2023年11月実際に出るNCLEX-RN試験問題集には正確で更新された問題
NCLEX-RN試験問題集でPDF問題とテストエンジン
NCLEX-RN試験はコンピュータ適応型であり、問題の難易度は受験者の回答によって決定されます。試験は受験者のスキルレベルに合わせて適応し、受験者が正解すると問題が難しくなり、不正解の場合は簡単になります。この形式により、各受験者は個別の能力に合わせたユニークな試験を受けることができます。
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 # 131
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:
- A. 3-2-0-0-2
- B. 3-1-1-0-2
- C. 2-2-0-2-2
- D. 2-1-1-0-2
正解：B
解説：
Section: Questions Set B
Explanation:
(A) This answer is an incorrect application of the GTPAL method.
One prior pregnancy was a preterm birth at 36 weeks (T = 1, P = 1; not T = 2). (B) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior pregnancy was preterm (T = 1, P = 1; not T = 2), and she has had no prior abortions (A = 0). (C) This answer is the correct application of GTPAL method. The client is currently pregnant for the third time (G = 3), her first pregnancy ended at term (>37 weeks) (T = 1), her second pregnancy ended preterm 20-33 weeks) (P = 1), she has no history of abortion (A = 0), and she has two living children (L = 2). (D) This answer is an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2).
質問 # 132
A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:
- A. Drooling
- B. Loss of ability to speak and communicate effectively
- C. Secondary infection resulting from poor oral hygiene
- D. Aspiration and weight loss
正解：D
解説：
(A) Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. (B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. (C) A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. (D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.
質問 # 133
Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20 years old. It is characterized by an absence of, or marked decrease in, circulating insulin. When teaching a newly diagnosed diabetes client, the nurse includes information on the functions of insulin:
- A. Catabolism and hyperglycemia
- B. Glycogenolysis and catabolism
- C. Glycogenolysis and facilitation of glucose use for energy
- D. Transport of glucose into body cells and storage of glycogen in the liver
正解：D
解説：
Explanation
(A) Lack of insulin causes glycogenolysis, catabolism, and hyperglycemia. (B) Insulin promotes the conversion of glucose to glycogen for storage and regulates the rate at which carbohydrates are used by cells for energy. (C) Insulin is anabolic in nature. (D) Glucose stimulates protein synthesis within the tissue and inhibits the breakdown of protein into amino acids.
質問 # 134
A mother called the physician's office to ask if it would help relieve her small daughter's abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice.
The nurse's response is based on the knowledge that:
- A. Heat would help to relax the abdominal muscles and relieve her pain
- B. Complaints of stomach ache are common in young children and are generally best ignored
- C. The symptoms could easily have been caused by constipation, which an enema would relieve
- D. Both heat and enemas stimulate intestinal motility and could increase the risk of perforation
正解：D
解説：
Section: Questions Set D
Explanation:
(A) Constipation does not cause fever or vomiting but may cause anorexia. Risk of perforation outweighs the possible benefits of an enema. (B) Heat will not relieve her symptoms but will increase intestinal motility and increase the risk of perforation. (C) Heat and enemas are contraindicated where severe abdominal pain is suspected because they increase intestinal motility and the risk of perforation. (D) Complaints accompanied by physical symptoms such as pain, anorexia, and fever should never be ignored.
質問 # 135
The nurse would expect to include which of the following when planning the management of the client with Lyme disease?
- A. Complete bed rest for 6-8 weeks
- B. High-protein diet with limited fluids
- C. IV amphotericin B
- D. Tetracycline treatment
正解：D
解説：
Explanation/Reference:
Explanation:
(A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. (C) IV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high-protein diet with limited fluids.
質問 # 136
The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include:
- A. Rounded shape of chest, smaller volume of air
- B. Diaphragmatic breathing, larger volume of air
- C. Larger number of alveoli, diaphragmatic breathing
- D. Fewer alveoli, slower respiratory rate
正解：A
解説：
(A) Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. (B) Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. (C) The adult has a larger number of alveoli than a child. (D) The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.
質問 # 137
A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?
- A. Measurement of his urine output for the past 8 hours
- B. Evaluation of an electrocardiogram
- C. Serum potassium lab values for the last several days
- D. Evaluation of his level of consciousness
正解：B
解説：
(A) The level of consciousness is not affected by elevated potassium levels. (B) An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. (C) Measurement of the urine output is not a priority nursing action at this time. (D) The client's serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.
質問 # 138
Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?
- A. "I would notify my physician immediately if I experience nausea, vomiting, and double vision."
- B. "I should only take the medication if my heart rate is greater than 100 bpm."
- C. "I should always take this medication with an antacid."
- D. "I could stop taking this medication when I begin to feel better."
正解：A
解説：
Explanation
(A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. (B) The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. "Feeling better" indicates the drug is working and medication therapy must be continued. (C) Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is
>100 bpm the physician should be notified. (D) Antacids decrease the effectiveness of digoxin.
質問 # 139
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
- A. Pain related to stimulation of nerve endings associated with obstruction of the pancreatic tract
- B. Altered nutrition: less than body requirements, related to inadequate intake associated with current anorexia, nausea, vomiting, and digestive enzyme loss
- C. Knowledge deficit related to treatment regimen
- D. Fluid volume deficit related to vomiting and nasogastric tube drainage
正解：A
解説：
Explanation
(A) Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. (B) Fluid volume deficit is being treated with IV fluid replacement. (C) Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. (D) Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
質問 # 140
Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?
