2024年最新の実際に出ると確認された 無料NCLEX NCLEX-RN試験問題
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質問 # 113
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
- A. Use microdrip tubing for the blood administration
- B. Have the registered nurse in charge assume responsibility for verifying the client and blood product information
- C. Take a baseline set of vital signs
- D. Hang Ringer's lactate as the companion fluid
正解：C
解説：
Section: Questions Set D
Explanation:
(A) A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. (B) The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. (C) Only a blood administration set should be used.
A microdrip tube would cause lysis of the red blood cells. (D) Proper identification of the recipient and the blood product must be validated by at least two people.
質問 # 114
Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:
- A. Diminished or absent femoral pulses
- B. Pulse pressure difference between the upper extremities
- C. A diastolic murmur
- D. A third heart sound
正解：A
解説：
(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 # 115
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. Bargaining
- C. Depression
- D. Anger
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 # 116
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. Alternate successive administrations
- C. Glucocorticoid followed by the bronchodilator
- D. According to the client's preference
正解：A
解説：
Explanation/Reference:
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 # 117
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. Old paint
- B. Stuffing from toy animals
- C. Pencils
- D. Dandelion leaves
正解：A
解説：
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 # 118
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. "I'm pleased that you get along so well with the staff. You must still know and abide by the rules."
- B. "I'm not the other nurses. You better read the rules yourself."
- C. "It is irrelevant whether you get along with the nurses."
- D. "OK, don't listen to the rules. See where you end up."
正解：A
解説：
(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 # 119
The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
- A. Infuse volume at 22 mL/hr.
- B. Infuse volume at 30 mL/hr.
- C. Infuse volume at 10 mL/hr.
- D. Infuse volume at 44 mL/hr.
正解：D
解説：
(A) The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is: Rate = Volume to Be Infused X Administration Set Drop Factor (microdrop: 60 gtts/min)Desired Time to Infuse in Minutes Rate = (10 + 12)22 X 60 30 = 44 mL/hr. (B, C, D) These values are incorrect.
質問 # 120
A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about bromocriptine should be given by the nurse?
- A. Bromocriptine is generally taken for 5 days.
- B. Bromocriptine stimulates the production of prolactin.
- C. Hypertension is a primary side effect.
- D. Her blood pressure must be stable before starting bromocriptine.
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Bromocriptine inhibits the secretion of prolactin. (B) Hypotension is a side effect of this drug; hypertension is not. (C) Bromocriptine is generally taken for 14 days. (D) The administration of bromocriptine is delayed at least 4 hours postpartum and given only when the client's blood pressure is stable, because it can cause hypotension and syncope.
質問 # 121
On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
- A. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
- B. Contact the lab and request a lithium level in 30 minutes, and call the physician.
- C. Withhold her lithium, and report her symptoms to the physician.
- D. Administer her next dosage of lithium, and then call the physician.
正解：C
解説：
Section: Questions Set F
Explanation:
(A) The client has lithium toxicity, and the nurse must withhold further dosages. (B) Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level. (C) Ensuring adequate intake of sodium chloride will promote excretion of lithium and will assist in managing the client's lithiumtoxicity. (D) A lithium blood level must be drawn immediately to determine the seriousness of the toxicity and to provide the physician with data for medical orders.
質問 # 122
A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:
- A. Place her to her mother's breast
- B. Place her under the radiant warmer
- C. Place her on a heated pad
- D. Dry her with blankets
正解：A
解説：
Explanation
(A) A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. (B) Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. (C) Skin-to-skin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. (D) Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result.
質問 # 123
Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?
- A. Verapamil (Isoptin)
- B. Epinephrine (Adrenalin)
- C. Amrinone (Inocor)
- D. Propranolol (Inderal)
正解：D
解説：
Explanation
(A) Verapamil has the respiratory side effect of nasal or chest congestion, dyspnea, shortness of breath (SOB), and wheezing. (B) Amrinone has the effect of increased contractility and dilation of the vascular smooth muscle. It has no noted respiratory side effects. (C) Epinephrine has the effect of bronchodilation through stimulation. (D) Propranolol, esmolol, and labetalol are all - blocking agents, which can increase airway resistance and cause bronchospasms.
質問 # 124
A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
- A. 100 gtt/min
- B. 5 gtt/min
- C. 50 gtt/min
- D. 1 gtt/min
正解：C
解説：
Explanation/Reference:
Explanation:
(A) This answer is a miscalculation. (B) This answer is a miscalculation. (C)50 gtt/min. (D) This answer is a miscalculation.
質問 # 125
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Respiratory rate for 1 minute
- B. Apical pulse for 1 minute
- C. Radial pulse for 1 minute
- D. Radial pulse for 2 minutes
正解：B
解説：
Explanation
(A) Respiratory rate is not directly affected by digoxin therapy. (B) A radial pulse is not as accurate as an apical pulse. Dysrhythmias may not be detected. (C) A radial pulse is not as accurate as an apical pulse, regardless of assessment time. (D) Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or
>120 bpm.
