完全版NCLEX-RN練習テスト865特別な問題と解答が待ってます！
NCLEX Certification問題集でNCLEX-RN試験完全版問題で試験学習ガイド
NCLEX-RN試験は、安全で効果的なケア環境、健康増進と維持、心理社会的完全性、生理学的完全性の4つのカテゴリで構成されています。これらのカテゴリは、患者ケア、薬理学、健康評価、看護倫理など、看護実践に関連するさまざまなトピックをカバーするサブカテゴリに分類されます。この試験はコンピューター化され、適応性があります。つまり、質問の難しさは、テストテイカーのパフォーマンスによって異なります。 NCLEX-RN試験に合格することは、登録された看護師になり、労働力に入りたいと考えている個人にとって重要なステップです。
質問 # 347
A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?
- A. 0.38 mL
- B. 2.7 mL
- C. Information given insufficient to determine the amount of atropine to be administered
- D. 0.06 mL
正解：A
解説：
Section: Questions Set G
Explanation:
(A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer. (B) The answer is correct.
0.4 mg = 1 mL:0.15 mg 5 = mL
0.4 x = 0.15
x = 0.15/0.4
x = 0.375 or 0.38 mL
(D) Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given.
質問 # 348
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. Have the client expose the area to air.
- B. Inform the physician.
- C. Encourage the client to take warm sitz baths.
- D. Apply ice to the perineum.
正解：C
解説：
(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 # 349
Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
- A. Polyuria, polydipsia, edema
- B. Vomiting, impaired consciousness, decreased blood pressure
- C. Fine hand tremor, headache, mental dullness
- D. Gastric irritation, nausea, diarrhea
正解：B
解説：
Explanation
(A) These symptoms are acute, common, and usually harmless central nervous system side effects of lithium.
(B) These symptoms of lithium toxicity are usually dose related. (C) These symptoms are acute, common, and usually harmless renal side effects of lithium. (D) These symptoms are acute, common, and usually harmless gastrointestinal side effects of lithium.
質問 # 350
Assessment of the client with pericarditis may reveal which of the following?
- A. Ventricular gallop and substernal chest pain
- B. Pericardial tamponade and widened pulse pressure
- C. Pericardial friction rub and pain on deep inspiration
- D. Narrowed pulse pressure and shortness of breath
正解：C
解説：
Section: Questions Set A
Explanation:
(A) No S3 or S4 are noted with pericarditis. (B) No change in pulse pressure occurs. (C) The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. (D) Tamponade is not typically seen early on, and no change in pulse pressure occurs.
質問 # 351
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
- A. Fresh fruit
- B. Saltine crackers and peanut butter
- C. A milkshake
- D. A ham and cheese sandwich
正解：A
解説：
Section: Questions Set G
Explanation:
(A) High levels of ammonia, a by-product of protein metabolism, can precipitate metabolic encephalopathy.
These clients need a diet high in carbohydrates and bulk. (B) Metabolic encephalopathy of the brain associated with liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism.
(C, D) Metabolic encephalopathy in liver failure is precipitated by elevated ammonia levels. Ammonia is a by- product of protein metabolism.
質問 # 352
An IDDM client's condition stabilizes. He begins to receive a daily injection of NPH insulin at 6:30 AM. The nurse can most likely expect a hypoglycemic reaction to occur that same day at:
- A. 7:30 PM-9:30 PM
- B. 8:30 AM-10:30 AM
- C. 2:30 PM-4:30 PM
- D. 10:30 PM-11:30 PM
正解：C
解説：
Explanation/Reference:
Explanation:
(A) This time describes the time of onset of NPH insulin's action, rather than its peak effect. (B) NPH insulin, an intermediateacting insulin, usually begins to lower serum glucose levels about 2 hours after administration. The action of NPH insulin peaks 8-14 hours after administration. It has a 20-30 hour duration. (C) The time stated is not the time of peak action for NPH insulin administered at 6:30 AM. (D) The time stated is not the time of peak action for NPH insulin administered at 6:30 AM.
質問 # 353
Nursing care for the parents of a child with a congenital heart defect would include:
- A. Identifying anger and resentment as destructive emotions that serve no purpose
- B. Acknowledging the fear and concern surrounding their child's health and assisting the parents through the grieving process as they mourn the loss of their fantasized healthy child
- C. Encouraging the parents not to tell the child about the seriousness of the congenital heart defect, so the child will function as normally as possible
- D. Expressing to the parents after the corrective surgery has been completed successfully that all their grief feelings will resolve
正解：B
解説：
(A) It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. (B) Parents of children with congenital heart defects go through a grieving process over the loss of their "healthy" child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. (C) Anger and resentment are normal feelings that must be dealt with appropriately. (D) Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the "defective" child who now may be essentially "normal."
