NCLEX-RN試験問題集を提供していますNCLEX問題
NCLEX-RN認定ガイドPDFはリアル試験問題で100%カバー率
NCLEX-RN試験は、ヘルスケア業界で最も難しいライセンス試験の1つとして広く認知されています。学生は、看護の概念や臨床実践を学び、テスト対策を徹底的に行い、サンプル問題や練習問題で練習するなど、広範な準備とトレーニングが必要です。
質問 # 23
A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale?
- A. To reduce fear of the unknown
- B. To prevent or minimize separation anxiety
- C. To keep the child calm
- D. To establish a trusting relationship
正解：B
解説：
Explanation
(A) Objects from home do not reduce fear of the unknown. Children need explanations, reassurance, and preparation for the unknown. Also, parental presence can promote comfort and feelings of security. (B) A calm, relaxed, and reassuring manner will assist in calming the child. The child's objects from home will not assist in calming the child. (C) A trusting relationship is based on the quality of the nurse-client relationship.
Objects from home have no impact. (D) Favorite objects from home assist in creating a familiar setting. Also, these objects may prevent or minimize separation from the child's usual routine and family support.
質問 # 24
A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in her senior year of high school after becoming pregnant. Shortly after the baby was born, he began to physically abuse her. She has attempted to leave him several times, but she has always returned. She is unable to support herself financially, and her husband threatens to kill her if she leaves him. This time, her husband has beaten her so badly she cannot stop the bleeding from the gash above her eye. She admits her husband caused her injury. In assessing a person after experiencing spousal abuse, which need has the highest priority?
- A. Assess suicide potential.
- B. Assess drug and alcohol use.
- C. Assess the level of anxiety, coping responses, and support systems.
- D. Assess the history of physical abuse.
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. (B) A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. (C) Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. (D) The spouse may be self-medicating herself with alcohol or drugs to escape an awful situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.
質問 # 25
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. Blurred vision and dizziness
- B. Eye pain and itching
- C. Feeling of eye pressure and headache
- D. Eye discharge and hemoptysis
正解：B
解説：
Section: Questions Set B
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 # 26
A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be:
- A. Hydralazine
- B. Sulfa
- C. Erythromycin
- D. Tetracycline
正解：C
解説：
(A) Sulfa is a teratogen and will cause kernicterus. (B) Tetracycline is a teratogen and will effect tooth development. (C) Hydralazine is not an antibiotic but a calcium channel blocker. (D) Erythromycin is safe during pregnancy and can be used when the client is allergic to penicillin.
質問 # 27
A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used:
- A. To suspend the leg in a sling without pull on the extremity
- B. By inserting pins to provide steady pull on the bone
- C. Intermittently to place a pull over the pelvis and lower spine
- D. With weights at both ends of the bed to maintain pull on the upper extremity
正解：B
解説：
(A) Skeletal traction is the application of traction directly to bone with the use of pins and wires or tongs for the purpose of providing a strong, steady, continuous longitudinal pull on the bone. It is indicated for preoperative immobilization and positioning of hip and femur fractures. (B) A type of skeletal traction (balanced suspension with a Thomas splint and Pearson attachment) uses a sling to support the extremity, but it also uses weights to provide a strong, steady continuouspull on the extremity. A sling is used instead of pins. (C) Pelvic traction provides an intermittent pull over the pelvis and bone, whereas skeletal traction is continuous. Pelvic traction does not use pins. (D) Skeletal traction uses weights at the end of the bed to provide a continuous pull on long bones. Weights are not applied to both ends of the bed.
質問 # 28
Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good." Which response by the nurse is most appropriate at this time?
- A. "You've been feeling sad and alone for some time now?"
- B. "I don't think you are worthless. I'm glad to see you, and we will help you."
- C. "I know with your wife and new baby that you do have a lot to live for."
- D. "Don't you think this is a sign of your illness?"
正解：A
解説：
(A)
This response does not acknowledge the client's feelings.
(B)
This is a closed question and does not encourage communication.
(C)
This response negates the client's feelings and does not require a response from the client. (D) This acknowledges the client's implied thoughts and feelings and encourages a response.
質問 # 29
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. Praise her for eating everything
- B. Observe behavior for 1-2 hours after meals to prevent vomiting
- C. Allow her privacy at mealtimes
- D. Encourage her to eat in moderation, choose foods that she likes, and avoid foods that she dislikes
正解：B
解説：
Section: Questions Set F
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 eye-to-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 # 30
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 feeding is infusing into the trachea.
