更新された2023年12月テストエンジン練習NCLEX-RN問題集と練習試験合格させます [Q422-Q446]

更新された2023年12月テストエンジン練習NCLEX-RN問題集と練習試験合格させます

問題集お試しセットNCLEX-RNテストエンジンで問題集トレーニングには865問あります

NCLEX-RN（National Council Licensure Examination for Registered Nurses）は、米国における看護師として実務を行うために必要な知識や技術を有するかどうかを判断するために設計された標準化された試験です。この試験は、National Council of State Boards of Nursing（NCSBN）によって実施され、州の看護委員会が免許の資格を判断するのに使用されます。

質問 # 422
A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that:

A. Bed rest with bathroom privileges will be ordered
B. Some oozing of blood at the arterial puncture site is normal
C. He will be kept NPO for 8-12 hours
D. The leg used for arterial puncture should be keptstraight for 8-12 hours

正解：D

解説：
Explanation
(A) Bed rest will be ordered for 8-12 hours postprocedure. Flexing of the leg at the arterial puncture site will occur if the client gets out of bed, and this is contraindicated after arteriography. (B) The client will be able to eat as soon as he is alert enough to swallow safely and that will depend on what medications areused for sedation during the procedure. (C) Oozing at the arterial puncture site is not normal and should be closely evaluated. (D) The leg where the arterial puncture occurred must be kept straight for 8-12 hours to minimize the risk of bleeding.

質問 # 423
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. Alba
B. Rosa
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 # 424
A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:

A. Fistula formation
B. Hypercalcemia
C. Respiratory obstruction
D. Myxedema

正解：C

解説：
Explanation/Reference:
Explanation:
(A) Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or tracheal compression from hemorrhage is a major complication after a thyroidectomy. (B) Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a major complication, not hypercalcemia. (C) Fistula formation is not a major complication associated with a thyroidectomy. It is a major complication with a laryngectomy.(D) Myxedema is hypothyroidism that occurs in adults and is not a complication of a thyroidectomy. A thyroidectomy client tends to develop thyroid storm, which is excess production of thyroid hormone.

質問 # 425
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction.
One comfort measure the nurse can employ is to:

A. Apply strong sacral pressure during the contraction
B. Place her in knee-chest position during the contraction
C. Have her push with each contraction
D. Use effleurage during the contraction

正解：A

解説：
Section: Questions Set F
Explanation:
(A) This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. (B) Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. (C) Sacral pressure will counteract the pressure created by the position of the fetal head. (D) The client is not completely dilated. Pushing is contraindicated until the second stage of labor.

質問 # 426
In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle?

A. Ischemic phase
B. Secretory phase
C. Menstrual phase
D. Proliferative phase

正解：B

解説：
Section: Questions Set B
Explanation
Explanation:
(A) Menses occurs during the menstrual phase, during which levels of both estrogen and progesterone are decreased. (B) The ovarian hormone responsible for the proliferative phase, during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone responsible for the secretory phase is progesterone, which is secreted by the corpus luteum and causes marked swelling in the uterine endometrium.
(D) The corpus luteum begins to degenerate in the ischemic phase, causing a fall in both estrogen and progesterone.

質問 # 427
In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal that should be reported immediately?

A. Visual changes
B. Leaking of clear yellow fluid from breasts
C. Backache
D. Constipation with hemorrhoids

正解：A

解説：
(A) Backache is a common complaint during pregnancy. Proper body mechanics, pelvic rock, back rubs, and other comfort measures should relieve the discomfort. In the presence of uterine contractions, the backache would radiate to the lower abdomen. (B) Colostrum is normal and can be present anytime in the second half of pregnancy. (C) Constipation and hemorrhoids are common and do need attention, but they do not constitute a dangerous situation. (D) Visual changes are possibly related to PIH. The client should be assessed immediately to rule out or prevent worsening of PIH.

質問 # 428
A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?

A. Puppets
B. Music
C. Riding toys
D. Books with colorful pictures

正解：A

解説：
Explanation/Reference:
Explanation:
(A) Books increase cognition, assist with fine motor skills, and augment language development. (B) Music provides auditory stimulation and large-muscle activity. (C) Riding toys provide large-muscle activity. (D) Puppets allow expression of feelings and fears that otherwise could not be directly communicated.

