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NCLEX-RN試験は、全米州議会看護委員会（NCSBN）によって管理されており、その内容は、登録看護のエントリーレベルの実践に必要な知識とスキルに基づいています。この試験は、看護師がさまざまなヘルスケア環境で患者に安全で効果的なケアを提供する準備ができるように設計されています。 NCLEX-RN試験に合格することは、米国の登録看護師としての免許の要件であり、看護師が成功を達成するために試験のために徹底的に準備することを目指すことが重要です。
質問 # 437
A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?
- A. The client's contractions are <2 minutes apart.
- B. The uterus relaxes between contractions.
- C. Duration of the contractions are 60 seconds.
- D. The client complains that she is tired.
正解：A
解説：
Explanation
(A) It is very important that there is a resting phase or relaxation period between the contractions. During this period, the uterus, placenta, and umbilical vessels re-establish blood flow. No resting phase between contractions can lead to fetal bradycardia, fetal hypoxia, and acidosis. It can also result in a tetanic contraction, which can cause uterine rupture. (B) The goal of the oxytocin infusion is to help establish a contraction pattern lasting 45-60 seconds occurring every 2 minutes and a uterine tonus of 60-70 mm Hg. (C) This choice is correct. The uterus has time to recover from the contraction. (D) The client's tiring is no indication to stop the infusion. She will be tired even without the infusion.
質問 # 438
A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion:
- A. The risks of exposure of the visitor to infectious organisms is great.
- B. Hospital regulations mandate that everyone in the facility adhere to appropriate codes.
- C. Adherence to the guidelines are the latest Centers for Disease Control and Prevention recommendations on use of protective apparel.
- D. The client is at extreme risk of acquiring infections.
正解：D
解説：
(A) Although clients with a compromised immune system may acquire infections, the primary emphasis is on protecting the client. (B, D) Most people are aware of the guidelines once they see posted signs, so quoting regulations is not likely to result in consistent adherence to regulations. (C) Clients with aplastic anemia have white cell counts of 2000 or lower, making them more vulnerable to infections from others.
質問 # 439
A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia?
- A. Klebsiellapneumonia
- B. Escherichia colipneumonia
- C. Legionella pneumophilapneumonia
- D. Pneumococcal pneumonia
正解：D
解説：
Explanation/Reference:
Explanation:
(A)Klebsiellapneumonia is caused by gram-negative bacteria. (B) Pneumococcal pneumonia is caused by gram-positive bacteria. (C)Legionella pneumophilapneumonia is a nonbacterial pneumonia. (D)E.
colipneumonia is caused by gram-negative bacteria.
質問 # 440
A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as "a cramp in my leg." An appropriate nursing action is to:
- A. Assess for pain with plantiflexion
- B. Assess for edema and heat of the right leg
- C. Instruct him to rub the cramp out of his leg
- D. Elevate right lower extremity with pillows propped under the knee
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Calf pain with dorsiflexion of the foot (Homans' sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. (C) Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D) A pillow behind the knee can be constricting and further impair blood flow.
質問 # 441
A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience?
- A. Decreased systolic pressure, cold skin, and anuria
- B. Marked elevation in blood pressure, respirations, and pulse
- C. Rapid pulse; narrowed pulse pressure; cool, moist skin
- D. No urinary output, tachycardia, and restlessness
正解：C
解説：
(A) Early shock does not exhibit the symptom of marked elevation in blood pressure. A narrowing of the pulse pressure is indicative of early shock. (B) Anuria is a clinical finding in late shock. (C) All of these clinical findings are congruent with early shock. (D) Absence of urinary output is a clinical finding in the late phase of shock.
質問 # 442
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale.
When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
- A. Liver
- B. Pulmonary system
- C. Left ventricle
- D. Superior vena cava
正解：B
解説：
Explanation/Reference:
Explanation:
(A) The foramen ovale permits a percentage of the blood to shunt from the right atrium to the left atrium.
The blood then goes to the left ventricle, permitting systemic fetal circulation with blood containing a higher O2 saturation. (B) As the blood shunts from the right atrium to the left atrium, the pulmonary system is bypassed. The fetus receives O2 from the maternal circulation, thereby permitting the partial bypass of the pulmonary system. (C) The foramen ovale is locatedin the atrial septum of the heart and does not affect the liver. (D) The superior vena cava returns blood to the heart, bringing blood to the location of the foramen ovale.