- B. The client aspirated tube feeding.
- C. The nurse has placed the suction catheter in the esophagus.
- D. This is a normal finding.
正解：B
解説：
Explanation/Reference:
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 # 31
A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to:
- A. Provide cathartic action within the colon
- B. Relieve the client's concern regarding possible infection
- C. Reduce the risk of intraoperative fever
- D. Reduce the risk of wound infection from anaerobic bacteria
正解：D
解説：
Section: Questions Set G
Explanation:
(A) Cathartic drugs promote evacuation of intestinal contents. (B) The client undergoing intestinal surgery is at increased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines. Administering antibiotics prophylactically can reduce the client's risk for infection. (C) Antibiotics are indicated in the treatment of infections and have no effect on emotions. (D) Antipyretics are useful in the treatment of elevated temperatures. Antibiotics would have an effect on infection, which causes temperature elevation, but would not directly affect such an elevation.
質問 # 32
In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
- A. Counseling a client with post-traumatic stress disorder
- B. Crisis intervention with an intoxicated teenager whose mother just committed suicide
- C. Teaching fifth-grade children the harmful effects of substance abuse
- D. Referring a client who has been on a detoxification unit to a rehabilitation center
正解：C
解説：
Explanation/Reference:
Explanation:
(A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.
質問 # 33
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. Headache
- C. Dysrhythmias
- D. Tetany
正解：C
解説：
Explanation/Reference:
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 # 34
A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg.
The nurse should:
- A. Remind the client that he no longer has that part of his leg and assure him he will be OK
- B. Give the client his order of Demerol 50 mg IM prn
- C. Call the physician to request a psychological consultation for the client
- D. Turn on the television to distract the client's attention from his amputated leg
正解：B
解説：
Explanation
(A) The nurse is ignoring the client's pain. Telling the client that he will be OK will not relieve his phantom pain. (B) The client does not need a psychological consultation. Phantom pain is a normal sensation experienced by clients with amputations. (C) Using the television as a distractor will not relieve the client's phantom pain. (D) Phantom pain is a normal, very real experience for an amputee and should be treated with pain medication.
質問 # 35
In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, "Forget all those rules. I always get along well with the nurses." Which nursing response to him would be most effective?
- A. "It is irrelevant whether you get along with the nurses."
- B. "I'm pleased that you get along so well with the staff.You must still know and abide by the rules."
- C. "OK, don't listen to the rules. See where you end up."
- D. "I'm not the other nurses. You better read the rules yourself."
正解：B
解説：
Explanation
(A) This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. (B) This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. (C) This answer is incorrect. It appears to have a negative connotation. There was no limit setting. (D) This answer is incorrect. The nurse obviously responded in a negative manner.
Learning takes place more readily when one is accepted, not rejected. No limits were set.
質問 # 36
While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?
- A. Apply ice to the perineum.
- B. Have the client expose the area to air.
- C. Inform the physician.
- D. Encourage the client to take warm sitz baths.
正解：D
解説：
Explanation
(A) The area is bruised and painful. This action would do nothing to help with the healing process of the perineum or to provide comfort. (B) Ice is effective immediately after birth to reduce edema and discomfort, but not on the 2nd postpartum day. (C) Sitz baths are useful if the perineum has been traumatized, because the moist heat increases circulation to the area to promote healing, relaxes tissue, and decreases edema. (D) The physician is not notified of bruising, but if a hematoma is present, then the physician is notified.
質問 # 37
The nurse is teaching a child's parents how to protect the child from lead poisoning. The nurse knows that a common source of lead poisoning in children is:
- A. Stuffing from toy animals
- B. Dandelion leaves
- C. Pencils
- D. Old paint
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Dandelion leaves are not a source of lead. (B) Pencils are not a source of lead poisoning. (C) Chewing on objects painted before 1960 is a common source of lead poisoning in children. Gasoline is another source. (D) Stuffed animals are not a source of lead.
質問 # 38
The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma. Neomycin decreases serum ammonia levels by:
- A. Decreasing nitrogen-forming bacteria in the intestines
- B. Decreasing the uptake of vitamin D, thereby drawing more water into the colon
- C. Irritating the bowel and promoting evacuation of stool
- D. Acidifying colon contents by causing ammonia retention in the colon
正解：A
解説：
(A) Neomycin interferes with protein synthesis in the bacterial cell, causing bacterial death. Neomycin reduces the growth of the ammonia-producing bacteria in the intestines and is used for the treatment of hepatic coma. (B) This choice describes the action of lactulose, another drug commonly used to decrease systemic ammonia levels. (C) Neomycin's action doesnotdecrease uptake of vitamin D to reduce serum ammonia levels. (D) Bowel irritation with diarrhea is more likely to occur with administration of lactulose rather than of neomycin. Besides, diarrhea is a side effect of a drug, not the action of the drug.
