JPNTest NCLEX-RNリアル試験問題NCLEX-RN練習問題集
厳密検証されたNCLEX-RN試験問題集と解答で無料提供のNCLEX-RN問題と正解付き
NCLEX-RN試験は、看護の実践、クライアントの必要性、および看護プロセスの候補者の知識を評価する多肢選択問題から構成されています。これらの問題は包括的で、薬理学、解剖学および生理学、看護プロシージャを含む幅広いトピックをカバーする場合があります。試験はコンピュータ適応型であり、問題の難易度は候補者の知識レベルに適応します。
NCLEX-RN（登録看護師のための全国評議会免許試験）は、登録看護師としてのキャリアを追求したい個人にとって重要な試験です。この試験は、安全で効果的な看護実践に必要な知識、スキル、能力をテストするように設計されています。 NCLEX-RN認定試験は、国立看護師委員会（NCSBN）によって提供され、米国とカナダの看護免許の基準として認識されています。
質問 # 272
During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of sodium salicylate?
- A. Dermatitis and blurred vision
- B. Unconsciousness and acetone odor of the breath
- C. Tinnitus and nausea
- D. Chills and an elevation of temperature
正解：C
解説：
(A) These are toxic symptoms of sodium salicylate. (B, C, D) These are not symptoms associated with sodium salicylate.
質問 # 273
A client with a head injury asks why he cannot have something for his headache. The nurse's response is based on the understanding that analgesics could:
- A. Stimulate the central nervous system
- B. Mask symptoms of increasing intracranial pressure
- C. Elevate the blood pressure
- D. Counteract the effects of antibiotics
正解：B
解説：
(A) Analgesic medication does not counteract the effects of antibiotics. (B) Analgesic medication may lower blood pressure elevated due to anxiety. (C) Analgesic medication, especially CNS depressants, is not given if there is danger of increasing ICP, because neurological changes may not be apparent. Also, further depression of the CNS is contraindicated. (D) Analgesics do not stimulate the CNS.
質問 # 274
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. Eating a moderate to high-protein diet
- B. Decreasing her fluids
- C. Increasing her carbohydrate intake
- D. Decreasing her sodium intake
正解：A
解説：
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 # 275
A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience?
- A. Marked elevation in blood pressure, respirations, and pulse
- B. Decreased systolic pressure, cold skin, and anuria
- C. Rapid pulse; narrowed pulse pressure; cool, moist skin
- D. No urinary output, tachycardia, and restlessness
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Early shock does not exhibit the symptom of marked elevation in blood pressure. A narrowing of the pulse pressure is indicative of early shock. (B) Anuria is a clinical finding in late shock. (C) All of these clinical findings are congruent with early shock. (D) Absence of urinary output is a clinical finding in the late phase of shock.
質問 # 276
Priapism may be a sign of:
- A. Altered neurological function
- B. Imminent death
- C. Urinary incontinence
- D. Reproductive dysfunction
正解：A
解説：
Explanation
(A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem.
質問 # 277
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale.
When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
- A. Pulmonary system
- B. Liver
- C. Left ventricle
- D. Superior vena cava
正解：A
解説：
Explanation
(A) The foramen ovale permits a percentage of the blood to shunt from the right atrium to the left atrium. The blood then goes to the left ventricle, permitting systemic fetal circulation with blood containing a higher O2 saturation. (B) As the blood shunts from the right atrium to the left atrium, the pulmonary system is bypassed.
The fetus receives O2 from the maternal circulation, thereby permitting the partial bypass of the pulmonary system. (C) The foramen ovale is locatedin the atrial septum of the heart and does not affect the liver. (D) The superior vena cava returns blood to the heart, bringing blood to the location of the foramen ovale.
質問 # 278
A mother who is breast-feeding her newborn asks the RN, "How can I express milk from my breasts manually?" The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:
- A. Alternately compress and release each nipple
- B. Roll the nipple and gently pull the nipple forward
- C. Slide the thumb and index finger forward from the outer border of the areola toward the end of the nipple
- D. Compress and release each breast at the outer border of the areola
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Manipulation of nipples will cause soreness and trauma. (B) Pulling the nipples will cause discomfort and soreness. (C) Sliding the thumb and index finger forward over the nipple will cause soreness. (D) The best method to express milk from the breast is to position the thumb and index finger at the outer border of the areola and compress. This is the location of the milk sinuses.
質問 # 279
A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?
- A. Sims'
- B. Fowler's
- C. Reverse Trendelenburg
- D. Trendelenburg
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Reverse Trendelenburg position increases pressure on the perineum. This position will not relieve cord pressure. (B) Fowler's position increases perineal pressure. Cord pressure would not be relieved. (C) Trendelenburg position will decrease perineal pressure. Cord compression will be decreased and increase in fetal blood flow occurs. (D) Sims' position does not relieve pressure on cord or perineum.
質問 # 280
A 24-year-old client presents to the emergency department protesting "I am God." The nurse identifies this as a:
- A. Hallucination
- B. Conversion
- C. Illusion
- D. Delusion
正解：D
解説：
Explanation
(A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.
