NCLEX NCLEX-RN試験問題（更新されたのは2024年）100%リアル問題解答
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NCLEX-RN試験は、登録看護師になるための重要なステップです。看護プログラムを修了した候補者は、試験を受験するために州看護委員会に申請する必要があります。試験に合格し、その他の免許要件を満たした後、登録看護師としての実践が可能になります。この試験は、看護を実践するために有資格な個人だけが免許を取得することを確認し、公衆を保護し、看護職の誠実性を維持するために設計されています。
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。
質問 # 425
A male client has experienced low back pain for several years. He is the primary support of his wife and six children. Although he would qualify for disability, he plans to continue his employment as long as possible.
His back pain has increased recently, and he is unable to control it with non-steroidal anti-inflammatory agents. He refuses surgery and cannot take narcotics and remain alert enough to concentrate at work. His physician has suggested application of a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following is an appropriate rationale for using a TENS unit for relief of pain?
- A. TENS units have an ultrasonic effect that relaxes muscles, decreases joint stiffness, and increases range of motion.
- B. TENS units produce endogenous opioids that affect the central nervous system with analgesic potency comparable to morphine.
- C. TENS units prevent muscle spasms, decrease the potential for further injury, and minimize pressure on joints.
- D. TENS units work on the gate-control theory of pain; biostimulation therapy of large fibers block painful stimuli.
正解：D
解説：
Explanation/Reference:
Explanation:
(A) TENS units do not have this effect, but whirlpool therapy does. (B) TENS units do not produce endogenous opioids, only the body can do that. (C) TENS units do work based on the gatecontrol theory of pain control. (D) TENS units do not have this effect, but possibly changing the client's position would.
質問 # 426
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
- A. Release restraints every 2 hours for client to exercise.
- B. Give fluids if the client requests them.
- C. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
- D. Measure vital signs at least every 4 hours.
正解：A
解説：
Explanation
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.
質問 # 427
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?
- A. Vitamin C
- B. Vitamin A
- C. Vitamin D
- D. Vitamin B1
正解：A
解説：
Explanation
(A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. (B) Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. (C) Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.
質問 # 428
A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
- A. Warmed solution decreases the risk of peritoneal infection
- B. Warmed solution helps dilate the peritoneal blood vessels
- C. Warmed solution helps keep the body temperature maintained within a normal range during instillation
- D. Warmed solution promotes a relaxed abdominal muscle
正解：B
解説：
(A) Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. (B) Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. (C) Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. (D) Relaxing the abdominal muscles does not facilitate peritoneal dialysis.
質問 # 429
When providing dietary teaching to an individual who has diabetes mellitus, type II, the nurse discusses the importance of consuming the recommended daily allowance of which of the following electrolytes?
- A. Sodium
- B. Magnesium
- C. HCO3
- D. Potassium
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Potassium intake that meets the recommended daily allowance is important, especially in clients who have a history of cardiac disease. (B) Low levels of magnesium can cause an increase in resistance to insulin and can lead to carbohydrate intolerance. (C) Sodium is an important electrolyte for all clients but has no direct effect on diabetes mellitus. (D) Bicarbonate plays an important role in acid-base balance. It is equally necessary for maintenance of all body functions.
質問 # 430
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. Breaks down bilirubin in the skin into substances that can be excreted in stool or urine
- C. Assists the baby's clotting mechanism
- D. Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)
正解：B
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 # 431
A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side.
The nurse identifies the most likely cause of this as:
- A. Left-sided pneumothorax
- B. Pneumonia
- C. Right mainstem bronchus intubation
- D. Inappropriate endotracheal tube size
正解：C
解説：
Explanation
(A) Appropriate endotracheal tube sizes for adults range from 7.0-8.5 mm. (B) Pneumothorax could be indicated by an absence of breath sounds on the affected side. However, in a recently intubated client, the first priority would be to consider tube malposition. (C) During intubation, the right mainstem bronchus can be inadvertently entered if the endotracheal tube is inserted too far. Left mainstem bronchus intubation almost never occurs because of the angle of the left mainstem bronchus. (D) Breath sounds for someone with pneumonia may be decreased over the areas of consolidation. However, in a recently intubated client, the first priority would be to consider tube malposition.