質問 # 429
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. Nearsightedness
B. Farsightedness
C. Lazy eye
D. Cataracts

正解：A

解説：
Explanation
(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 # 430
At 32 weeks' gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, "How do I prepare for the test I am scheduled for?" The RN will most likely inform her of the following instructions to help prepare her for the test:

A. "You will need to drink 6 to 8 glasses of water to fill your bladder."
B. "Do not eat any food or drink any liquids before the test is started."
C. "You will have to remain as still as you possibly can."
D. "You need to know that an IV is always started before the test."

正解：C

解説：
Section: Questions Set C
Explanation:
(A) An IV line is not started in a nonstress test, because this test is used as an indicator of fetal well-being. This test measures fetal activity and heart rate acceleration. (B) The bladder does not have to be full prior to this test. It is not a sonogram test where a full bladder enables other structures to be scanned. (C) It has been proved that eating or drinking liquids prior to the test can assist in increasing fetal activity. (D) Any maternal activity will interfere with the results of the test.

質問 # 431
Goal setting for a client with Meniere's disease should include which of the following?

A. Prevention of infection
B. Prevention of a fall injury
C. Frequent ambulation
D. Consumption of three meals per day

正解：B

解説：
(A) Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. (B) Vertigo resulting in balance problems is one of
the most common manifestations of Meniere's disease. (C) Adequate nutrition is important, but the emphasis in Meniere's disease is not the number of meals per day but a decrease in intake of sodium. (D) Infection is not an anticipated problem.

質問 # 432
Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:

A. Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirations
B. Obtain pulse and blood pressure readings noting rate and quality of pulse
C. Review physician's orders, administering medications as ordered
D. Reassure the client that his surgery is over and that he is in the recovery room

正解：A

解説：
Explanation/Reference:
Explanation:
(A) Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airway is the nurse's priority action. (B) Obtaining the vital signs is an important action, but it is secondary to airway management. (C) Reorienting a client to time, place, and person after surgery is important, but it is secondary to airway and vital signs. (D) Airway management takes precedence over physician's orders unless they specifically relate to airway management.

質問 # 433
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia.
She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?

A. Displacement
B. Intellectualization
C. Rationalization
D. Dissociation

正解：B

解説：
Explanation
(A) Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. (B) Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using.
(C) Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. (D) Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object.

質問 # 434
A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:

A. "Visitors are not allowed. We will telephone you to inform you of her progress."
B. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment."
C. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment."
D. "There's really no need to stay with her. She's going to sleep for several hours after the treatment."

正解：B

解説：
Section: Questions Set F
Explanation:
(A) It is within the nurse's realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members. (C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off. (D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.

質問 # 435
An 11-month-old infant is admitted with a possible diagnosis of pyloric stenosis. Which of the following best describes the characteristic clinical manifestations of pyloric stenosis?

A. Pain, especially when eating
B. Poor appetite and sucking reflex
C. Increased frequency and quantity of stools
D. Palpable olive-shaped mass in the epigastrium just right of the umbilical cord

正解：D

解説：
Explanation
(A) There is no evidence of pain in infants with pyloric stenosis whether eating or not. (B) There are both good appetite and feeding habits in these children. (C) Because of regurgitation, there is usually decreased frequency and quantity of stools and also signs of dehydration and weight loss. (D) Along with upper abdominal distention, there is a characteristic palpable olive-shaped mass located to the right of the umbilicus.

質問 # 436
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. Her cervix shows she will likely deliver soon
B. She may be in preterm labor because this is more common with multiple pregnancies
C. The nurse should not be alarmed because mild uterine activity is common at 32 weeks' gestation
D. She most likely has a urinary tract infection (UTI) because this is common with pregnancy

正解：B

解説：
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 # 437
A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:

A. Promote fetal lung maturation
B. Increase uteroplacental circulation
C. Treat fetal respiratory distress syndrome
D. Prevent uterine infection

正解：A

解説：
(A) Respiratory distress syndrome occurs in the newborn, not the fetus. It may be treated postnatally with surfactant therapy. (B) Betamethasone is a corticosteroid, not an anti-infective drug; therefore, its use would not prevent uterine infection. (C) Betamethasone binds with glucocorticoid receptors in alveolar cells to increase production of surfactant, thus increasing lung maturity in the preterm fetus. (D) Betamethasone does not affect uteroplacental circulatory exchange.