質問 # 443
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. Take a baseline set of vital signs
- B. Use microdrip tubing for the blood administration
- C. Hang Ringer's lactate as the companion fluid
- D. Have the registered nurse in charge assume responsibility for verifying the client and blood product information
正解：A
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 # 444
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. Apply ice to the perineum.
- C. Inform the physician.
- D. Encourage the client to take warm sitz baths.
正解：D
解説：
Explanation/Reference:
Explanation:
(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 # 445
A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?
- A. State nursing practice act
- B. American Nurses' Association Standards of Maternal- Child Health Nursing
- C. International Council of Nurses' Code
- D. AWHONN Standards for the Nursing Care of Women and Newborns
正解：A
解説：
Explanation/Reference:
Explanation:
(A) The state nursing practice act determines the standard of care for the professional nurse. (B) AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. (C) American Nurses' Association Standards are published as recommendations and guidelines for maternalchild health nursing. (D) The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.
質問 # 446
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
- A. The client may not recognize the early symptoms of PIH
- B. Self-discipline is required to control caloric intake throughout the pregnancy
- C. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
- D. Immediate treatment of mild PIH includes the administration of a variety of medications
正解：A
解説：
Section: Questions Set B
Explanation:
(A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH.
質問 # 447
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Inspiration is longer than expiration
- B. Breath sounds are high pitched
- C. Breath sounds are slightly muffled
- D. Inspiration and expiration are equal
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Inspiration is normally longer in vesicular areas. (B) Highpitched sounds are normal in bronchial area.
(C) Muffled sounds are considered abnormal. (D) Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
質問 # 448
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, "What is the greatest risk to my baby if it is born prematurely?" The RN's answer should be:
- A. Hypoglycemia
- B. Hyperglycemia
- C. Lack of development of the intestines
- D. Lack of development of the lungs
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. (B) Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. (C) Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to the premature infant. (D) Infants born before 37 weeks' gestation are at greatest risk for an insufficient amount of surfactant in the alveoli system of the lungs. Surfactant helps to prevent lung collapse and ensures stability of the respiratory system so that the infant can maintain his own respirations once the umbilical cord is severed at birth.
質問 # 449
Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:
- A. The traction pull should result in an immediate increase in comfort and reduce the need for pain medication
- B. The client will need special skin care at the pin site according to hospital policy or the physician's preference
- C. The nurse may lift only the weights that are applying traction in order to reposition him in bed
- D. The client should be discouraged from participating in self-care activities to avoid the risk of disrupting the traction
正解：B
解説：
Explanation
(A) Skeletal traction, including the weights that are applying the traction, is never released by the nurse. (B) It is necessary to keep the pin site clean and free from infection. (C) When first placed in traction, the client may experience increased discomfort as a result of the traction pull fatiguing the muscle. (D) When the child in traction is allowed to participate in his care, it gives him a measure of control and helps him to cope with the situation.
質問 # 450
A successful executive left her job and became a housewife after her marriage to a plastic surgeon. She started doing volunteer work for a charity organization. She developed pain in her legs that advanced to the point of paralysis. Her physicians can find no organic basis for the paralysis. The client's behavior can be described as:
- A. Conversion reaction
- B. Agoraphobia
- C. Housework phobia
- D. Malingering
正解：A
解説：
Explanation
(A) A typical phobia does not result in physical symptoms (i.e., paralysis). (B) Malingering is pretending to be ill. This person has a true paralysis. (C) A conversion reaction is a physical expression of an emotional conflict. It has no organic basis. (D) Agoraphobia is fear of public places.
質問 # 451
A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
- A. Put in a nasogastric tube and lavage the child's stomach.
- B. Monitor muscular status.
- C. Place child on respiratory assistance.
- D. Teach mother poison prevention techniques.
正解：A
解説：
Explanation/Reference:
Explanation:
(A) The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. (B) Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. (C) The mother's anxiety is probably so high that preventive guidance will be ineffective. (D) Respiratory assistance is not needed if the child's respiratory function is unaltered.
