最新版を今すぐ試そう！[2023年10月] 試験準備には欠かさない！NCLEX-RN問題集
有能な受験者がシミュレーション済みのNCLEX-RN試験PDF問題を試そう
NCLEX-RNは、アメリカ合衆国での看護師の資格取得の重要なコンポーネントです。この試験は、候補者の看護実践、クライアントのニーズ、看護プロセスに関する知識と技能を評価します。この試験に合格することは、看護師としてのライセンスの取得に重要なステップであり、資格のある個人のみが看護活動を行うことを保証します。
NCLEX-RN試験は、テストテイカーのパフォーマンスに応じて、75〜265の質問で構成されています。質問はコンピューターで生成されており、安全で効果的なケア環境、健康増進と維持、心理社会的完全性、生理学的完全性の4つの分野でテストテイカーの知識をテストするように設計されています。この試験は、テストテイカーの批判的思考と問題解決能力、および健全な看護判断を下す能力をテストするように設計されています。
質問 # 497
An 80-year-old widow is living with her son and daughter-in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?
- A. A person with adequate communication and coping skills who is employed by the family
- B. A family member who is having marital problems and is regularly abusing alcohol
- C. A friend of the family who wants to help but is minimally competent
- D. A lifelong friend of the client who is often confused
正解：B
解説：
Section: Questions Set D
Explanation:
(A) This answer is correct. Two risk factors are identified in this answer. (B) This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. (C) This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. (D) This answer is incorrect. This individual has a vested interest in providing care.
質問 # 498
MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity:
- A. Magnesium oxide
- B. Calcium gluconate
- C. Calcium hydroxide
- D. Naloxone (Narcan)
正解：B
解説：
Explanation
(A, B) These drugs are not antidotes for MgSO4. (C) This drug is the standard antidote and should always be readily available when MgSO4is being administered. (D) This drug is an antidote for narcotics, not MgSO4.
質問 # 499
An 18-month-old child has been playing in the garage. His mother brings him to a nurse's home complaining of his mouth being sore. His lips and mouth are soapy and white, with small ulcerated areas beginning to form.
The child begins to vomit. His pulse is rapid and weak. The nurse suspects that the child has:
- A. Inhaled gasoline fumes
- B. Lead poisoning
- C. Eaten construction chalk
- D. Ingested a caustic alkali
正解：D
解説：
Section: Questions Set G
Explanation:
(A, C, D) These agents would not cause ulcerations on mouth and lips. (B) Strong alkali or acids will cause burns and ulcerations on the mucous membranes.
質問 # 500
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 have to remain as still as you possibly can."
- B. "Do not eat any food or drink any liquids before the test is started."
- C. "You need to know that an IV is always started before the test."
- D. "You will need to drink 6 to 8 glasses of water to fill your bladder."
正解：A
解説：
Explanation/Reference:
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 # 501
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 client should be discouraged from participating in self-care activities to avoid the risk of disrupting the traction
- D. The nurse may lift only the weights that are applying traction in order to reposition him in bed
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 # 502
A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?
- A. "I will not drive but ride in the front seat of the car with a seat belt on for my first doctor's appointment."
- B. "When I bathe tomorrow morning, I will be very careful not to get soap on my incision."
- C. "I am allowed to exercise by walking for short periods."
- D. "Teach my husband about the diet. He'll be doing all the cooking now."
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt. (B) Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. (C) Activity instructions include: avoid sitting for long periods and get exercise by walking. Lifting more than 5 lb of weight is also prohibited. (D) The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization.A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations.
質問 # 503
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
- A. September 14th
- B. December 26th
- C. December 9th
- D. November 23rd
正解：D
解説：
Explanation
(A) Naele's rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. (B) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule. (C) Naele's rule presumes that the woman has a
28-day menstrual cycle, with conception occurringon the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule. (D) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14thday of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule.