質問 # 438
A 35-year-old client is admitted to the hospital for elective tubal ligation. While the nurse is doing preoperative teaching, the client says, "The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?" The best explanation for the nurse to give the client would be that balanced anesthesia:

A. Is a combination of several anesthetic agents or drugs producing a smooth induction and minimal complications
B. Is a type of regional anesthesia
C. Uses equal amounts of inhalation agents and liquid agents
D. Does not depress the central nervous system

正解：A

解説：
Explanation
(A) Regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. (B) Varying amounts of anesthetic agents are used when employing balanced anesthesia. Amounts depend on age, weight, condition of the client, and surgical procedure. (C) General anesthesia is a drug-induced depression of the central nervous system that produces loss of consciousness and decreased muscle activity. (D) Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications.

質問 # 439
Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?

A. She should be able to resume sexual activity.
B. She should be able to manage her own care.
C. She should be able to return to a regular diet.
D. She should be able to control evacuation of her bowels.

正解：D

解説：
Section: Questions Set E
Explanation:
(A) Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels.
The ileostomy will drain liquid stool continuously. (B) The client should be able to return to a normal, well- balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. (C) The client should be able to resume sexual activity. She will be able to wear a pouch. (D) The client has no other health or mental problems and should be able to manage her own ileostomy.

質問 # 440
A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:

A. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through the nose.
Repeat 4-5 times to complete the series
B. Purse the lips and take quick, short breaths approximately 18-20 times/min
C. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more times to complete the series every
1-2 hours while awake
D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20-24 times/min

正解：C

解説：
Explanation
(A) This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. (B) Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. (C) Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. (D) Inhaling and exhaling at a rate of 20-24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.

質問 # 441
In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal that should be reported immediately?

A. Visual changes
B. Leaking of clear yellow fluid from breasts
C. Backache
D. Constipation with hemorrhoids

正解：A

解説：
Explanation/Reference:
Explanation:
(A) Backache is a common complaint during pregnancy. Proper body mechanics, pelvic rock, back rubs, and other comfort measures should relieve the discomfort. In the presence of uterine contractions, the backache would radiate to the lower abdomen. (B) Colostrum is normal and can be present anytime in the second half of pregnancy. (C) Constipation and hemorrhoids are common and do need attention, but they do not constitute a dangerous situation. (D) Visual changes are possibly related to PIH. The client should be assessed immediately to rule out or prevent worsening of PIH.

質問 # 442
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. Avoiding discussion of his annoying behavior
B. Encouraging him to engage in recreational activities
C. Contracting with him for the amount of time he will spend on the compulsive behaviors
D. Encouraging the client to set a time schedule and deadlines for himself

正解：C

解説：
(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 # 443
The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?

A. "Do you drink alcohol on a regular basis?"
B. "Do you take aspirin on a regular basis?"
C. "Do you eat red meat?"
D. "Have your stools been normal?"

正解：A

解説：
Explanation/Reference:
Explanation:
(A) Aspirin does not affect folic acid absorption. (B) Folic acid deficiency is strongly associated with alcohol abuse. (C) Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. (D) Folic acid does not affect stool character.

質問 # 444
A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following?

A. "Provide supplements for the child between breastfeeding so you will have enough milk."
B. "Nurse the child more frequently during this growth spurt."
C. "Wait 4 hours between feedings so that your breasts will fill up."
D. "Start the child on solid food."

正解：B

解説：
Section: Questions Set B
Explanation:
(A) Solid foods introduced before 4-6 months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. (B) Production of milk is supply and demand. A common growth spurt occurs at
3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. (C) Supplementation will decrease the infant's appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. (D) Rigid feeding schedules lead to a decreased milk supply, whereas frequent nursing signals the mother's body to produce a correspondingly increased amount of milk.

質問 # 445
The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?