- A. Decreased PaO2
- B. Increased PaCO2
- C. Decreased base excess
- D. Increased HCO3
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B) Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation.
Renal disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would increase to compensate for acidosis.
質問 # 141
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. "Blowing air under the cast using a hair dryer on cool setting often relieves itching."
- B. "Guide a towel under and through the cast and moveit back and forth to relieve the itch."
- C. "Slide a ruler under the cast and scratch the area."
- D. "Gently thump on cast to dislodge dried skin that causes the itching."
正解：A
解説：
Explanation/Reference:
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 # 142
A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?
- A. Seizure
- B. Headache
- C. Ataxia
- D. Bulging fontanelles
正解：B
解説：
Section: Questions Set C
Explanation:
(A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) Seizure is a late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure.
質問 # 143
Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
- A. Thiamine and pyroxidine
- B. Folic acid and niacin
- C. Vitamin A and biotin
- D. Vitamin C and zinc
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine.
(B) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (C) Chronic alcoholism can lead to deficiencies of vitamins A, D, K, and B complex. (D) Vitamins A, D, K, and B require bile salts to be absorbed from the gastrointestinal tract. A damaged liver does not form bile salts.
質問 # 144
Parents of young children often need anticipatory guidance from the nurse. Parents may have little knowledge regarding growth and development. Which of the following toys and activities would the nurse suggest as appropriate for a toddler?
- A. Mobiles, rattle, squeeze toys
- B. Simple card games, puzzles, bicycle, television
- C. Pull-toys, large ball, dolls, sand and water play, music
- D. Cutting, pasting, string beads, music, dolls
正解：C
解説：
Section: Questions Set D
Explanation:
(A) These activities are suited for the preschool-age child (3-5 years old). The activities are not safe for a toddler. (B) Infants (0-1 year) like these toys. (C) These activities provide the toddler (1-3 years old) with a variety of physical activities for play. (D) The toddler lacks the physical and cognitive abilities for these activities. The tasks are far better suited for the school-age child.
質問 # 145
A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to:
- A. Administer methergine IM
- B. Remove the retained placental fragments
- C. Massage the fundus until firm
- D. Assist the client to the bathroom and provide cues to stimulate urination
正解：C
解説：
Explanation
(A) Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage.
Methergine may be administered in this clinical situation, but fundal massage would be the first response. (B) Removal of retained placental fragments is done by the physician and is not the first response. (C) If the fundus rises and is deviated, particularly to theright, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. (D) A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
質問 # 146
A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, "My doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms?
- A. Projection
- B. Suppression
- C. Displacement
- D. Reaction formation
正解：A
解説：
Explanation
(A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one's thoughts or feelings to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences.
質問 # 147
A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?
- A. Visceral
- B. Gustatory
- C. Auditory
- D. Olfactory
正解：B
解説：
(A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory perceptions of taste. (C) Olfactory hallucinations involve sensory perceptions of smell. (D) Visceral hallucinations involve sensory perceptions of sensation.
質問 # 148
A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:
- A. Gastritis
- B. Peritonitis
- C. Pulmonary embolism
- D. Evisceration
正解：B
解説：
Explanation
(A) Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. (B) Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. (C) Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. (D) Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.
質問 # 149
One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is:
- A. Auditory nerve damage resulting in permanent hearing loss
- B. Cerebral edema resulting in hydrocephalus
- C. Syndrome of inappropriate antiduretic hormone
- D. Peripheral circulatory collapse
正解：D
解説：
Explanation
(A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death. (B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (C) Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (D) Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome.
質問 # 150
A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse's anger by using a condescending tone of voice with other clients and staff persons. Which of the following statements from the nurse would be most appropriate in acknowledging feelings regarding the client's behavior?
- A. "Why do you treat me that way?"
- B. "Are you trying to get me angry?"
- C. "I feel angry when I hear that tone of voice."
- D. "You make me angry when you talk to me that way."
正解：C
解説：
Explanation
The nurse appropriately states how he or she feels when the client speaks in a condescending manner. (B) This statement indicates that the client has control over the nurse. No one makes another person angry; each individual has a choice. (C) "Why" questions usually put a person on the defensive. In addition, the client cannot "make" the nurse angry. The client does not have that control. (D) Again, a "why" statement places the client on the defensive.
質問 # 151
A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be:
- A. Chloride
- B. Potassium
- C. HCO3
- D. Sodium
正解：B
解説：
Section: Questions Set D
Explanation:
(A) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes is not as important as potassium monitoring. (B) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes is not as important as potassium monitoring. (C) Potassium will need to be closely monitored because of its effects on the heart. Hypokalemia could result in supraventricular tachyarrhythmias. (D) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes is not as important as potassium monitoring.
質問 # 152
Parents of a child with rheumatic fever express concern that she will always be arthritic. The nurse discusses their concerns and tells them the joint pain usually:
- A. Is responsive to ibuprofen (Motrin)
- B. Is relieved by aspirin
- C. Subsides in<3 weeks
- D. Subsides in 3-6 days
正解：C
解説：
Explanation
(A) Joints usually remain inflamed and tender until the disease runs its course in<3 weeks. (B) This response does not answer the question of whether she will always be arthritic. (C) This response does not answer the question asked. (D) The disease takes<3 weeks to run its course.
質問 # 153
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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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