質問 # 504
The most frequent cause of early postpartum hemorrhage is:
- A. Coagulation disorders
- B. Uterine atony
- C. Hematoma
- D. Retained placental fragments
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Hematomas, which are the result of damage to a vessel wall without laceration of the tissue, are a cause, though not the most frequent cause. (B) Coagulation disorders are among the causes of postpartal hemorrhage, but they are less common. (C) The most frequent causes of hemorrhage in the postpartal period are related to an interference with involution of the uterus. Uterine atony is the most frequent cause, occurring in the first 24 hours after delivery. (D) Retained placental fragments are also a cause, although these bleeds usually occur 7-14 days after delivery.
質問 # 505
A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:
- A. Enlargement of the uterus
- B. Chadwick's sign
- C. FHR by ultrasound
- D. Breast tenderness and enlargement
正解：C
解説：
Section: Questions Set F
Explanation:
(A) Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. (B) FHR (movement) observed on ultrasound is a positive diagnosis of pregnancy. (C) Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. (D) Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.
質問 # 506
A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:
- A. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day.
- B. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving.
- C. Do frequent room checks to be sure that the client is not hiding food or throwing it away.
- D. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat.
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self- starvation. (B) Distraction does not focus on the client's need for control. (C) Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. (D) Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.
質問 # 507
Cystic fibrosis is transmitted as an autosomal recessive trait. This means that:
- A. Both parents must be carriers for a child to have the disease
- B. Fathers carry the gene and pass it to their daughters
- C. Both parents must have the disease for a child to have the disease
- D. Mothers carry the gene and pass it to their sons
正解：A
解説：
Section: Questions Set G
Explanation:
(A) Cystic fibrosis is not an X-linked or sex-linked disease. (B) The only characteristic on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child.
質問 # 508
A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?
- A. Check neurological and circulatory status of the affected leg hourly.
- B. Encourage exercises in the unaffected extremities.
- C. Place a trochanter roll along the upper thigh of the affected leg.
- D. Encourage her to cross and uncross her legs.
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Exercising the unaffected extremities will prevent contractures and emboli. (B) Crossing and uncrossing the affected leg after surgery can dislocate the joint. (C) Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. (D) A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.
質問 # 509
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. Give an oral dose of lithium antidote.
- B. Recognize this as an expected response to lithium.
- C. Administer a stat dose of lithium as necessary.
- D. Request an order for a stat blood lithium level.
正解：D
解説：
Explanation/Reference:
Explanation:
(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 # 510
Home-care instructions for the child following a cardiac catheterization should include:
- A. Notify the physician if a slight bruise develops around the insertion site.
- B. Give aspirin if the child complains of pain at the insertion site.
- C. Use sponge bathing until stitches are removed.
- D. Keep a clean, dry dressing on the insertion site for 2 days.
正解：C
解説：
(A) A small bruise may develop around the insertion site and is not a reason for alarm. (B) It is best to keep the child out of the bathtub until the sutures are removed. (C) Acetaminophen, not aspirin, is the drug of choice if there is pain at the insertion site. (D) The insertion site should be kept clean and dry and open to air.
質問 # 511
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：
Explanation
(A, C, D) These foods are allowed with a colostomy. (B) Gasforming foods such as cabbage should be avoided.
質問 # 512
Other drugs may be ordered to manage a client's ulcerative colitis. Which of the following medications, if ordered, would the nurse question?
- A. Psyllium
- B. 6-Mercaptopurine
- C. Loperamide (Imodium)
- D. Methylprednisolone sodium succinate (Solu-Medrol)
正解：B
解説：
Explanation
(A) Methylprednisolone sodium succinate is used for its anti-inflammatory effects. (B) Loperamide would be used to control diarrhea. (C) Psyllium may improve consistency of stools by providing bulk. (D) An immunosuppressant such as 6-mercaptopurine is used for chronic unrelenting Crohn's disease.
質問 # 513
An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
- A. Boardlike, rigid abdomen
- B. Liquid stool
- C. Loss of the urge to defecate
- D. Abdominal pain
正解：B
解説：
Explanation
(A) A boardlike, rigid abdomen would point to a perforated bowel, not a fecal impaction. (B) When a client is fecally impacted, a common symptom is the urge to defecate but the inability to do so. (C) When an impaction is present, only liquid stool will be able to pass around the impacted site. (D) Abdominal pain without distention is not a sign of a fecal impaction.
