2024年最新のNCLEX-RN試験資料NCLEX-RN学習ガイド
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質問 # 31
Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial-and full-thickness burns to 25% of her body?
- A. Edema
- B. Urine output
- C. Bulging fontanelle
- D. Hypertension
正解：B
解説：
Section: Questions Set B
Explanation:
(A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age.
質問 # 32
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
- A. Temperature rise to 102_F rectally
- B. Blood pressure increase from 100/80 to 115/85 after lunch
- C. Headache that is unresponsive to acetaminophen (Tylenol)
- D. Pulse rate ranges between 68 bpm and 76 bpm
正解：A
解説：
Explanation/Reference:
Explanation:
(A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. (B) Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. (C) Pulse rates between
68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. (D) An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.
質問 # 33
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
- A. 30 weeks
- B. 10 weeks
- C. 20 weeks
- D. 16 weeks
正解：C
解説：
Explanation/Reference:
Explanation:
(A) At 10 weeks, the fundus is located slightly above the symphysis pubis. (B) At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. (C) At 20 weeks, the fundus is located approximately at the umbilicus. (D) At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
質問 # 34
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. The symptoms could easily have been caused by constipation, which an enema would relieve
- B. Heat would help to relax the abdominal muscles and relieve her pain
- C. Complaints of stomach ache are common in young children and are generally best ignored
- D. Both heat and enemas stimulate intestinal motility and could increase the risk of perforation
正解：D
解説：
(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 # 35
A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?
- A. Wearing knee-high stockings
- B. Sitting with legs crossed at ankles
- C. Wearing support pantyhose
- D. Wearing thromboembolic disease (TED) stockings
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Sitting with the legs crossed at the ankles does not interfere with circulation or create pressure points.
(B) TED stockings will help to reduce the varicosity by supporting the vein. Stockings must be applied with legs elevated. (C) Support pantyhose help to reduce the varicosity by supporting the vein. They also provide support to the uterus and allow for better return circulation. Hose must be applied like TED stockings. (D) Knee-high stockings create constriction and pressure points that interfere with circulation in the lower extremities.
質問 # 36
A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing:
- A. Pneumonia
- B. Pulmonary emboli
- C. Pulmonary edema
- D. An extension of his myocardial infarction
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Extensions of his myocardial infarction would be chest pain unrelieved with nitroglycerin, cardiac enzyme elevations, and electrocardiographic changes. (B) Persons with pneumonia may complain of weakness and shortness of breath and have crackles in their lung bases. However, they would also have sputum production and leukocytosis. (C) Persons who have had myocardial infarctions (especially anterior wall) are at risk of developing left ventricular heart failure, which is a major cause of pulmonary edema.
Pulmonary edema is manifest by shortness of breath, weakness, and crackles on auscultation of the lung fields. (D) Pulmonary emboli may be accompanied by shortness of breath, weakness, and crackles.
However, the pulmonary hypertension that accompanies pulmonary emboli results in signs of increased systemic venous pressure as well.
質問 # 37
Discharge teaching for the client who has a total gastrectomy should include which of the following?
- A. Need for the client to increase fluid intake to 3000 mL/day
- B. Follow-up visits every 3 weeks for the first 6 months
- C. Need to eat three full meals with plenty of fiber per day
- D. B12 injections needed for the rest of the client's life
正解：D
解説：
(A) There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. (B) Followup visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. (C) With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. (D) Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.
質問 # 38
Prior to an amniocentesis, a fetal ultrasound is done in order to:
- A. Locate the position of the placenta and fetus
- B. Evaluate the amount of amniotic fluid
- C. Ensure that the fetus is mature enough to perform the amniocentesis
- D. Evaluate fetal lung maturity
正解：A
解説：
(A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for gestational dating, although it does not separately determine lung maturity. (B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine congenital anomalies. (C) Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of pregnancy.
質問 # 39
A 24-year-old graduate student recognizes that he has a phobia. He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?
- A. He states that he no longer fears dark places.
- B. He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom.
- C. He enters a concert, but as the lights dim, he does not experience anxiety.
- D. He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens.
正解：D
解説：
Explanation/Reference:
Explanation:
(A) This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. (B) The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. (C) The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy prematurely. (D) Does he experience anxiety in the darkroom? He may have taken this job to force himself to deal with the phobia directly.
