[2024年10月27日]Fast2test NCLEX-RN問題集でNCLEX Certification合格確定させる練習問題集
NCLEX NCLEX-RN実際にある問題とブレーン問題集
質問 # 116
A female client admitted to the labor and delivery unit thinks her bag of water "broke" approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:
- A. Place the nitrazine test paper at the cervical os and note the color change.
- B. Note the color and amount of fluid on her clothes.
- C. Notify the physician.
- D. Assess the FHR.
正解：D
解説：
Section: Questions Set F
Explanation:
(A) Amniotic fluid is generally pale and straw colored. Meconium-stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate priority. (B) With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis. Assessing FHR ascertains fetal well-being. (C) More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician. (D) Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This intervention, though appropriate, is not the immediate priority.
質問 # 117
On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:
- A. Gently massage the uterus until firm, express any clots, and note the amount and character of lochia
- B. Administer analgesics as ordered to relieve discomfort
- C. Catheterize the client and reassess the uterus
- D. Begin IV fluids and administer oxytocic medication
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Gentle massage and expression of clots will let the fundus return to a state of firmness, allowing the uterus to function as the "living ligature." (B) A distended bladder may promote uterine atony; however, after determining the bladder is distended, the nurse would have the client void. Catheterization is only done if normal bladder function has not returned. (C) Oxytocic medications are ordered and administered if the uterus does not remain contracted after gentle massage and determining if the bladder is empty. (D) The client is not complaining of discomfort or pain; therefore, analgesics are not necessary.
質問 # 118
A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?
- A. Photosensitivity, orthostatic hypotension, dry mouth
- B. High fever, tachycardia, stupor, renal failure
- C. Lip smacking, chewing, blinking, lateral jaw movements
- D. Constipation, blurred vision, drowsiness
正解：C
解説：
(A) These symptoms are found in clients with neuroleptic malignant syndrome. (B) These symptoms are found in clients with tardive dyskinesia. (C) These are normal side effects found in clients taking antipsychotic medications. (D) These are also normal side effects found in clients taking antipsychotic medications.
質問 # 119
A 52-year-old female client is admitted to the hospital in acute renal failure. She has been on hemodialysis for the past 2 years. Stat arterial blood gases are drawn on the client yielding the following results: pH
7.30, PCO2 51 mm Hg, HCO3, 18 mEq/L, PaO2, 84 mm Hg. The nurse would interpret these results as:
- A. Compensated metabolic alkalosis
- B. Partially compensated metabolic alkalosis
- C. Combined respiratory and metabolic acidosis
- D. Respiratory acidosis
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Compensated metabolic alkalosis would be reflected by the following: pH within normal limit (7.35-
7.45), PCO2 > 45 mm Hg, HCO3 >26 mEq/L. (B) Respiratory acidosis would be reflected by the following:
pH < 7.35, PCO2 > 45 mm Hg, HCO3 within normal limits (22-26 mEq/L). (C) Partially compensated metabolic alkalosis would be reflected by the following: pH > 7.45, PCO2 > 45 mm Hg, HCO3 > 26 mEq/L.
(D) Combined respiratory and metabolicacidosis would be reflected by the following: pH < 7.35, PCO2 >
45 mm Hg, HCO3 < 22 mEq/L.
質問 # 120
A female client with major depression stated that "life is hopeless and not worth living." The nurse should place highest priority on which of the following questions?
- A. "How has your appetite been recently?"
- B. "How is your relationship with your husband?"
- C. "How has your depression affected your daily livingactivities?"
- D. "Have you thought about hurting yourself?"
正解：D
解説：
(A) Although eating habits are important to assess, they are less important than suicidal intent. (B) Maintenance of the client's life is the priority; assessment of suicidal intent is imperative. (C) Relationships and support systems are an important part of assessment, but they are less important than suicidal intent. (D) Daily living activities will give additional information about the level of depression, and are less significant than suicidal intent, although this information may give additional information about the actual plan for a suicidal attempt.
質問 # 121
The most commonly known vectors of Lyme disease are:
- A. Ticks
- B. Fleas
- C. Mites
- D. Mosquitoes
正解：A
解説：
Explanation
(A) Mites are not the common vector of Lyme disease. (B) Fleas are not the common vector of Lyme disease.
(C) Ticks are the common vector of Lyme disease. (D) Mosquitoes are not the common vector of Lyme disease.