質問 # 39
After several days, an IDDM client's serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for:
- A. One-fourth cup dry cottage cheese
- B. Two slices of bacon
- C. One ounce of ham
- D. One frankfurter
正解：A
解説：
Section: Questions Set F
Explanation:
(A) A frankfurter is a high-fat meat on the diabetic exchange list. (B) Ham is a medium-fat meat on the diabetic exchange list, unless it is a center-cut slice. (C) One strip of bacon equals onefatexchange rather than ameatexchange. Dietary substitutions should occur within exchange lists and not between exchange lists. (D) Diabetic meat-exchange lists are categorized into lean meat foods, medium-fat meats, and high-fat meats.
Cottage cheese (dry, 2% butterfat), one-fourth cup, can substitute for one lean-meat exchange.
質問 # 40
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?
- A. "You should take aspirin instead of acetaminophen (Tylenol) for headaches."
- B. "Carry a medications alert card with you at all times."
- C. "You should use a straight-edge razor when shaving your arms and legs."
- D. "If you forget to take your morning dose, double the night time dose."
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. (B) Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. (C) Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. (D) An electric razor should be used to prevent accidental cutting, which can lead to bleeding.
質問 # 41
The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:
- A. Discussing their needs with other family members
- B. Seeking support from their minister
- C. Discussing their needs with the nursing staff
- D. Refusing to participate in the child's care
正解：D
解説：
Explanation
(A, B, C) These methods are healthy ways of dealing with anxiety. (D) Participation minimizes feelings of helplessness and powerlessness. It is important that parents have accurate information and that they seek support from sources available to them.
質問 # 42
A client hospitalized with a medical diagnosis of adjustment disorder versus personality disorder states,
"Nobody cares about the clients." The nurse's most effective response would be:
- A. "How can you say that I don't care? We just met."
- B. "You will feel differently about us in a few days."
- C. "What makes you think the nurses don't care?"
- D. "You seem angry. Tell me more about how you feel."
正解：D
解説：
Explanation
(A) This statement is a defensive response that places the nurse in a vulnerable countertransference position, and at the same time, fails to challenge the client's "splitting" behavior. (B) This statement is a defensive response by the nurse. In addition, this type of nontherapeutic statement requests that the client explain the reasons for her behavior, a difficult task for an individual with limited insight. (C) This statement is a nontherapeutic response that both ignores the intensity of the client's emotions and the dynamics underlying
"splitting" behavior. (D) By simultaneously acknowledging the client's emotional intensity and gently challenging her "splitting" behavior, the nurse addresses the client's current distortions and prepares for further interventions with angry or ambivalent feelings.
質問 # 43
A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:
- A. Nipple and bottle
- B. Syringe
- C. A straw and cup
- D. Gavage tube
正解：B
解説：
Explanation/Reference:
Explanation:
(A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3-month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This minimizes the amount of sucking needed.
質問 # 44
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
- A. 30 weeks
- B. 10 weeks
- C. 20 weeks
- D. 16 weeks
正解：C
解説：
Section: Questions Set E
Explanation:
(A) At 10 weeks, the fundus is located slightly above the symphysis pubis. (B) At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. (C) At 20 weeks, the fundus is located approximately at the umbilicus. (D) At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
質問 # 45
When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:
- A. 25 mL
- B. 50 mL
- C. 20 mL
- D. 30 mL
正解：B
解説：
Section: Questions Set D
Explanation:
(A) A residual volume of 20 mL is not excessive. (B) A residual volume of 25 mL is not excessive. (C) A residual volume of 30 mL is not excessive. (D) Tube feedings should be withheld and physician notified for residual volumes of 50-100 mL.
質問 # 46
......
合格させるNCLEX-RN試験にはリアル問題解答：https://www.goshiken.com/NCLEX/NCLEX-RN-mondaishu.html
合格できるNCLEX-RNレビューガイド、信頼され続けるNCLEX-RNテストエンジン：https://drive.google.com/open?id=12o4Pvoiu-RWZwp_WHINnGDszKNHXwlCF