質問 # 40
A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:
- A. Bring the child to the ER immediately.
- B. Give the child 1 cup of water to induce vomiting.
- C. Give the child 10 mL of syrup of ipecac with a sip of water.
- D. Give the child 15 mL of syrup of ipecac.
正解：A
解説：
Explanation
(A) Before giving any emetic, the substance ingested must be known. (B) At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. (C) Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. (D) Vomiting should never be induced in an unconscious client because of the risk of aspiration.
質問 # 41
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
- A. Prevent fluid from entering the pleural space
- B. Provide a means to measure chest drainage
- C. Prevent air from entering the pleural space
- D. Provide an indicator of respiratory effort
正解：C
解説：
(A) A chest tube extends from the pleural space to a collection device. The tube is placed below the surface of the saline so that air cannot enter the pleural space. (B) Fluid may enter the pleural space as a result of injury or disease. A chest tube may drain fluid from the pleural space, but the water seal is not involved in this. (C) Chest drainage should be measured, but the water seal is not involved in this. (D) Fluctuations in the tube in the water-sealed bottle will give an indication of respiratory effort, but that is not the purpose of the water seal.
質問 # 42
A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, "I just couldn't take it anymore." The nurse's best response to this disclosure would be:
- A. "How long have you been in the hospital."
- B. "You shouldn't do things like that, just tell someone you feel bad."
- C. "I'm sure you probably didn't mean to kill yourself."
- D. "Tell me more about what you couldn't take anymore."
正解：D
解説：
Explanation
(A) Disapproving gives the impression that the nurse has a right to pass judgment on the client's thoughts, actions, or ideas. (B) Giving a broad opening gives the client encouragement to continue with verbalization.
(C) Failing to acknowledge the client's feelings conveys a lack of understanding and empathy. (D) Changing the subject takes the conversation away from the client and is indicative of the nurse's anxiety or insensitivity.
質問 # 43
A client is diagnosed with organic brain disorder. The nursing care should include:
- A. Challenging educational programs
- B. Organized, safe environment
- C. Long, extended family visits
- D. Detailed explanations of procedures
正解：B
解説：
Explanation
(A) A priority nursing goal is attending to the client's safety and well-being. Reorient frequently, remove dangerous objects, and maintain consistent environment. (B) Short, frequent visits are recommended to avoid overstimulation and fatigue. (C) Short, concise, simple explanations are easier to understand. (D) Mental capability and attention span deficits make learning difficult and frustrating.
質問 # 44
When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
- A. Irritability relieved by feeding formula
- B. Polyuria and polydipsia
- C. Hypothermia and azotemia
- D. Anemia and vomiting
正解：B
解説：
Section: Questions Set A
Explanation:
(A) Anemia and vomiting are not cardinal signs of diabetes insipidus. (B) Polyuria and polydipsia are the cardinal signs of diabetes insipidus. (C) Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. (D) Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.
質問 # 45
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. Require no special care after the procedure
- D. Have transient memory loss, confusion, andheadache
正解：D
解説：
Section: Questions Set D
Explanation:
(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 # 46
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
- A. Impaired thinking
- B. Nutritional status
- C. Rest and activity impairment
- D. Possible harm to self
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.
質問 # 47
The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation.
When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:
- A. Rinsing with water
- B. Rinsing with hydrogen peroxide
- C. Rinsing with baking soda
- D. Using a water pik
正解：D
解説：
Explanation/Reference:
Explanation:
(A) This technique provides effective rinsing and gingival stimulation. (B) This technique does not provide gingival stimulation. (C) This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child. (D) This technique provides effective rinsing but not gingival stimulation.
質問 # 48
A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:
- A. Increase uteroplacental circulation
- B. Promote fetal lung maturation
- C. Treat fetal respiratory distress syndrome
- D. Prevent uterine infection
正解：B
解説：
(A) Respiratory distress syndrome occurs in the newborn, not the fetus. It may be treated postnatally with surfactant therapy. (B) Betamethasone is a corticosteroid, not an anti-infective drug; therefore, its use would not prevent uterine infection. (C) Betamethasone binds with glucocorticoid receptors in alveolar cells to increase production of surfactant, thus increasing lung maturity in the preterm fetus. (D) Betamethasone does not affect uteroplacental circulatory exchange.
