[2023年12月25日] 完全版には更新されたのはNCLEX Certification（NCLEX-RN）認定サンプル問題
最新のNCLEX NCLEX-RNリアル試験問題集PDF
NCLEX-RN試験は、アメリカ合衆国で看護師になりたい人にとって必要不可欠な、厳格かつ包括的な試験です。試験に合格するには、多大な準備と勉強が必要ですが、看護の充実したキャリアに向けた重要なマイルストーンとなります。
質問 # 510
A dose of theophylline may need to be altered if a client with COPD:
- A. Has a history of arthritis
- B. Is concurrently on cimetidine for ulcers
- C. Is allergic to morphine
- D. Operates machinery
正解：B
解説：
Explanation
(A) The effects of morphine or an allergic response to the drug will not affect theophylline clearance. (B) Xanthines are used cautiously in clients with severe cardiac disease, liver disease, cor pulmonale, hypertension, or hyperthyroidism. Arthritis does not influence the dosage of theophylline. (C) Theophylline does not cause sedation or drowsiness. Conversely, its side effects may be exhibited by central nervous system stimulation. (D) Cimetidine decreases theophylline clearance from the system and increases theophylline levels in the blood, thus increasing the risk of toxicity.
質問 # 511
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
- A. Measure vital signs at least every 4 hours.
- B. Give fluids if the client requests them.
- C. Release restraints every 2 hours for client to exercise.
- D. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
正解：C
解説：
Explanation
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.
質問 # 512
A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?
- A. Antipsychotic medications
- B. Antimania medication
- C. Antianxiety medications
- D. Antidepressant medications
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Antipsychotic medications are also known as major tranquilizers. (B) Antidepressants fall into different categories, such as the tricyclics or the MAO inhibitors. (C) Antianxiety medications are also known as minor tranquilizers. (D) Antimania medications are those such as lithium and lithium carbonate (Lithobid).
質問 # 513
In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis:
- A. Has unpredictable remissions and exacerbations
- B. Becomes progressively debilitating without remission
- C. Is rapidly fatal
- D. Responds quickly to antimicrobial therapy
正解：A
解説：
(A) Multiple sclerosis eventually becomes debilitating, but it is characterized by remission of symptoms. (B) Remissions and exacerbations are unpredictable with multiple sclerosis.
The client experiences progressive dysfunction after each exacerbation episode. (C) Multiple sclerosis is usually slowly progressive. (D) Multiple sclerosis is an autoimmune disease. Antimicrobial therapy has no effect on its course.
質問 # 514
A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child's case manager knows that treatment has been effective when:
- A. The child is removed from the home and placed in foster care
- B. The child's father is arrested for child abuse
- C. The child's parents identify the ways in which he is different from the rest of the family
- D. The child's parents can identify appropriate behaviors for children in his age group
正解：D
解説：
(A) Removing an abused child from the home and placement in a foster home are not the desired outcome of treatment. (B) Children who are perceived as "different" from the rest of the family are more likely to be abused. (C) Although legal action may be taken against abusive parents, it is not an indicator of an effective treatment program. (D) Identification of age-appropriate behaviors is essential to the role of parents, because misunderstanding children's normal developmental needs often contributes to abuse or neglect.
質問 # 515
A couple is planning the conception of their first child.
The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day:
- A. 16+2 days
- B. 22+2 days
- C. 20+2 days
- D. 14+2 days
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days. (B) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 16). (C) Ovulation occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 22).
質問 # 516
A physician's order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL.
What dosage should the nurse administer to the infant?
- A. 1 mEq
- B. Not enough information to calculate
- C. 1.13 mEq
- D. 2 mEq
正解：D
解説：
(A) This answer is a miscalculation. (B) This answer is a miscalculation. (C) 1.33 mEq = 1 mL, then 1.5 mL X=1.99, or 2 mEq. (D) Information is adequate for calculation.
質問 # 517
A client is being admitted to the labor and delivery unit. She has had previous admissions for "false labor." Which clinical manifestation would be most indicative of true labor?
