[2023年11月] 合格させるNCLEX-PN試験一発合格、最新のNCLEX-PN JPNTestの提供する試験問題
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質問 # 348
In an obstetrical emergency, which of the following actions should the nurse perform first after the
baby delivers?
- A. Suction the baby's mouth and nose.
- B. Place extra padding under the mother to absorb blood from the delivery.
- C. Wrap the baby in a clean blanket to preserve warmth.
- D. Cut the umbilical cord using sterile scissors.
正解：A
解説：
After the baby delivers, the nurse should clear the mouth and nose of the infant first. Choice 4 is the next step. Choices 1 and 2 might be performed depending on the situation.Safety and Infection Control
質問 # 349
A nurse reviewed the arterial blood gas reading of a 25 year-old male. The nurse should be able to conclude the patient is experiencing which of the following conditions?
Bicarbonate ion-25 mEq/l
PH-7.41
PaCO2-29 mmHg
PaO2-54 mmHg
(FiO2)-.22
- A. respiratory alkalosis
- B. metabolic alkalosis
- C. metabolic acidosis
- D. respiratory acidosis
正解：A
解説：
Respiratory alkalosis-elevated pH, and low carbon dioxide levels, no compensation noted.
質問 # 350
Elderly persons with pernicious anemia should be instructed __________.
- A. that diarrhea can be a transient side effect of B12 injections
- B. that oral B12 is safer and less expensive than parenteral replacement
- C. that they do not need to return for follow-up for at least a month after initiation of treatment
- D. to increase their dietary intake of foods high in B12
正解：A
解説：
Section: Physiological Integrity
Explanation:
Pernicious anemia is a megaloblastic, macrocytic, normochronic anemia caused by a deficiency of the intrinsic factor produced by the stomach.
This results in malabsorption of vitamin B12, which is necessary for DNA synthesis and maturation of RBC.
Education should include side effects of Vitamin B12, which can include pain and burning at the injection site, peripheral vascular thrombosis, and transient diarrhea.
質問 # 351
The mnemonic "PERLA" is useful for the assessment of the eyes.
What does PERLA stand for?
- A. Patient eyes are equally recessed and responsive to light and acuity
- B. Patient eyes are equally responsive to light and acuity
- C. Pupils equally reactive to light and acuity
- D. Pupils equally reactive to light and accommodation
正解：D
解説：
Section: Health Promotion and Maintenance
Explanation:
The mnemonic "PERLA" stands for pupils equally reactive to light and accommodation, not acuity.
Visual acuity is tested with the Snellen Chart among adult patients.
質問 # 352
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. watching TV nightly until midnight
- B. getting a back rub and drinking a glass of warm milk
- C. taking a cool shower and drinking a hot cup of tea
- D. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
正解：B
解説：
Explanation/Reference:
Explanation:
These are appropriate measure to promote sleep. Choices 1, 2, and 3 are all stimulation actions that increase arousal and wakefulness. Basic Care and Comfort
質問 # 353
A nurse is assessing a patient that has undergone a recent CABG. The nurse notices a mole with irregular edges with a bluish color. The nurse should:
- A. Recommend a dermatological consult to the MD.
- B. Note the location of the mole and contact the physician via the telephone.
- C. Note the location of the mole and follow-up with the attending physician viathe medical record and phone call.
- D. Remove the mole with a sharp's debridement technique, following chargenurse approval.
正解：C
解説：
Contacting the attending physician via the medical record is appropriate due to the possibility of melanoma.
質問 # 354
A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction.
Which of the following always requires cross-matching?
- A. packed red blood cells
- B. plasma
- C. granulocytes
- D. platelets
正解：A
解説：
Section: Physiological Integrity
Explanation:
Packed red blood cells contain antigens and antibodies that must be matched between donor and recipient.
Platelets, plasma and granulocytes do not contain red cells; thus, they require no cross-matching.
質問 # 355
A patient has recently been prescribed Albuterol. Which of the following changes are not associated with Albuterol?
- A. Bronchodilation
- B. Sensory changes
- C. Tachycardia
- D. Hypertension
正解：B
解説：
Explanation/Reference:
Explanation:
Tachycardia, hypertension, and bronchodilation can all occur with Albuterol.
質問 # 356
After securing the client's safety from a faulty electric bed, the nurse should take which action?
- A. Notify the physician.
- B. Discuss the matter with the client's significant others.
- C. Prepare an incident report.
- D. Document the incident in the client's record in detail.
正解：C
解説：
After the situation is safe for the client, the nurse should record the occurrence on an incident form according to the agency protocol.Safety and Infection Control
質問 # 357
The PN is selecting a meal from the cart for a pediatric Jewish patient who follows a kosher diet.
Which of these meals would be most appropriate for the patient?
- A. salmon and broccoli
- B. pepperoni pizza slice
- C. cheeseburger and side salad
- D. shrimp tacos and chips
正解：A
解説：
Section: Psychosocial Integrity
質問 # 358
A primary belief of psychiatric mental health nursing is:
- A. some behaviors have no meaning and cannot be understood.
- B. most people have the potential to change and grow.
- C. every person is worthy of dignity and respect.
- D. human needs are individual to each person.
正解：C
解説：
Explanation/Reference:
Explanation:
Every person is worthy of dignity and respect. Every person has the potential to change and grow. All people have basic human needs in common with others. All behavior has meaning and can be understood from the client's perspective. Psychosocial Integrity
質問 # 359
Mr.H. is upset regarding being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:
- A. the right to refuse treatment.
- B. the right to reasonable response to requests.
- C. the right to confidentiality.
- D. the right to examine and question the bill.
正解：C
解説：
Confidentiality is the maintenance of privacy of information. The question does not suggest that confidentiality has been breached. The client is likely to demand the other rights and may exercise them in choosing to leave the hospital early.Coordinated Care
質問 # 360
When giving an intramuscular injection to an infant. Which of the following sites is preferred?
- A. Ventrogluteal region
- B. Vastus lateralis
- C. Deltoid
- D. Dorsogluteal region
正解：B
解説：
Explanation/Reference:
Explanation:
Vastus lateralis is the ideal choice for infants.
質問 # 361
The death of a beloved spouse places the surviving partner in __________ type of crisis.
- A. reactive
- B. nonreactive
- C. situational
- D. maturational
正解：C
解説：
Section: Safe and Effective Care Environment
Explanation:
A situational crisis is an unexpected, unplanned event, such as the death of a spouse.
Reactive is a normal maturational crisis; reactive and nonreactive are not recognized crisis states.
質問 # 362
The most effective nursing strategy to assist a client in recognizing and using personal strength includes:
- A. encouraging the client's self-identification of strengths.
- B. promoting the client's active external thinking.
- C. listening to the client and providing advice as needed.
- D. assisting the client in maintaining an external locus of control.
正解：A
解説：
Explanation/Reference:
Explanation:
Encouraging the client to identify his own strengths is the most effective strategy. Psychosocial Integrity
質問 # 363
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