質問 # 49
When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:
- A. When exercise is increased, there is no change in insulin needs
- B. When exercise is increased, insulin needs are increased
- C. When exercise is decreased, insulin needs are decreased
- D. When exercise is increased, insulin needs are decreased
正解：D
解説：
Explanation/Reference:
Explanation:
(A) If the client's insulin is increased when activity level is increased, hypoglycemia may result. (B) Exercise decreased the blood sugar by promoting uptake of glucose by the muscles. Consequently, less insulin is needed to metabolize ingested carbohydrates. Extra food may be required for extra activity. (C) This statement directly contradicts the correct answer and is inaccurate. (D) When exercise is decreased, the client's insulin dose does not need to be altered unless the blood sugar becomes unstable.
質問 # 50
A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:
- A. Prepare child to enter mainstream education
- B. Facilitate optimal development
- C. Provide respite care for the mother
- D. Provide a demanding and challenging educational program
正解：B
解説：
Explanation
(A) Respite care for the family may be needed, but it is not the primary goal of a preschool program. (B) Facilitation of optimal growth and development is essential for every child. (C) A demanding and challenging educational program may predispose the child to failure. Children with retardation should begin with simple and challenging educational programs. (D) Mental retardation associated with Down syndrome may not permit mainstream education. A preschoolprogram's primary goal is not preparation for mainstream education but continuation of optimal development.
質問 # 51
The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma.
Neomycin decreases serum ammonia levels by:
- A. Decreasing nitrogen-forming bacteria in the intestines
- B. Irritating the bowel and promoting evacuation of stool
- C. Decreasing the uptake of vitamin D, thereby drawing more water into the colon
- D. Acidifying colon contents by causing ammonia retention in the colon
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Neomycin interferes with protein synthesis in the bacterial cell, causing bacterial death. Neomycin reduces the growth of the ammonia-producing bacteria in the intestines and is used for the treatment of hepatic coma. (B) This choice describes the action of lactulose, another drug commonly used to decrease systemic ammonia levels. (C) Neomycin's action doesnotdecrease uptake of vitamin D to reduce serum ammonia levels. (D) Bowel irritation with diarrhea is more likely to occur with administration of lactulose rather than of neomycin. Besides, diarrhea is a side effect of a drug, not the action of the drug.
質問 # 52
An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?
- A. Partial thromboplastin time
- B. Bleeding time
- C. Platelet count
- D. Complete blood count
正解：A
解説：
Explanation
(A) Partial thromboplastic time measures activity of thromboplastin, which depends on the intrinsic clotting factors deficient in children who are hemophiliacs. (B) Platelet counts are normal in hemophilia. (C) Hemophilia does not affect the complete blood count. (D) Bleeding times are normal in hemophiliacs. They measure the time interval for the bleeding from small superficial wounds to cease.
質問 # 53
Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:
- A. Obtain pulse and blood pressure readings noting rate and quality of pulse
- B. Review physician's orders, administering medications as ordered
- C. Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirations
- D. Reassure the client that his surgery is over and that he is in the recovery room
正解：C
解説：
Explanation
(A) Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airway is the nurse's priority action. (B) Obtaining the vital signs is an important action, but it is secondary to airway management. (C) Reorienting a client to time, place, and person after surgery is important, but it is secondary to airway and vital signs. (D) Airway management takes precedence over physician's orders unless they specifically relate to airway management.
質問 # 54
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
- A. She places her infant on her right side after feeding her.
- B. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.
- C. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
- D. She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time.
正解：D
解説：
Explanation
(A) This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. (B) Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. (C) "Bottle propping" is an unsafe practice because it increases the likelihood of aspiration. (D) This practice is one correct way of burping an infant.
質問 # 55
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse experts to find the sputum to be:
- A. Green colored
- B. Pink-tinged and frothy
- C. Rust colored
- D. Bright red with streaks
正解：C
解説：
(A)
Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such asKlebsiellapneumonia. (B) Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum.
(C)
Green-colored sputum is more characteristic ofPseudomonasthan of gram-positive bacterial pneumonia. (D) Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.
質問 # 56
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