完全版は2023年最新のNCLEX-RN試験問題集テストガイドはトレーニング専門問題
試験準備と合格するための最高なカバー率問題集を提供しています これで試験準備せよNCLEX-RN
この試験では、健康増進と維持、心理社会的完全性、生理学的適応、薬理および非経口療法など、看護実践に関連する幅広いトピックをカバーしています。質問は、テストテイカーの批判的思考と臨床的推論スキル、ならびに現実世界の状況で看護の概念と原則を適用する能力をテストするために設計されています。
NCLEX-RN試験は、最大265問の問題から構成され、候補者は最大6時間で受験することができます。この試験はコンピュータ適応型であり、候補者のパフォーマンスに基づいて問題の難易度が変化します。試験は、患者ケア、安全、薬理学、健康促進、疾患予防など、様々なトピックをカバーしています。
質問 # 267
Children often experience visual impairments. Refractive errors affect the child's visual activity. The main refractive error seen in children is myopia. The nurse explains to the child's parents that myopia may also be described as:
- A. Cataracts
- B. Farsightedness
- C. Nearsightedness
- D. Lazy eye
正解：C
解説：
(A) Cataracts are not considered refractive errors. Cataracts canbe described as opacity of the lens. (B)Hyperopiais the term forfarsightedness. One can see objects at a distance more clearlythan close objects. (C)Myopiais the term for nearsightedness.Objects that are close in distance are more clearly seen. (D) Lazyeye refers to strabismus or misalignment of the eyes.
質問 # 268
The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
- A. Quinidine gluconate or sulfate (Quinaglute,Quinidex)
- B. Nitroglycerin IV (Tridil)
- C. Digoxin (Lanoxin)
- D. Lidocaine (Xylocaine)
正解：D
解説：
Explanation
(A) Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos.
(B) Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. (C) Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. (D) Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing.
質問 # 269
A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:
- A. Should put the client in seclusion until he promises to behave appropriately
- B. Should allow other clients to observe the acting out so that they can learn from the experience
- C. Should apply full restraints until the behavior is under control
- D. Must use the least restrictive measure possible to control the behavior
正解：D
解説：
Explanation/Reference:
Explanation:
(A) This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take "time-out" before placing the client in seclusion, givingmedication as necessary, or restraining. (B) This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. (C) This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting- out behaviors.
質問 # 270
A client is 6 weeks pregnant. During her first prenatal visit, she asks, "How much alcohol is safe to drink during pregnancy?" The nurse's response is:
- A. Up to 4 oz weekly
- B. Up to 2 oz daily
- C. Up to 1 oz daily
- D. No alcohol
正解：D
解説：
Explanation
(A, B, C) No amount of alcohol has been determined safe for pregnant women. Alcohol should be avoided owing to the risk of fetal alcohol syndrome. (D) The recommended safe dosage of alcohol consumption during pregnancy is none.
質問 # 271
A client is experiencing muscle weakness and lethargy. His serum K+ is 3.2. What other symptoms might he exhibit?
- A. Dysrhythmias
- B. Numbness of extremities
- C. Tetany
- D. Headache
正解：A
解説：
Section: Questions Set B
Explanation:
(A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency.
質問 # 272
A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:
- A. Notify the physician
- B. Raise the client's head and place her feet in a dependent position
- C. Place the client on 2 liters of O2 via nasal cannula
- D. Administer furosemide (Lasix) 20 mg IV push
正解：B
解説：
(A) Raising the client's head and placing her feet in a dependent position is an independent nursing action that can be taken to decrease venous return and to reduce pulmonary congestion. (B) Notifying the physician is an appropriate action that should be taken after the client is positioned to maximize her respiratory status. (C) Placing the client on O2may be done with a physician's order or according to an institution's standing orders; however, other actions should be taken first. (D) Furosemide 20 mg IV push is an appropriate medication for the client, but it must be ordered by her physician.
質問 # 273
A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:
- A. Hyperoxygenate before and after suctioning
- B. Suction for a maximum of 30 seconds
- C. Maintain clean technique during suctioning
- D. Suction for a maximum of 20 seconds
正解：A
解説：
Explanation
(A) The maximum time for suctioning is 10-15 seconds. (B) Supplemental O2should be administered before and after suctioning to reduce hypoxia. (C) The maximum time for suctioning is 10-15 seconds. (D) Strict sterile technique should be used during suctioning.
質問 # 274
When the nurse is evaluating lab data for a client 18-24 hours after a major thermal burn, the expected physiological changes would include which of the following?
- A. Elevated hematocrit
- B. Elevated serum calcium
- C. Elevated serum sodium
- D. Elevated serum protein
正解：A
解説：
Section: Questions Set A
Explanation:
(A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid.
Hyponatremia may continue for days to several weeks because of sodium loss to edema, sodium shifting into the cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site (third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing to hemoconcentration from hypovolemia. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the client is adequately hydrated.
質問 # 275
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
- A. Urine output is 20 mL/hr
- B. MgSO4 serum levels are > 15 mg/dL
- C. Respirations are > 16 breaths/min
- D. Deep tendon reflexes are absent
正解：C
解説：
Section: Questions Set B
Explanation:
(A) MgSO4 is a central nervous system depressant. Loss of reflexes is often the first sign of developing toxicity.