質問 # 432
A couple is planning the conception of their first child.
The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day:
- A. 20+2 days
- B. 14+2 days
- C. 22+2 days
- D. 16+2 days
正解：A
解説：
(A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days. (B) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 16). (C) Ovulation occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 22).
質問 # 433
The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse's action should be to:
- A. Encourage coughing and deep breathing each hour
- B. Remove the postoperative dressing to check for bleeding
- C. Increase O2 from 2-3 L/min
- D. Obtain arterial blood gases
正解：A
解説：
Explanation
(A) Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. (B) Arterial blood gases are not indicated because there is no other information indicating impendingdanger. (C) Increasing O2 rate is not indicated without additional information. (D) Removing the dressing is not indicated without additional information.
質問 # 434
An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse's understanding of normal fluid requirements for this infant?
- A. 330 mL/day
- B. 240 mL/day
- C. 960 mL/day
- D. 680 mL/day
正解：D
解説：
Section: Questions Set E
Explanation:
(A, C, D) These answers are incorrect. (B) Normal fluid requirement for this pediatric client is based on the fact that 0-10 kg of weight equals 100 mL/kg per day. This infant weighs 15 pounds (6.8 kg). Thus, 100 mL X 6.8
680 mL/day.
質問 # 435
The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
- A. "Gently thump on cast to dislodge dried skin that causes the itching."
- B. "Blowing air under the cast using a hair dryer on cool setting often relieves itching."
- C. "Guide a towel under and through the cast and move it back and forth to relieve the itch."
- D. "Slide a ruler under the cast and scratch the area."
正解：B
解説：
(A) Cool air will often relieve pruritus without damaging the cast or irritating the skin. (B)
The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. (C) Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. (D) This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.
質問 # 436
To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?
- A. Positive inotropic therapy
- B. Increase in balance of myocardial O2 supply and demand
- C. Negative chronotropic therapy
- D. Afterload reduction therapy
正解：A
解説：
Section: Questions Set A
Explanation:
(A) Inotropic therapy will increase contractility, which will increase myocardial O2 demand. (B) Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. (D) Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand.
質問 # 437
A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:
- A. Be comforted when he is held
- B. Not notice that his mother has left
- C. Withdraw and become listless
- D. Cry
正解：D
解説：
Explanation
(A) It will be difficult to comfort a 2 year old with a headache without his mother. (B) This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help. (C) An awake 2 year old will notice when his mother leaves. (D) An older child may withdraw when feeling afraid, but a 2 year old will probably show more aggressive behavior.
質問 # 438
A behavioral modification program is recommended by the multidisciplinary team working with a 15-year- old client with anorexia nervosa. A nursing plan of care based on this modality would include:
- A. Restriction to the unit until she has gained 2 lb
- B. Role playing the client's eating behaviors
- C. Encouraging her to verbalize her feelings concerning food and food intake
- D. Provision for a high-calorie, high-protein snack between meals
正解：A
解説：
Explanation/Reference:
Explanation:
(A) This answer is incorrect. Role playing is based on learning but is not based on the behavioral modification model. (B) This answer is correct. The behavioral modification model is based on negative and positive reinforcers to change behavior. (C) This answer is incorrect. Verbal catharsis is not an intervention based on behavioral modification. (D) This answer is incorrect. Although an acceptable nursing intervention, it is not based on behavioral modification.
質問 # 439
A 25-year-old outpatient presents with a diagnosis of compulsive personality disorder. His coworkers become annoyed with his rigid, perfectionistic manner and preoccupation with trivial details and schedules.
A nursing intervention appropriate for this client would include:
- A. Contracting with him for the amount of time he will spend on the compulsive behaviors
- B. Avoiding discussion of his annoying behavior
- C. Encouraging the client to set a time schedule and deadlines for himself
- D. Encouraging him to engage in recreational activities
正解：A
解説：
Explanation/Reference:
Explanation:
(A) This answer is incorrect. The client will work hard at the activity instead of enjoying it. (B) This answer is incorrect. The nurse should allow the client to discuss these thoughts, within limits, not to avoid discussing them. (C) This answer is incorrect. The compulsive client tends to control time to excess. It should not be encouraged. (D) This answer is correct. A contract with the client regarding the amount of time that will be spent discussing the compulsive activities is appropriate. Time allotted should be gradually decreased.