質問 # 354
A 13-year-old hemophiliac is hospitalized for hemarthrosis of his right knee. To relieve the pain, the nurse should:
- A. Encourage active range of motion to right knee
- B. Administer aspirin for pain
- C. Apply moist heat to the right knee
- D. Place on bed rest; elevate and splint the right knee
正解：D
解説：
(A) Immobilization, splinting, and bed rest will reduce the bleeding. Once bleeding is reduced or stopped, the pain will subside. (B) Moist heat causes vasodilation and bleeding. Ice or cold compresses should be applied. (C) Aspirin decreases platelet aggregation, which causes bleeding. (D) Active range of motion aggravates bleeding and damages the synovial sac during bleeding episodes.
質問 # 355
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
- A. Maintain a fluid intake of at least 2000 mL daily
- B. Wash her hands before and after voiding
- C. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps
- D. Drink at least 8 oz of cranberry juice daily
正解：C
解説：
(A)
Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission.
(D)
Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth.
質問 # 356
A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal bottle of a three-bottle chest drainage system serves which of the following purposes?
- A. Preventing accumulation of blood around the heart
- B. Preventing air from entering the chest upon inspiration
- C. Pressure regulator
- D. Collection bottle for drainage
正解：B
解説：
Explanation
(A) There is a separate collection bottle for drainage as part of a chest drainage system. (B) In a three-bottle chest drainage system, one bottle serves only as a pressure regulator. (C) Mediastinal chest tubes prevent accumulation of blood around the heart immediately following heart surgery. (D) The purpose of the water-seal bottle in any chest drainage setup is to allow air out of the chest, but not back in. This negative pressure promotes lung expansion.
質問 # 357
What is the appropriate nursing action for a child with increased intracranial pressure?
- A. Child lying flat
- B. Head of bed elevated 45 degrees with child's head maintained in a neutral position
- C. Head turned to side
- D. Frequent visitation for stimulation
正解：B
解説：
(A) Elevation of head of bed and neutral head position promote drainage of cerebrospinal fluid. (B) Flat position increases intracranial pressure and impedes cerebrospinal fluid drainage. (C) Head turned to either side impedes cerebrospinal fluid drainage. (D) Child should be in a calm, quiet environment with minimal stimulation.
質問 # 358
A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?
- A. Olfactory
- B. Visceral
- C. Auditory
- D. Gustatory
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory perceptions of taste. (C) Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral hallucinations involve sensory perceptions of sensation.
質問 # 359
A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?
- A. Watching Sesame Street on television
- B. Assembling a puzzle with large pieces
- C. Being taken for a wheelchair ride
- D. Listening to a story about the Muppets
正解：B
解説：
Explanation
(A) A 2-year-old child is in the stage of autonomy, according to Erikson. Assembling a puzzle with large pieces enables her to "do it herself." (B) A wheelchair ride would probably be fun, but it is not directed toward helping the child to achieve autonomy. (C) Listening to a story may be fun and educational, but it is not directed toward helping the child to achieve autonomy. (D) Watching television may be a favorite activity, but it does not foster autonomy.
質問 # 360
A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be:
- A. May 7
- B. May 10
- C. November 10
- D. November 7
正解：B
解説：
Explanation
(A) Wrong calculation (B) Wrong calculation (C) Wrong calculation
(D) Nagele's rule is: Expected Date of Confinement = Last
Menstrual Period - 3 months + 7 days + 1 year
質問 # 361
The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:
- A. Hold the vial under warm water for 10-15 minutes and shake vigorously before drawing medication into the syringe.
- B. Weigh once a week and report to the physician any weight gain of10 lb.
- C. Store the medication in a refrigerator and allow to stand at room temperature for 30 minutes prior to administration.
- D. Limit fluid intake to 500 mL/day.
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Weight should be obtained daily. (B) Fluid is not restricted but is given according to urine output. (C) The medication does not have to be stored in a refrigerator. (D) Holding the vial under warm water for 10-
15 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution.
質問 # 362
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being "on the move," sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?
- A. Feelings of helplessness and hopelessness
- B. Short, polite responses to interview questions
- C. Introspection related to his present situation
- D. Exaggerated self-importance
正解：D
解説：
Explanation
(A) During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. (B) Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration.
(C) Grandiosity and an inflated sense of self-worth are characteristic of this disorder. (D) Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.