質問 # 122
A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion?
- A. Photosensitivity, orthostatic hypotension, dry mouth
- B. High fever, tachycardia, stupor, renal failure
- C. Lip smacking, chewing, blinking, lateral jaw movements
- D. Constipation, blurred vision, drowsiness
正解：C
解説：
Section: Questions Set F
Explanation:
(A) These symptoms are found in clients with neuroleptic malignant syndrome. (B) These symptoms are found in clients with tardive dyskinesia. (C) These are normal side effects found in clients taking antipsychotic medications. (D) These are also normal side effects found in clients taking antipsychotic medications.
質問 # 123
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：
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 # 124
A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?
- A. Peanut butter and jelly sandwich and milk
- B. Corn beef and cabbage and boiled potatoes
- C. Oatmeal, whole-wheat toast, and milk
- D. Tuna on whole-wheat bread and iced tea
正解：B
解説：
(A, C, D) These foods are allowed with a colostomy. (B) Gasforming foods such as cabbage should be avoided.
質問 # 125
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. Refusing to participate in the child's care
- B. Discussing their needs with the nursing staff
- C. Seeking support from their minister
- D. Discussing their needs with other family members
正解：A
解説：
(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 # 126
The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:
- A. Rinsing with hydrogen peroxide
- B. Rinsing with baking soda
- C. Rinsing with water
- D. Using a water pik
正解：D
解説：
(A) This technique provides effective rinsing and gingival stimulation. (B) This technique does not provide gingival stimulation. (C) This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child. (D) This technique provides effective rinsing but not gingival stimulation.
質問 # 127
Primary nursing diagnoses for the antisocial client are:
- A. Impaired social interaction, ineffective individual coping, and altered self-concept
- B. Altered communication processes and altered recreational patterns
- C. Altered body image and altered thought processes
- D. Alteration in perception and altered self-concept
正解：A
解説：
(A)
This answer is incorrect. Perception is not altered because the client is not psychotic.
(B)
This answer is correct. The antisocial client lacks responsibility, accountability, and social commitment; has impaired problem-solving ability; tends to overuse defense mechanisms; lies and steals; and is often grandiose concerning self. (C) This answer is incorrect. Altered communication processes do not characterize this client. The antisocial person communicates well and tends to have a charming personality. (D) This answer is incorrect. Altered thought processes refer to delusional thinking, which is bizarre and fixed, and do not characterize this client.
質問 # 128
During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:
- A. Enhanced detoxification of drugs
- B. The formation of collateral circulation
- C. A loss of phagocytic activity
- D. Faulty processing of bilirubin
正解：D
解説：
(A) A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases the susceptibility to infections. (B) The faulty processing of bilirubin produces bilesalts, which are irritating to the skin. (C) The detoxification of drugs is impaired with cirrhosis of the liver. (D) Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caput medusae.
質問 # 129
A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing:
- A. Hyperkalemia
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Hyponatremia
正解：C
解説：
Explanation
(A) Sodium level is within normal limits. (B) Sodium level is within normal limits. (C) pH level is consistent with alkalosis. (D) With an NG tube attached to low, intermittent suction, acids are removed and a client will develop metabolic alkalosis.
質問 # 130
A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?
- A. Food restriction is imposed to reduce weight.
- B. Fat requirements are increased owing to the possibility of ketoacidosis.
- C. Caloric distribution should be calculated to fit activity patterns.
- D. Concentrated sweets are taken during increased activity.
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Concentrated sweets are eliminated from diet planning. Complex carbohydrates may be taken at the time of increased activity. (B) Food restriction is not used for diabetic control of growing children. Caloric restriction may be imposed for weight control if necessary. (C) Total caloric intake and proportions of basic nutrients should be consistent from day to day. Distribution of these calories should fit the activity pattern.
Extra food is needed for increased activity. A balance of food, exercise, and insulin should be maintained.
(D) Because of the increased risk of atherosclerosis, the fat percentage of the total caloric intake is reduced.
質問 # 131
A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, "The doctor said I have stones that need to be removed; where are they?" The nurse knows that the best explanation for this is to tell her that:
- A. There are stones present in her gallbladder
- B. There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain
- C. There are stones present in her common bile duct
- D. There are stones present in her kidneys
正解：C
解説：
Explanation
(A)Cholelithiasisis the correct term used to describe the presence of stones in the gallbladder.