(B) Urinary output at < 25 mL/hr or 100 mL in 4 hours may result in the accumulation of toxic levels of magnesium. (C) The therapeutic serum range for MgSO4 is 6-8 mg/dL. Higher levels indicate toxicity. (D) Respirations of >16 breaths/min indicate that toxic levels of magnesium have not been reached. Medication administration would be safe.
質問 # 276
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
- A. Self-discipline is required to control caloric intake throughout the pregnancy
- B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
- C. Immediate treatment of mild PIH includes the administration of a variety of medications
- D. The client may not recognize the early symptoms of PIH
正解：D
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 # 277
A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?
- A. "This shot will prevent me from becoming sensitized to Rh-positive blood."
- B. "I understand that if my baby is Rh positive I'll be getting another one of these injections."
- C. "This shot should help to protect me in future pregnancies if this baby is Rh positive, like my husband."
- D. "I'm getting this shot so that my baby won't develop antibodies against my blood, right?"
正解：D
解説：
Explanation/Reference:
Explanation:
(A) RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh- positive antigens. (B) If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. (C) Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. (D) RhoGAM prevents maternal sensitization to Rh-positive blood.
質問 # 278
A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.
- A. Altered bowel elimination
- B. Altered nutrition
- C. Fluid volume deficit
- D. Anxiety
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Fluid volume deficit is the major problem. Symptoms of dehydration are evident. The effects of fluid and electrolyte balance may be life threatening. Rehydration can be accomplished effectively through IV fluids and electrolytes. (B) Vomiting may also signal a nutritional problem. However, the nutritional problem would be secondary to fluid and electrolyte disturbances. The infant may also be placed on NPO status.
(C) With vomiting, a decrease in the size and number of stools is expected. (D) The infant cannot verbalize feelings of anxiety. Anxiety would not be an appropriate diagnosis.
質問 # 279
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：
Explanation
(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 # 280
The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?
- A. Neosporin sulfate
- B. Mafenide acetate
- C. Silver sulfadiazine
- D. Povidone-iodine
正解：B
解説：
Section: Questions Set A
Explanation:
(A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The side effects of mafenide acetate include bone marrow suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone-iodine is decreased renal function.
質問 # 281
The initial treatment for a client with a liquid chemical burn injury is to:
- A. Irrigate the area with neutralizing solutions
- B. Flush the exposed area with large amounts of water
- C. Inject calcium chloride into the burned area
- D. Apply lanolin ointment to the area
正解：B
解説：
(A) In the past, neutralizing solutions were recommended, but presently there is concern that these solutions extend the depth of burn area. (B) The use of large amounts of water to flush the area is recommended for chemical burns. (C) Calcium chloride is not recommended therapy and would likely worsen the problem. (D) Lanolin is of no benefit in the initial treatment of a chemical injury and may actually extend a thermal injury.
質問 # 282
At 38 weeks' gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing?
- A. "I feel dizzy."
- B. "I have a backache."
- C. "I am cold."
- D. "I am nauseous."
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Cold is not a symptom of hyperventilation. This could be due to the temperature of the room. (B) Backache is not a symptom of hyperventilation. This is probably due to the gravid uterus and its effect on the back muscles, or it may be due to the client's position in bed. (C) Dizziness is the first symptom of hyperventilation. It occurs because the body is eliminating too much CO2. (D) Nausea is not a symptom of hyperventilation. It could be a symptom of pain.
質問 # 283
The medication that best penetrates eschar is:
- A. Mafenide acetate (Sulfamylon)
- B. Silver sulfadiazine (Silvadene)
- C. Povidone-iodine (Betadine)
- D. Neomycin sulfate (Neosporin)
正解：A
解説：
(A) Mafenide acetate is bacteriostatic against gram-positive and gram-negative organisms and is the agent that best penetrates eschar. (B) Silver sulfadiazine poorly penetrates eschar. (C) Neomycin sulfate does not penetrate eschar. (D) Povidoneiodine does not penetrate eschar.
質問 # 284
A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?
- A. Have child gargle and do toothbrushing to remove old blood.
- B. Observe for evidence of bleeding.
- C. Give warm clear liquids when fully alert.
- D. Encourage the child to cough up blood if present.
正解：B
解説：
Explanation/Reference:
Explanation:
(A) The nurse should discourage the child from coughing, clearing the throat, or putting objects in his mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert. Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual, may occur. The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright red blood, continuous swallowing, and changes in vital signs.
質問 # 285
A 4 days postpartum client who is gravida 3, para 3, isexamined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client's lochia as:
- A. Rosa
- B. Alba
- C. Rubra
- D. Serosa
正解：D
解説：
Explanation
(A) Lochia rubra is bloody with clots and occurs 1-3 days postpartum. (B) There is no such term as lochia rosa. (C) Lochia serosa is a pink-brown discharge with a serosanguineous consistency that occurs 4-9 days postpartum. (D) Lochia alba is yellow to white in color and occurs approximately 10 days postpartum.
質問 # 286
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