[2022年01月09日]NCLEX-RN試験問題集でリアル試験と100%同じ問題と解答
NCLEX-RNテストエンジン問題集トレーニングには865問あります
質問 206
The nurse instructs a client on the difference between true labor and false labor. The nurse explains, "In true labor:
- A. Uterine contractions will strengthen with walking."
- B. Uterine contractions will weaken with walking."
- C. The fetus does not descend."
- D. The cervix does not dilate."
正解: A
解説:
(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 207
On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:
- A. Take a warm shower and express milk from both breasts until empty
- B. Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes
- C. Apply ice packs to the breasts and wear a supportive, well-fitting bra
- D. Allow the infant to breast-feed at the next feeding time to empty the breasts
正解: C
解説:
Explanation/Reference:
Explanation:
(A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. (B) Breast-feeding every 11⁄2-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottlefeeding mother. (C) Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. (D) Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.
質問 208
Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must emphasize the importance of:
- A. Increasing her carbohydrate intake
- B. Eating a moderate to high-protein diet
- C. Decreasing her fluids
- D. Decreasing her sodium intake
正解: B
解説:
Explanation/Reference:
Explanation:
(A) Women with pregnancy-induced hypertension have a reduced plasma volume secondary to venous vessel constriction, not hypovolemia; therefore, sodium restriction is not recommended. It is suggested that these women avoid extremely salty foods. (B) Drinking six to eight glasses of water per day facilitates optimal fluid volume and renal perfusion, but it will not decrease the venous vessel constriction of pregnancy-induced hypertension. (C) Carbohydrate needs increase during pregnancy, specifically during the second and third trimesters, but they have not been linked to pregnancy-induced hypertension. (D) Loss of urinary protein (proteinuria) is associated with increased permeability of the large protein molecules with pregnancy-induced hypertension.Additional dietary protein also helps increase the plasma colloidal osmotic pressure. Diets deficient in protein have been linked to pregnancy-induced hypertension.
質問 209
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
- A. Wash her hands before and after voiding
- B. Drink at least 8 oz of cranberry juice daily
- C. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps
- D. Maintain a fluid intake of at least 2000 mL daily
正解: C
解説:
Explanation/Reference:
Explanation:
(A) Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission. (D) Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth.
質問 210
A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:
- A. Develops a temperature of 102_F
- B. Has no bowel sounds
- C. Has a urine output of 200 mL for 4 hours
- D. Cries easily and says she is having abdominal pain
正解: A
解説:
(A) The client may be more tearful than normal due to the stress of the surgery and its implications for her future life. She would be expected to have pain following surgery. (B) A temperature of 102_F indicates an infectious process. This is not a normal sequence to surgery and indicates a need for further assessment. (C) The client is expected to have no bowel soundsfor 24-48 hours after surgery because of the trauma to the bowel. (D) Normal urine output is 30 mL/hr. This represents an output of 50 mL/hr, which is greater than normal.
質問 211
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. Potassium
- B. Sodium
- C. Magnesium
- D. HCO3
正解: C
解説:
(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 212
A 24-hours' postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:
- A. Apply an ice pack
- B. Teach her Kegel exercises
- C. Administer the prescribed medication for pain
- D. Assist her with a sitz bath
正解: D
解説:
(A) Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before medication is given. (B) Pain medication can be given when other comfort measures such as a sitz bath and topical applications are ineffective. (C) Kegel exercises facilitate sitting by decreasing tension on the episiotomy. They will not be effective for pain control or sustained comfort level. (D) Ice packs are appropriate to apply in the first 12 hours postdelivery to produce vasoconstriction and to reduce edema to the area.
質問 213
A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?
- A. Information given insufficient to determine the amount of atropine to be administered
- B. 0.38 mL
- C. 2.7 mL
- D. 0.06 mL
正解: B
解説:
Section: Questions Set G
Explanation:
(A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer. (B) The answer is correct.
0.4 mg = 1 mL:0.15 mg 5 = mL
0.4 x = 0.15
x = 0.15/0.4
x = 0.375 or 0.38 mL
(D) Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given.
質問 214
To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:
- A. Keep the client's legs extended and discourage any movement.
- B. Dangle the client's legs over the edge of the bed every shift.
- C. Massage the client's calves briskly every shift.
- D. Have the client tighten and relax leg muscles several times daily.
正解: D
解説:
Explanation/Reference:
Explanation:
(A) Dangling the client's legs over the edge of the bed will contribute to stasis and pooling of blood and increases the risk of thrombus formation. (B) Massaging the client's calves could result in dislodging an embolus. (C) Decreased movement will contribute to pooling of blood and increased risk of venous thrombosis. (D) Tightening and relaxing leg muscles increases circulation and decreases the risk of venous thrombosis.
質問 215
A pregnant woman at 36 weeks' gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of
100 mL of milk?
- A. One small scoop (90 g) vanilla ice cream and 1 tbsp chocolate syrup
- B. One package vitamin-fortified gelatin drink
- C. Thirty grams powdered skim milk and 1 egg
- D. Fifty milliliters light cream and 2 tbsp corn syrup
正解: C
解説:
Explanation
(A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add protein.