質問 # 514
In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because:
- A. A decreased serum albumin level indicates kidney disease.
- B. The iron stores needed for tissue repair are inadequate.
- C. The proteins needed for tissue repair are diminished.
- D. A decreased serum albumin causes fluid movement into the blood vessels, causing dehydration.
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Serum albumin levels indicate the adequacy of protein stores available for tissue repair. (B) Serum albumin does not measure iron stores. (C) Serum albumin levels do not measure kidney function. (D) A decreased serum albumin level would cause fluid movement out of blood vessels, not into them.
質問 # 515
A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16-20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis B.
After a brief hospital stay, she is discharged to her parent's home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client's family. The nurse explains necessary precautions, which include:
- A. Laundering clothes separately in cold water with a chloride solution
- B. Isolation of the client from the remainder of the family
- C. No necessary precautions because she is beyond the contagious phase
- D. Separate bathroom facilities if possible; if not, then cleansing daily of the facilities with a chloride solution
正解：D
解説：
Explanation
(A) Isolation is not necessary, even in the acute phase. (B) Separate bathroom facilities are recommended. If unavailable, daily cleansing with a chloride solution is recommended. (C) Precautions continue to be necessary while the client is in the active phase of hepatitis. (D) Clothes are to be laundered separately in hot water with a chloride solution.
質問 # 516
A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
- A. Inspect the site for color, warmth, and sensation
- B. Assess the site for bruising or hematoma
- C. Auscultate the site for a bruit
- D. Assess the site for leakage of blood or fluids
正解：C
質問 # 517
The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:
- A. Causes competition at iron-receptor sites between iron and vitamin B1
- B. Will cause more premenstrual cramping
- C. Will bind calcium and therefore interfere with its metabolism
- D. Interferes with iron absorption because the iron precipitates as an insoluble substance
正解：D
解説：
(A) Eating chalk is not related to calcium and its absorption. (B) Poor nutritional habits may result in increased discomfort during premenstrual days, but this is not a primary reason for the client to stop eating chalk. Premenstrual discomfort has not been mentioned. (C) Iron is rendered insoluble and is excreted through the gastrointestinal tract. (D) There is no competition between the two nutrients.
質問 # 518
A client is pleased about being pregnant, yet states, "It is really not the best time, but I guess it will be OK." The nurse's assessment of this response is:
- A. This response is abnormal, to be re-evaluated at the next visit.
- B. This response is normal in the first trimester.
- C. Client may have a poor relationship with her husband.
- D. Initial maternal-infant bonding may be poor.
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of "not now" in the first trimester. The statement still leaves room for exploration. (B) There are no data to support this. This statement by the mother still leaves room for exploration. (C) Ambivalenceis normal during the first trimester. Reva Rubin addresses the issue of "not now." This fact should be shared with the mother during further exploration of the comment. (D) It is not abnormal. If it were, another month would also be too long to wait.
質問 # 519
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. Have the registered nurse in charge assume responsibility for verifying the client and blood product information
- D. Hang Ringer's lactate as the companion fluid
正解：A
解説：
Section: Questions Set D
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 # 520
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NCLEX-RN試験に合格することは、米国とカナダでの許可を受けた看護師としての資格取得のための要件です。この試験は、看護師が患者に対して高品質なケアを提供できる有能で安全な実践者であることを確認するために設計されています。試験は挑戦的なものであるかもしれませんが、復習コース、学習ガイド、模擬試験など、多くの資源が準備されています。献身と努力により、個人はNCLEX-RN試験に合格し、看護師としてのキャリアを始めることができます。
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合格するに必要な問題集はNCLEX-RN試験：https://drive.google.com/open?id=1kS-NHba1pduV4ZF7p9DqPQ2Fwg-ctVQJ