質問 # 440
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, "Nurse, the baby is coming." As the nurse responds to her call, which one of the following observations should the nurse make first?
- A. Time the contractions.
- B. Inspect the perineum.
- C. Prepare a sterile area for delivery.
- D. Auscultate for fetal heart rate (FHR).
正解：B
解説：
(A) The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. (B) Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. (C) If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. (D) Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.
質問 # 441
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
- A. Protect the outer surface of the pad from contamination
- B. Cleanse and wipe the perineum from front to back
- C. Place and adjust the pad from back to front
- D. Wear gloves for the procedure
正解：B
解説：
(A) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. (B) The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. (C) Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. (D) The inner surface of the pad should not be touched to maintain asepsis.
質問 # 442
An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse's understanding of normal fluid requirements for this infant?
- A. 330 mL/day
- B. 240 mL/day
- C. 960 mL/day
- D. 680 mL/day
正解：D
解説：
Explanation
(A, C, D) These answers are incorrect. (B) Normal fluid requirement for this pediatric client is based on the fact that 0-10 kg of weight equals 100 mL/kg per day. This infant weighs 15 pounds (6.8 kg). Thus, 100 mL X
6.8 = 680 mL/day.
質問 # 443
Which of the following blood gas parameters primarily reflects respiratory function?
- A. PCO2
- B. Base excess
- C. CO2 content of the blood
- D. HCO3
正解：A
解説：
Explanation/Reference:
Explanation:
(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 # 444
A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate?
- A. Request an order for a stat blood lithium level.
- B. Administer a stat dose of lithium as necessary.
- C. Give an oral dose of lithium antidote.
- D. Recognize this as an expected response to lithium.
正解：A
解説：
(A)
These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal.
(B)
These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which may be validated by lab studies. (D) There is no known lithium antidote.
質問 # 445
Dietary planning is an essential part of the diabetic client's regimen. The American
Diabetes Association recommends which of the following caloric guidelines for daily meal planning?
- A. 70% complex carbohydrate, 20%-30% protein, 10%-20% fat
- B. 60% complex carbohydrate, 12%-15% protein, 20%-25% fat
- C. 45% complex carbohydrate, 25%-30% protein, 30%-35% fat
- D. 50% complex carbohydrate, 20%-25% protein, 20%-25% fat
正解：B
解説：
(A) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney as it is metabolized. (B) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney. (C) The percentage of carbohydrates is too high; the percent range of protein is too high, and of fat, too low. (D) This combination provides enough carbohydrates to maintain blood glucose levels, enough protein to maintain body repair, and enough fat to ensure palatability.
質問 # 446
A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7-8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:
- A. She may be in preterm labor because this is more common with multiple pregnancies
- B. She most likely has a urinary tract infection (UTI) because this is common with pregnancy
- C. The nurse should not be alarmed because mild uterine activity is common at 32 weeks' gestation
- D. Her cervix shows she will likely deliver soon
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Her cervical exam is normal. There are no cervical changes at this time. (B) Braxton Hicks contractions may be common throughout pregnancy, but they are not regular. (C) Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32 weeks in a woman carrying triplets are of great concern. She may be in preterm labor. (D) UTIs are common in pregnancy due to the enlarging uterus compressing the ureters and the stasis of urine. The woman would be more likely to complain of urinary frequency and urgency, fever or chills, and malodorous urine with a UTI.
質問 # 447
A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:
- A. Have him sign a "no-suicide" contract.
- B. Provide him with a safe and structured environment.
- C. Isolate him from stressful situations that may precipitate a depressive episode.
- D. Assist him to develop more effective coping mechanisms.
正解：D
解説：
Explanation
(A) This statement represents a short-term goal. (B) Long-term therapy should be directed toward assisting the client to cope effectively with stress. (C) Suicide contracts represent short-term interventions. (D) This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality.
質問 # 448
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