あなたを合格させるNCLEX Certification NCLEX-RN試験問題集で2023年10月19日には865問あります
NCLEX-RN無料試験学習ガイド！（更新された865問あります)
NCLEX-RN試験は、米国で登録看護師として練習したい人にとっては必須テストです。これは、候補者の看護知識とスキルの包括的な評価であり、批判的思考と問題解決スキルを現実世界の状況に適用する能力をテストするように設計されています。 NCLEX-RN試験に合格することは、免許を取得し、登録看護師としてのキャリアを開始する上で重要なステップです。
NCLEX-RN試験は、米国の州立看護評議会（NCSBN）によって実施されています。コンピュータ適応型テストであり、問題の難易度は受験者の回答能力に合わせて調整されます。試験は、単純な看護タスクから複雑なものまで、受験者の能力レベルを評価するように設計されています。試験は、全国の各テストセンターで実施され、受験者は試験に登録し、資格をNCSBNに提出する必要があります。
質問 # 324
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4" and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
- A. Assess vital signs
- B. Obtain an accurate weight
- C. Search the client's purse for pills
- D. Assign her to a room with someone her own age
正解：A
解説：
Explanation
(A) On admission, vital signs are the highest priority. Weight is not a vital sign. (B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a high priority. (C) Vital signs are a high priority when working with selfdestructive clients. (D) Room assignment is of low priority.
質問 # 325
A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:
- A. "Visitors are not allowed. We will telephone you to inform you of her progress."
- B. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment."
- C. "There's really no need to stay with her. She's going to sleep for several hours after the treatment."
- D. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment."
正解：D
解説：
(A) It is within the nurse's realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members. (C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off. (D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.
質問 # 326
The family member of a child scheduled for heart surgery states, "I just don't understand this open-heart or closed-heart business. I'm so confused! Can you help me understand it?" The nurse explains that patent ductus arteriosus repair is:
- A. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery.
- B. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed.
- C. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.
- D. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery.
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-lung machine. (B) Patent ductus arteriosus is a ductus arteriosus that does not close shortlyafter birth but remains patent. Repair is a closed-heart procedure involving ligation of the patent ductus arteriosus. (C) Coronary artery bypass graft surgery is an open-heart surgical procedure in which blocked coronary arteries are bypassed using vessel grafts. (D) Percutaneous transluminal coronary angioplasty is a closedheart procedure that improves coronary blood flow by increasing the lumen size of narrowed vessels.
質問 # 327
A client is being admitted to the labor and delivery unit. She has had previous admissions for "false labor." Which clinical manifestation would be most indicative of true labor?
- A. Uterine contractions
- B. Increased bloody show
- C. Progressive dilatation and effacement of the cervix
- D. Decreased discomfort with ambulation
正解：C
解説：
Explanation
(A) Bloody show is considered a sign of imminent labor, which usually begins in 24-48 hours. An increase in bloody show is an indication that the cervix is changing. (B) Contractions of true labor produce progressive cervical effacement and dilatation. (C) Contractions of false labor may mimic those of true labor. However, the contractions of false labor do not produce progressive effacement and dilatation of the cervix. (D) In true labor, the discomfort is not relieved by ambulation; walking may intensify the discomfort.
質問 # 328
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. Have him drink 4 oz of orange juice
- B. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink
- C. Ask him to dissolve three pieces of hard candy in his mouth
- D. Monitor him closely until dinner arrives
正解：A
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 # 329
A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:
- A. Gastritis
- B. Evisceration
- C. Peritonitis
- D. Pulmonary embolism
正解：C
解説：
Explanation
(A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. (D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.
質問 # 330
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
- A. Decreased cardiac output
- B. Fluid volume excess
- C. Severe hypotension
- D. Fluid volume deficit
正解：B
解説：
Section: Questions Set B
Explanation:
(A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty- eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D) Hypertension is the result of hypervolemia.
質問 # 331
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 resume sexual activity.
- B. She should be able to return to a regular diet.
- C. She should be able to control evacuation of her bowels.
- D. She should be able to manage her own care.
正解：C
解説：
Explanation/Reference:
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 # 332
For the past several months, an elderly female client with Alzheimer's disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:
- A. A more advanced stage of Alzheimer's disease than previously experienced by the client
- B. Early symptoms of Parkinson's disease
- C. The need to change her medication from haloperidol to another antipsychotic drug to lessen symptoms
- D. Tardive dyskinesia, which may be a side effect of antipsychotic medication
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol.
Discontinuing the medication can alleviate symptoms. (B) Although mild tremors are an early sign of Parkinson's disease, haloperidol must be discontinued first and the client further evaluated. (C) These symptoms do not necessarily indicate a more advanced stage of Alzheimer's disease. (D) Most antipsychotic drugs are chemically similar and will produce the same side effects.
質問 # 333
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:
- A. Tetracycline
- B. Ampicillin
- C. Magnesium sulfate (MgSO4)
- D. Oxytocin
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Oxytocin is prescribed to stimulate uterine contractions. (B) MgSO4is a central nervous system depressant prescribed to prevent and control convulsions related to preeclampsia. (C) Ampicillin is a penicillin derivative with no known teratogenic effects.
This is the safest antibiotic during pregnancy. (D) Tetracycline stains teeth yellow and is not as safe as ampicillin during pregnancy.
