must first obtain information regarding the client's perception of the medication regimen.
(D) The first step in the teaching process is to determine the client's perception.
質問 # 116
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