質問 # 363
The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:
- A. Maintain her interest in school
- B. Provide for physical and psychological rest
- C. Provide a nutritious diet
- D. Maintain contact with her parents
正解：B
解説：
Explanation/Reference:
Explanation:
(A) This goal is helpful, but rest is essential during the acute phase. (B) Rest is essential for healing to occur and for pain to be relieved. (C) This goal is important, but rest is essential. (D) This goal should be part of the plan of care, but it is not the priority during the acute phase.
質問 # 364
A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
- A. Always allow the most vocal person to state the problem first.
- B. Allow family members to assume the seats as they choose.
- C. Encourage the mother to speak for the children.
- D. Interpret immediately what seems to be going on within the family.
正解：B
解説：
Explanation
(A) One will always hear what the most vocal person has to say. It is best to start with the quietest family member to encourage that person to express emotions. (B) All family members are encouraged to speak for themselves. (C) In the initial family assessment, only data collection occurs; interpretations are made later. (D) Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.
質問 # 365
A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:
- A. Allowing him to plan, assist in, and perform his own care whenever possible
- B. Following a standardized plan of care for burn clients formulated by a world-renowned burn center
- C. Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy
- D. Adhering to a strict schedule of diet, exercise, and wound care
正解：A
解説：
(A) A regimented schedule, allowing no flexibility, will not foster the client's self-esteem. (B) Isolating the client may only enhance his feelings of social isolation due to his disfigurement. (C) Standardized care plans must be personalized and adapted to each client's situation. (D) Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.
質問 # 366
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
- A. November 23rd
- B. December 26th
- C. December 9th
- D. September 14th
正解：A
解説：
Explanation
(A) Naele's rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. (B) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule. (C) Naele's rule presumes that the woman has a
28-day menstrual cycle, with conception occurringon the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule. (D) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14thday of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule.
質問 # 367
A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for "his nerves." Included in the client's plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if:
- A. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life
- B. Client promises that he will not abuse aprazolam after discharge
- C. Client is able to verbalize effects of substance abuse on the body
- D. Client has remained substance free during hospitalization and is discharged
正解：A
解説：
(A) This client response does not address stress reduction techniques. Verbal response focuses only on the problem. (B) Exercise or physical activity is a common strategy or coping technique used to reduce stress and anxiety. (C) Verbalizing effects of substance abuse on the body may help with insight and break through denial, but it is not a strategy to reduce anxiety. (D)Remaining substance-free does indicate motivation to change lifestyle of substance abuse or dependence, and it is not a stress reduction strategy in itself.
質問 # 368
On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:
- A. Leukoplakia
- B. Candidiasis
- C. Xerosteromia
- D. Stomatitis
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Xerostomia is dry mouth. (B) Candidiasis can be rubbed off, but it will bleed. (C) Leukoplakia cannot be rubbed off. (D) Stomatitis is caused by candidiasis and gram-negative bacteria.
質問 # 369
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. Distribute written material to supplement verbal instructions
- B. Discuss the danger of overmedication
- C. Explain the side effects of the medication
- D. Explore the client's perception regarding medication therapy
正解：D
解説：
(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 # 370
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. 2000 mL/24 hr
- C. 1600 mL/24 hr
- D. 900 mL/24 hr
正解：C
解説：
Explanation/Reference:
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 # 371
A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:
- A. Noise or bright lights may precipitate a convulsion.
- B. The client is restless.
- C. The elevated blood pressure causes photophobia.
- D. External stimuli are annoying to the client with PIH.
正解：A
解説：
Explanation/Reference:
Explanation:
(A) The client may be anxious and hyperresponsive to stimuli but not necessarily restless. (B) This is not a physiological response to an elevated blood pressure in PIH. (C) The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. (D) External stimuli might induce a convulsion but are not annoying to the client with PIH.
質問 # 372
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NCLEX-RN 試験は、コンピューター化された適応型テスト（CAT）であり、質問は受験者の回答に基づいて選択されます。受験者は適度な難易度の質問から始め、次の質問は前の質問に対する回答によって決定されます。試験はこのように続き、コンピュータプログラムが受験者の能力レベルを決定するまで続きます。試験は、健康促進、心理社会的完全性、生理的適応、薬理学および親血管療法など、幅広い看護トピックをカバーしています。NCLEX-RN 試験は、広範な勉強と準備を必要とする難しい試験です。しかし、試験に合格することは、ライセンスを取得し、看護職の充実したキャリアに進むための重要なステップです。
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