- A. Decreased discomfort with ambulation
- B. Increased bloody show
- C. Uterine contractions
- D. Progressive dilatation and effacement of the cervix
正解：D
解説：
Explanation
(A) Bloody show is considered a sign of imminent labor, which usually begins in 24-48 hours. An increase in bloody show is an indication that the cervix is changing. (B) Contractions of true labor produce progressive cervical effacement and dilatation. (C) Contractions of false labor may mimic those of true labor. However, the contractions of false labor do not produce progressive effacement and dilatation of the cervix. (D) In true labor, the discomfort is not relieved by ambulation; walking may intensify the discomfort.
質問 # 518
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. "Teach my husband about the diet. He'll be doing all the cooking now."
- B. "I will not drive but ride in the front seat of the car with a seat belt on for my first doctor's appointment."
- C. "When I bathe tomorrow morning, I will be very careful not to get soap on my incision."
- D. "I am allowed to exercise by walking for short periods."
正解：D
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 # 519
One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is:
- A. Syndrome of inappropriate antiduretic hormone
- B. Cerebral edema resulting in hydrocephalus
- C. Auditory nerve damage resulting in permanent hearing loss
- D. Peripheral circulatory collapse
正解：D
解説：
Section: Questions Set A
Explanation/Reference:
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 # 520
Clinical manifestations seen in left-sided rather than in right-sided heart failure are:
- A. Dyspnea and jaundice
- B. Elevated central venous pressure and peripheral edema
- C. Hypotension and hepatomegaly
- D. Decreased peripheral perfusion and rales
正解：D
解説：
Explanation/Reference:
Explanation:
(A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. (D) Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales.
質問 # 521
A 48-year-old client presents with a long history of severedepression unrelieved by medication. He is admitted to the hospital for electroconvulsive therapy. Familymembers are very concerned about this therapy and are requesting information about aftereffects of the treatment. The nurse informs the family that he will:
- A. Be alert and oriented immediately after the treatment
- B. Have insomnia for the first few days
- C. Have transient memory loss, confusion, andheadache
- D. Require no special care after the procedure
正解：C
解説：
(A) This answer is correct. The client will be confused and have a memory loss, which is usually temporary, after electroconvulsive shock therapy. (B) This answer is incorrect. The client will experience transient memory loss, look bewildered, and be confused initially. (C) This answer is incorrect. The client will sleep immediately following the treatment. (D) This answer is incorrect. Vital signs are taken at least hourly after treatment. The client is monitored for hypotension, tachycardia, respiratory problems, and possible seizure activity.
質問 # 522
A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that:
- A. This is usually temporary
- B. The nurse will keep him dry, and he should notify the nurse when this happens
- C. This is related to the bladder spasms and will soon stop
- D. He should not be concerned about it because it will resolve quickly
正解：A
解説：
Explanation/Reference:
Explanation:
(A) This problem is temporary, but it may take some time to resolve, especially in an older man. (B) This problem is usually temporary, but it may take some time to resolve. (C) Keeping the client dry will not relieve his anxiety about his incontinence. (D) The bladder spasms are not the cause of the client's incontinence.
質問 # 523
A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?
- A. Papilledema
- B. Strabismus
- C. Hearing test
- D. Gait
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or ambylopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision screening. It is part of neurological assessment.
質問 # 524
A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?
- A. Delirium is an insidious process.
- B. Delirium entails progressive intellectual and behavioral deterioration.
- C. The delirious client is incapable of returning to his previous level of functioning.
- D. The delirious client is capable of returning to his previous level of functioning.
正解：D
解説：
Explanation
(A) This answer is correct. If the cause is removed, the delirious client will recover completely. (B) This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. (C) This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. (D) This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.
質問 # 525
A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, I feel like I have to urinate again!" Which of the following is the most appropriate initial nursing response?
- A. Check the collection bag and tubing to verify that the catheter is draining properly.
- B. Ask her if she has felt this way before.
- C. Instruct her to do Kegel exercises to diminish the urge to void.
- D. Assure her that this is most likely the result of bladder spasms.