質問 # 452
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. Remove the postoperative dressing to check for bleeding
- B. Obtain arterial blood gases
- C. Increase O2 from 2-3 L/min
- D. Encourage coughing and deep breathing each hour
正解：D
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 # 453
In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:
- A. Increased left ventricular systolic pressures and hypertrophy
- B. Increased pressure in the pulmonary veins and pulmonary edema
- C. Systemic venous engorgement
- D. Decreased pulmonary blood flow and cyanosis
正解：A
解説：
(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 # 454
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
- A. Bradypnea and bradycardia
- B. Shortness of breath and sharp pain on the affected side
- C. Increased breath sounds on the affected side
- D. Crackles or rales on the affected side
正解：B
解説：
Explanation/Reference:
Explanation:
(A) With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. (B) With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. (C) Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. (D) With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).
質問 # 455
An 8-year-old child is admitted to the hospital for surgery. She has had no previous hospitalizations, and both she and her family appear anxious and fearful. It will be most helpful for the nurse to:
- A. Explain that as soon as the child goes to the operating room she will have time to answer any questions the family has
- B. Take the child to her room and calmly and matter-offactly begin to get her ready to go to the operating room
- C. Tell the child and her family that there is nothing to worry about, that the operation will not take long, and she will soon be as "good as new"
- D. Take time to orient the child and her family to the hospital and the forthcoming events
正解：D
解説：
Explanation
(A) This action does nothing to prepare the child and her family for what will happen or to relieve their anxiety and fear. (B) This action provides security by preparing the child and the family for what will happen and will help to relieve fear and anxiety. (C) This action does nothing to help prepare the child for what will happen and does not give the parents permission to ask questions until later. (D) This action provides possibly false reassurance and may prevent the child and/or the family from asking pressing questions.
質問 # 456
The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, "I get them whenever I bump into anything." The nurse would expect to note a decrease in which of the following laboratory tests?
- A. Hemoglobin level
- B. WBC count
- C. Number of lymphocytes
- D. Number of platelets
正解：D
解説：
(A) Thrombocytopenia, a decrease in platelets, occurs in lupus and causes a decrease in blood coagulation and thrombus formation. (B) Clients with lupus will have a decrease in the WBC count decreasing their resistance to infection. (C) Clients with lupus may have a decrease in the hemoglobin level causing anemia. (D) Leukopenia, a decrease in white blood cells, is seen in lupus and decreases resistance to infection.
質問 # 457
The nurse instructs a client on the difference between true labor and false labor. The nurse explains, "In true labor:
- A. The cervix does not dilate."
- B. Uterine contractions will strengthen with walking."
- C. Uterine contractions will weaken with walking."
- D. The fetus does not descend."
正解：B
解説：
Section: Questions Set C
Explanation:
(A) Uterine contractions increase with activity. (B) Walking will increase the strength and regularity of uterine contractions in true labor. (C) Uterine contractions that are strong and regular facilitate cervical dilation. (D) Regular, strong uterine contractions, as in true labor, result in fetal descent.
質問 # 458
As a postoperative cholecystectomy client completes tomorrow's dinner menu, the nurse knows that one of the following meal choices will best provide the essential vitamin(s) necessary for proper tissue healing?
- A. Chicken breast fillet in tomato sauce, potatoes, mustard greens, orange and strawberry slices
- B. Liver, white rice, spinach, tossed salad, custard pudding
- C. Fish fillet, carrots, mashed potatoes, butterscotch pudding
- D. Roast chicken, gelatin with sliced fruit
正解：A
解説：
(A) This meal choice provides more of the vitamins A, D, and K than of vitamin C.
(B) This meal choice provides more of the vitamins A, B12, and D than of vitamin C.
(C) This meal choice provides more of the vitamins A, B1 (thiamine), niacin, and microminerals than of vitamin C.
(D) This meal choice provides foods rich in vitamin C, which are essential in tissue healing.
質問 # 459
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NCLEX-RN（登録看護師の全国評議会免許試験）は、米国の登録看護師（RNS）の知識とスキルを評価するために設計された標準化されたテストです。この試験は、国家評議会の看護委員会（NCSBN）によって管理されており、RNSが米国で看護を実践するライセンスを取得するために必要です。
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