(B)Nephrolithiasis,orrenal calculi,is the correct term used to describe the presence of stones in the kidney.
(C)Choledocholithiasisis the correct term used to describe the presence of stones in the common bile duct.
(D)Cholecystitisis the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.
質問 # 132
A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, "Something is wrong. This is like my labor." Which reply by the nurse identifies the physiological response of the client?
- A. "Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement."
- B. "The same hormone that is released in response to the baby's sucking, causing milk to flow, also causes the uterus to contract."
- C. "Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract."
- D. "There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it."
正解：B
解説：
Section: Questions Set F
Explanation:
(A) Mammary growth as well as milk production and maintenance in the breast occur in response to hormones produced primarily by the hypothalamus and the pituitary gland. (B) Prolactin stimulates the alveolar cells of the breast to produce milk. It is important in the initiation of breast-feeding. (C) Oxytocin, which is released by the posterior pituitary, stimulates the let-down reflex by contraction of the myoepithelial cells surrounding the alveoli. In addition, it causes contractions of the uterus and uterine involution. (D) Afterpains may occur with retained placental fragments. A boggy uterus and continued bleeding are other symptoms that occur in response to retained placental fragments.
質問 # 133
A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.
Teaching related to skin care for the client would include which of the following?
- A. Teach her to cover broken skin in the treated area with a medicated ointment.
- B. Encourage her to wear a tight-fitting vest to support her scapula.
- C. Teach her to completely clean the skin to remove all ointments and markings after each treatment.
- D. Encourage her to avoid direct sunlight on the area being treated.
正解：D
解説：
Explanation
(A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on the treated area.
This could interfere with treatment. (C) Radiation therapy clients should wear loose-fitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun.
質問 # 134
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. "Your grandfather and father were both alcoholics?"
- B. "It sounds like you're intellectualizing your drinking problem."
- C. "Risk factors can often be controlled by self-responsibility."
- D. "That might be a problem. Tell me more about them."
正解：C
解説：
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 # 135
A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:
- A. Second stage of labor
- B. Transition stage of labor
- C. Fourth stage of labor
- D. Third stage of labor
正解：B
解説：
(A) The fourth stage begins after expulsion of the placenta. Client symptoms are: fatigue; chills; scant, bloody vaginal discharge; and nausea. (B) The third stage is from birth to expulsion of placenta. Client symptoms are uterine contractions, gush of blood, and perineal pain. (C) The transition stage is characterized by strong uterine contractions and cervical dilation. Clientsymptoms are irritability, restlessness, belching, muscle tremors, nausea, and vomiting. (D) The second stage is characterized by full dilation of cervix. Client symptoms are perineal bulge, pushing with contractions, great irritability, and leg cramps.
質問 # 136
The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?
- A. 12-Lead ECG
- B. Serum electrolytes
- C. Complete blood count
- D. Arterial blood gases
正解：B
解説：
(A) Furosemide, a potassium-depleting diuretic, inhibits the reabsorption of sodium and chloride from the loop of Henle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B) Severe acid-base imbalances influence the movement of potassium into and out of the cells, but arterial blood gases to not measure the serum potassium level. (C) Furosemide is a potassium-depleting diuretic. A complete blood count does not reflect potassium levels. (D) Abnormalities in potassium (both hyperkalemia and hypokalemia) are reflected in ECG changes, but these changes do not occur until the abnormality is severe.
質問 # 137
A laboratory technique specific for diagnosing Lyme disease is:
- A. Increased serum potassium level
- B. Decreased serum calcium level
- C. Heterophil antibody test
- D. Polymerase chain reaction
正解：D
解説：
Section: Questions Set A
Explanation:
(A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level.
質問 # 138
A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for:
- A. Impaired physical mobility
- B. Ineffective breathing pattern
- C. Knowledge deficit
- D. Urinary retention
正解：B
解説：
(A) The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a priority nursing diagnosis postoperatively. (B) The client will have a Foley catheter for a day or two after surgery. Urinary retention is usually not a problem once the Foley catheter is removed. (C) A client having a cholecystectomy should not be physically impaired. In fact, the client is encouraged to begin ambulating soon after surgery. (D) Because of the location of the incision, the client having a cholecystectomy is reluctant to breathe deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.
質問 # 139
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