質問 # 126
In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:
- A. Systemic venous engorgement
- B. Increased pressure in the pulmonary veins and pulmonary edema
- C. Increased left ventricular systolic pressures and hypertrophy
- D. Decreased pulmonary blood flow and cyanosis
正解：C
解説：
Section: Questions Set A
Explanation/Reference:
Explanation:
(A) These signs are seen in pulmonic stenosis or in response to pulmonary congestion and edema and mitral stenosis. (B) These signs are seen primarily in mitral stenosis or as a late sign in aortic stenosis after left ventricular failure. (C) These signs are seen primarily in right-sided heart valve dysfunction. (D) Left ventricular hypertrophy occurs to increase muscle mass and overcome the stenosis; left ventricular pressures increase as left ventricular volume increases owing to insufficient emptying.
質問 # 127
A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby's condition. The nurse knows that the pediatrician has discussed the baby's condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first?
- A. Tell the mother that this is not a serious condition.
- B. Tell the mother that this condition has been successfully treated with exercises, casts, and/or braces.
- C. Question the mother and find out what the pediatrician has told her about the baby's condition.
- D. Call the orthopedist and request that he come to see the baby now.
正解：C
解説：
Explanation/Reference:
Explanation:
(A) The nurse should call the orthopedist after assessing the mother's knowledge. (B) The nurse must first assess the knowledge of the parent before attempting any explanation. (C) The nurse should assess the mother's knowledge of the baby's condition as the first priority. (D) This answer is correct, but the priority is
B.
質問 # 128
A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?
- A. Pain in his legs when he walks
- B. Thirst, weight loss, and polyuria
- C. Weight gain, edema in his lower extremities, and shortness of breath
- D. Drowsiness and lethargy after his activities
正解：C
解説：
Explanation
(A) Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure. The client should be cautioned to increase his activities slowly. (B) Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. (C) Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. (D) All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The client's activity level should be evaluated.
質問 # 129
The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include:
- A. Rounded shape of chest, smaller volume of air
- B. Diaphragmatic breathing, larger volume of air
- C. Fewer alveoli, slower respiratory rate
- D. Larger number of alveoli, diaphragmatic breathing
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. (B) Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. (C) The adult has a larger number of alveoli than a child. (D) The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.
質問 # 130
A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:
- A. Continue to monitor the foot
- B. Assure the client that his foot is fine
- C. Notify the physician immediately
- D. Reposition and reassess the foot
正解：C
解説：
Section: Questions Set D
Explanation:
(A) The client is losing blood supply to his left foot. Continuing to monitor the foot will not help restore the blood supply to the foot. (B) The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the foot and/or leg. (C) The presenting symptoms are of an emergency nature and require immediate intervention. (D) This action would be giving the client false assurance.
質問 # 131
One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, "It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers." The nurse's best response would be:
- A. "That might be a problem. Tell me more about them."
- B. "Risk factors can often be controlled by self-responsibility."
- C. "Your grandfather and father were both alcoholics?"
- D. "It sounds like you're intellectualizing your drinking problem."
正解：B
解説：
Section: Questions Set G
Explanation:
(A) Focusing is an effective therapeutic strategy. This response, however, allows the client to "defocus" off the topic of learning how to accept responsibility for his behavior and future growth. (B) The nurse can educate the client about both the "genetic risk" for the development of alcoholism and ways to make long-term healthy lifestyle changes. (C) This response is inappropriately confrontational and condescending to the client. (D) Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here.
質問 # 132
In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery?
- A. Left anterior descending coronary artery
- B. Right coronary artery
- C. Circumflex coronary artery
- D. Left main coronary artery
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in mostindividuals. (B) Occlusion of the left main coronary artery causes bundle branch blocks and premature ventricular contractions. (C) Occlusion of the circumflex artery does not cause bradycardia. (D) Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this form of occlusion impairs left ventricular function.
質問 # 133
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 establish a trusting relationship
- B. To keep the child calm
- C. To prevent or minimize separation anxiety
- D. To reduce fear of the unknown
正解：C
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 # 134
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
- A. Prevents the development of ophthalmia neonatorum
- B. Assists the baby's clotting mechanism
- C. Breaks down bilirubin in the skin into substances that can be excreted in stool or urine
- D. Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)
正解：C
解説：
(A) The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. (B) The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. (C) Excessive bilirubin accumulates when the infant's liver cannothandle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. (D) Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
質問 # 135
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
- A. Pallor and itching of the face and neck
- B. Headache and facial flushing
- C. Circumoral pallor and lightheadedness
- D. Dizziness and tachypnea
正解：B
解説：
Section: Questions Set A
Explanation:
(A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms.
質問 # 136
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