質問 # 281
A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes:
- A. Alternate successive administrations
- B. Bronchodilator followed by the glucocorticoid
- C. According to the client's preference
- D. Glucocorticoid followed by the bronchodilator
正解：B
解説：
Explanation/Reference:
Explanation:
(A) The client would not receive therapeutic effects of the glucocorticoid when it is inhaled through constricted airways. (B) Bronchodilating the airways first allows for the glucocorticoid to be inhaled through open airways and increases the penetration of the steroid for maximum effectiveness of the drug. (C) Inac- Inaccurate use of the inhalers will lead to decreased effectiveness of the treatment. (D) Client teaching regarding the use and effects of inhalers will promote client understanding and compliance.
質問 # 282
The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
- A. A birth defect
- B. Anemia
- C. Nicotine withdrawal
- D. A low birth weight
正解：D
解説：
Section: Questions Set F
Explanation:
(A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn.
質問 # 283
A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?
- A. Books with colorful pictures
- B. Riding toys
- C. Puppets
- D. Music
正解：C
解説：
Explanation
(A) Books increase cognition, assist with fine motor skills, and augment language development. (B) Music provides auditory stimulation and large-muscle activity. (C) Riding toys provide large-muscle activity. (D) Puppets allow expression of feelings and fears that otherwise could not be directly communicated.
質問 # 284
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. Diaphragmatic breathing, larger volume of air
- B. Rounded shape of chest, smaller volume of air
- C. Fewer alveoli, slower respiratory rate
- D. Larger number of alveoli, diaphragmatic breathing
正解：B
解説：
Explanation
(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 # 285
A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:
- A. "Just ignore the behavior and it should disappear by age 8."
- B. "I understand your concern and will assist you with a referral."
- C. "This is appropriate behavior for a preschooler and should not be a concern."
- D. "Try not to worry because you will just upset your child."
正解：C
解説：
Explanation
(A) This is normal for a preschooler, and a referral is not appropriate. (B) Telling a parent not to worry is unhelpful. This response does not address the mother's concern. (C) This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. (D) This behavior is normal development for a preschooler.
質問 # 286
A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?
- A. Thirst, weight loss, and polyuria
- B. Pain in his legs when he walks
- C. Weight gain, edema in his lower extremities, and shortness of breath
- D. Drowsiness and lethargy after his activities
正解：C
解説：
(A) Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure. The client should be cautioned to increase his activities slowly. (B) Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. (C) Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. (D) All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The client's activity level should be evaluated.
質問 # 287
A female client with major depression stated that "life is hopeless and not worth living." The nurse should place highest priority on which of the following questions?
- A. "How has your depression affected your daily livingactivities?"
- B. "Have you thought about hurting yourself?"
- C. "How is your relationship with your husband?"
- D. "How has your appetite been recently?"
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Although eating habits are important to assess, they are less important than suicidal intent. (B) Maintenance of the client's life is the priority; assessment of suicidal intent is imperative. (C) Relationships and support systems are an important part of assessment, but they are less important than suicidal intent.
(D) Daily living activities will give additional information about the level of depression, and are less significant than suicidal intent, although this information may give additional information about the actual plan for a suicidal attempt.
質問 # 288
Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:
- A. The violent behavior subsides, and the client agrees to behave
- B. The physician orders it
- C. A therapeutic alliance has been established, and violent behavior subsides
- D. The nurse deems that removal of restraints is necessary
正解：C
解説：
Section: Questions Set F
Explanation:
(A) The physician may order release of restraints, but prior to that, the client must meet criteria for release. (B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence. (C) If the client only "agrees to behave" after violent behavior subsides, he has developed no insight into cause and effect of violence or his response to stress. (D)Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary.
質問 # 289
The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse's action should be to:
- A. Encourage coughing and deep breathing each hour
- B. Remove the postoperative dressing to check for bleeding
- C. Obtain arterial blood gases
- D. Increase O2 from 2-3 L/min
正解：A
解説：
(A) Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. (B) Arterial blood gases are not indicated because there is no other information indicating impendingdanger. (C) Increasing O2 rate is not indicated without additional information. (D) Removing the dressing is not indicated without additional information.
質問 # 290
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Breath sounds are high pitched
- B. Inspiration is longer than expiration
- C. Inspiration and expiration are equal
- D. Breath sounds are slightly muffled
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Inspiration is normally longer in vesicular areas. (B) Highpitched sounds are normal in bronchial area.
(C) Muffled sounds are considered abnormal. (D) Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
質問 # 291
A 24-year-old woman who is gravida 1 reports, "I can't take iron pills because they make me sick." She continues, "My bowels aren't moving either." In counseling her based on these complaints, the nurse's most appropriate response would be, "It would be beneficial for you to eat . . .
- A. eggs."
- B. green leafy vegetables."
- C. red meat."
- D. prunes."
正解：D
解説：
Explanation
(A) Prunes provide fiber to decrease constipation and are an excellent source of dietary iron, as the prenatal client is not taking her supplemental iron and iron-deficiency anemia is common during pregnancy. (B) Green leafy vegetables provide a source of fiber and iron; however, prunes are a better source of both. (C) Red meat is a good iron source but will not address the constipation problem. (D) Eggs are a good iron source but do not address the constipation problem.
質問 # 292
A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:
- A. Tell the physician her concerns
- B. Report her suspicions to the authorities
- C. Confront the child's mother
- D. Talk to the child's father
正解：B
解説：
Explanation
(A) Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. (B) All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. (C) Talking to the child's father may or may not help the child, and the nurse is not required by law to do so. (D) Confrontation may not be indicated; the nurse is not required by law to confront the child's mother with these suspicions.
質問 # 293
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