質問 # 334
The medication that best penetrates eschar is:
- A. Silver sulfadiazine (Silvadene)
- B. Povidone-iodine (Betadine)
- C. Mafenide acetate (Sulfamylon)
- D. Neomycin sulfate (Neosporin)
正解：C
解説：
(A) Mafenide acetate is bacteriostatic against gram-positive and gram-negative organisms and is the agent that best penetrates eschar. (B) Silver sulfadiazine poorly penetrates eschar. (C) Neomycin sulfate does not penetrate eschar. (D) Povidoneiodine does not penetrate eschar.
質問 # 335
The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:
- A. 1300 mL/24 hr
- B. 900 mL/24 hr
- C. 2000 mL/24 hr
- D. 1600 mL/24 hr
正解：D
解説：
Explanation
(A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours. (C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours.
質問 # 336
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. Intermittently to place a pull over the pelvis and lower spine
- B. By inserting pins to provide steady pull on the bone
- C. To suspend the leg in a sling without pull on the extremity
- D. With weights at both ends of the bed to maintain pull on the upper extremity
正解：B
解説：
Explanation/Reference:
Explanation:
(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 # 337
A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:
- A. Establish an effective, habitual breathing pattern
- B. Promote normal growth and development
- C. Help him overcome respiratory infections
- D. Create a sense of well-being and self-worth
正解：A
解説：
Explanation
(A) Regular exercise does promote a sense of well-being and selfworth, but this is not the ultimate goal of exercise for this client. (B) Regular chest physiotherapy, not exercise per se, helps to prevent respiratory infections. (C) Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern. (D) Along with adequate nutrition and minimization of pulmonary complications, exercise does help promote normal growth and development. However, exercise is promoted primarily to help establish a habitual breathing pattern.
質問 # 338
In addition to changing the mother's position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:
- A. Apply a cord clamp to the exposed cord, and cover with a sterile towel.
- B. Cover the cord with a wet sponge.
- C. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying.
- D. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.
正解：D
解説：
Explanation
(A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.
質問 # 339
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. Bronchodilator followed by the glucocorticoid
- B. According to the client's preference
- C. Alternate successive administrations
- D. Glucocorticoid followed by the bronchodilator
正解：A
解説：
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 # 340
Which of the following blood gas parameters primarily reflects respiratory function?
- A. HCO3
- B. Base excess
- C. CO2 content of the blood
- D. PCO2
正解：D
解説：
(A) The lungs are responsible for regulation of CO2, and this parameter primarily reflects respiratory function. (B) CO2 content of the blood is an indirect measure of respiratory function. (C) HCO3 is a measure of kidney function only and is important in acid-base balance. (D) Base excess represents the excess of HCO3 and is not reflective of respiratory function.
質問 # 341
A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3. (D) Metabolic acidosis is determined by low pH and HCO3.
質問 # 342
A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?
- A. Primary nurses will ensure privacy.
- B. The same nurses will prevent infant fatigue and frustration.
- C. The same nurses will prevent parental fatigue and frustration.
- D. By assigning the same nurses to the child, the nurses can begin to learn the infant's cues and feeding behaviors.
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Consistent primary care nurses can better interpret infant cues and note feeding behaviors. (B) In nonorganic failure to thrive the parent-infant dyad has already experienced difficulties in the relationship.
These parents may already feel dissatisfied and frustrated. The primary nurse would be unable to prevent this. (C) Assigning a primary nurse does not ensure that infant fatigue and frustration will not occur or can be prevented. (D) Providing privacy does not ensure a change in feeding behavior.
質問 # 343
An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?
- A. Apply ice packs to both legs.
- B. Apply Silvadene cream (silver sulfadiazine).
- C. Immerse both legs in cool water.
- D. Begin debridement by removing all charred clothing from wound.
正解：C
解説：
(A)
Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound first. This creates further tissue damage. Debridement is not the first nursing action. (C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection.
(D)
Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.
質問 # 344
A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?
- A. Antimania medication
- B. Antidepressant medications
- C. Antianxiety medications
- D. Antipsychotic medications
正解：C
解説：
(A) Antipsychotic medications are also known as major tranquilizers. (B) Antidepressants fall into different categories, such as the tricyclics or the MAO inhibitors. (C) Antianxiety medications are also known as minor tranquilizers. (D) Antimania medications are those such as lithium and lithium carbonate (Lithobid).
質問 # 345
A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis-Alteration in comfort, pain related to:
- A. Increased excretion of lactic acid due to myocardial hypoxia
- B. Increased blood flow through the coronary arteries
- C. Decreased stimulation of the sympathetic nervous system
- D. Decreased secretion of catecholamines secondary to anxiety
正解：A
解説：
Explanation
(A) Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. (B) Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed toward increasing the blood flow through coronary arteries. (C) Chest pain causes an increase in the stimulation of the sympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. (D) Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasing the workload of the heart.
質問 # 346
......
NCLEX-RN試験に合格することは、米国とカナダでの許可を受けた看護師としての資格取得のための要件です。この試験は、看護師が患者に対して高品質なケアを提供できる有能で安全な実践者であることを確認するために設計されています。試験は挑戦的なものであるかもしれませんが、復習コース、学習ガイド、模擬試験など、多くの資源が準備されています。献身と努力により、個人はNCLEX-RN試験に合格し、看護師としてのキャリアを始めることができます。
NCLEX-RN問題集はNCLEX Certification認証済み試験問題と解答：https://jp.fast2test.com/NCLEX-RN-premium-file.html
実際に出ると確認されたNCLEX-RN試験問題集と解答でNCLEX-RN無料更新：https://drive.google.com/open?id=11CvzGcw9vmy4VwMS_2MhqBq8d1T9yFx5