正解：A
解説：
(A) Although this may be an appropriate response, the initial response would be to assure the patency of the catheter. (B) The most frequent reason for an urge to void with an indwelling catheter is blocked tubing. This response would be the best initial response. (C) Kegel exercises while a retention catheter is in place would not help to prevent a voiding urge and could irritate the urethral sphincter. (D) Though the nurse would want to ascertain whether the client has felt the same urge to void before, the initial response should be to assure the patency of the catheter.
質問 # 526
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. Interferes with iron absorption because the iron precipitates as an insoluble substance
- B. Will bind calcium and therefore interfere with its metabolism
- C. Will cause more premenstrual cramping
- D. Causes competition at iron-receptor sites between iron and vitamin B1
正解：A
解説：
Explanation/Reference:
Explanation:
(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 # 527
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:
- A. Insist that she remain at the table and eat a balanced diet.
- B. Provide nutritious finger foods several times a day.
- C. Offer to go to the dining room with her and allow her to open the food and inspect what she eats.
- D. Order a high-calorie diet with supplements.
正解：B
解説：
Section: Questions Set D
Explanation:
(A) The client is not able to sit for long periods. Forcing her to remain at the table will increase her anxiety and cause her to become hostile. (B) This action will not ensure that the client eats what is ordered. Dietary orders are not within the nurse's scope of practice. (C) Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating "on the run." (D) These clients are not suspicious of the food or insecure in moving about the unit alone.
質問 # 528
A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her
7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high- risk prenatal clinic. The client's weight increase is most likely due to:
- A. Overeating and subsequent obesity
- B. Fluid retention
- C. Hypertension due to kidney lesions
- D. Obesity prior to conception
正解：B
解説：
Section: Questions Set B
Explanation
Explanation:
(A) Overeating can lead to obesity, but not to edema. (B) There is no indication of obesity prior to pregnancy.
PIH is more prevalent in the underweight than in the obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. (D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.
質問 # 529
Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
- A. Folic acid and niacin
- B. Thiamine and pyroxidine
- C. Vitamin A and biotin
- D. Vitamin C and zinc
正解：B
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 # 530
A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:
- A. Cross client's legs tightly
- B. Leave the room to call the physician
- C. Control the delivery by guiding expulsion of fetus
- D. Push against the perineum to stop delivery
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Controlling the rapid delivery will reduce the risk of fetal injury and perineal lacerations. (B) The nurse should always remain with a client experiencing a precipitous delivery. (C) Pushing against the perineum may cause fetal distress. (D) Crossing of legs may cause fetal distress and does not stop the delivery process.
質問 # 531
A 26-year-old client is in a treatment center for aprazolam (Xanax) abuse and continues to manifest moderate levels of anxiety 3 weeks into the rehabilitation program, often requesting medication for "his nerves." Included in the client's plan of care is to identify alternate methods of coping with stress and anxiety other than use of medication. After intervening with assistance in stress reduction techniques, identifying feelings and past coping, the nurse evaluates the outcome as being met if:
- A. Client is able to verbalize effects of substance abuse on the body
- B. Client has remained substance free during hospitalization and is discharged
- C. Client promises that he will not abuse aprazolam after discharge
- D. Client demonstrates use of exercise or physical activity to handle nervous energy following conflicts of everyday life
正解：D
解説：
(A) This client response does not address stress reduction techniques. Verbal response focuses only on the problem. (B) Exercise or physical activity is a common strategy or coping technique used to reduce stress and anxiety. (C) Verbalizing effects of substance abuse on the body may help with insight and break through denial, but it is not a strategy to reduce anxiety. (D)Remaining substance-free does indicate motivation to change lifestyle of substance abuse or dependence, and it is not a stress reduction strategy in itself.
質問 # 532
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NCLEX-RN試験に合格することは、アメリカ合衆国でライセンスを持つ登録看護師になるための重要なステップです。この試験は、挑戦的に設計されており、候補者は高い知識、技能、競争力を示さなければなりません。しかし、NCLEX-RN試験に合格することは、看護の充実したキャリアにつながる重要なステップであり、成功した候補者は患者を助け、地域社会での違いを作り出す充実したキャリアを楽しむことができます。
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NCLEX-RN練習テスト問題更新されたのは865問があります：https://drive.google.com/open?id=1kS-NHba1pduV4ZF7p9DqPQ2Fwg-ctVQJ