Eggs are good sources of protein while low in fat and calories. (C) The benefit of protein from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is contraindicated or limited in pregnancy. (D) Although most animal proteins are higher in protein than plant proteins, gelatin is not. It loses protein during the processing for food consumption.
質問 216
A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:
- A. Pass a nasogastric tube through the left nostril
- B. Perform a halo test and glucose level on the drainage
- C. Gently suction the nasal drainage to protect the airway
- D. Place a 4 X 4 gauze in the nares to impede the flow
正解: B
解説:
(A)
Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses.
(B)
Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy.
質問 217
A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?
- A. A decreased blood sugar level
- B. Fluctuating levels with a predawn increase
- C. An increased blood sugar level
- D. A normal blood sugar level
正解: C
解説:
(A) Blood sugar levels increase when the body responds to stress and illness. (B) Blood sugar levels increase when the body responds to stress and illness. (C) Hyperglycemia occurs because glucose is produced as the body responds to the stress and illness of cellulitis. (D) Blood sugar levels remain elevated as long as the body responds to stress and illness.
質問 218
A client's renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate?
- A. Low calcium and phosphorus, acid ash
- B. Low calcium, high phosphorus
- C. High calcium, low phosphorus
- D. Two-gram sodium diet
正解: A
解説:
Explanation
(A) The stones consist of calcium and phosphorus; therefore, these minerals should be avoided. A high-calcium diet is contraindicated. (B) A high-phosphorus diet is contraindicated. (C) A 2-g sodium diet is a cardiac diet. (D) A low-calcium and phosphorus diet will reduce further calculi formation.
質問 219
A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within:
- A. 10 days
- B. 2-4 weeks
- C. 3 months
- D. 2 months
正解: B
解説:
Explanation
(A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2-4 weeks before improvement of symptoms is noted. (C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of drug therapy.
質問 220
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?
- A. "I've been having a dull pain at the upper left shoulder."
- B. "I don't remember anything in particular, I just haven't felt well."
- C. "I've only been urinating three times a day lately."
- D. "My legs have been numb for three months."
正解: B
解説:
Explanation/Reference:
Explanation:
(A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. (D) Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
質問 221
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. "Slide a ruler under the cast and scratch the area."
- B. "Guide a towel under and through the cast and moveit back and forth to relieve the itch."
- C. "Blowing air under the cast using a hair dryer on cool setting often relieves itching."
- D. "Gently thump on cast to dislodge dried skin that causes the itching."
正解: C
解説:
Explanation
(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 222
A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?
- A. Activity intolerance related to imbalance between oxygen supply and demand
- B. Decreased cardiac output related to ineffective pumping action of the heart
- C. Altered growth and development related to decreased intake of food
- D. Altered nutrition: less than body requirements related to inability to take in adequate calories
正解: B
解説:
Explanation/Reference:
Explanation:
(A) Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. (B) The decreased intake occurs due to fatigue from the altered cardiac output. (C) Fatigue occurs due to the decreased cardiac output. (D) The ineffective action of the myocardium leads to inadequate O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development.
質問 223
The therapeutic blood-level range for lithium is:
- A. 1.0-2.0 mEq/L
- B. 2.0-2.5 mEq/L
- C. 0.25-1.0 mEq/L
- D. 0.5-1.5 mEq/L
正解: D
解説:
Explanation
(A) This range is too low to be therapeutic. (B) This is the therapeutic range for lithium. (C) This range is above the therapeutic level. (D) This range is toxic and may cause severe side effects.
質問 224
A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:
- A. He should be on a high-fiber diet.
- B. He does not need to make any modifications.
- C. He should drink minimal amounts of fluids.
- D. He should eat a low-residue diet.
正解: A
解説:
Explanation
(A) Clients with diverticulosis should maintain a high-fiber diet and prevent constipation with bran or bulk laxatives. (B) Lowresidue diets lead to constipation and are contraindicated in clients with diverticulosis. (C) Clients with diverticulosis should drink at least eight glasses of water each day to prevent constipation. (D) Clients with diverticulosis should modify their diet to include high-fiber foods and bulk laxatives.
質問 225
A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:
- A. Sucking his thumb
- B. Crying
- C. Rolling from his back to his tummy
- D. Falling asleep
正解: B
解説:
Explanation/Reference:
Explanation:
(A) A child with a subdural hematoma has increased ICP. Crying may significantly increase this pressure.
(B) Adequate sleep is essential, but it is important that the child can be aroused from sleep after head injury. (C) This child is free to roll from his back to his abdomen. (D) Thumb-sucking serves to reduce anxiety and should not be prevented at this time.
質問 226
A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?
- A. 1 PM
- B. 9 AM
- C. 3 PM
- D. 11 AM
正解: D
解説:
(A) This time is incorrect because regular insulin would peak after the teenager has eaten breakfast. (B) This time is incorrect because it is after lunch when the NPH peaks. (C) Regular insulin peaks in 2-3 hours and has a duration of 4-6 hours. NPH insulin's onset is 4-6 hours and peaks in 8-16 hours. Blood sugar would peak after meals and be lowest before meals and during the night. (D) This time is incorrect because it is before the NPH and after the regular insulin peak times.
質問 227
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