National Council Licensure Examination(NCLEX-RN)練習テスト2025年最新のNCLEX-RNストレスなしで合格させちゃう！
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NCLEX-RN 試験は、コンピューター化された適応型テスト（CAT）であり、質問は受験者の回答に基づいて選択されます。受験者は適度な難易度の質問から始め、次の質問は前の質問に対する回答によって決定されます。試験はこのように続き、コンピュータプログラムが受験者の能力レベルを決定するまで続きます。試験は、健康促進、心理社会的完全性、生理的適応、薬理学および親血管療法など、幅広い看護トピックをカバーしています。NCLEX-RN 試験は、広範な勉強と準備を必要とする難しい試験です。しかし、試験に合格することは、ライセンスを取得し、看護職の充実したキャリアに進むための重要なステップです。
NCLEX-RN試験は、看護における候補者の知識とスキルの包括的な評価です。健康増進、病気の予防、患者ケア、看護管理など、幅広いトピックをカバーしています。この試験は、複数の選択の質問と、すべての適用、ホットスポット、順序付けられた回答の質問を含む代替形式の質問で構成されています。
NCLEX-RN試験は、ライセンス取得とRNとしての実践を行うために合格する必要のあるハイステークステストです。試験は、すべてのライセンスを持つRNが、安全かつ効果的な医療を提供するために必要な知識とスキルを持っていることを確認するために設計されています。さらに、試験は看護の実践や医療配信の変化を反映するように常に更新され、RNが最新のベストプラクティスにアップデートされることを保証しています。
質問 # 143
A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:
- A. Nipple and bottle
- B. Gavage tube
- C. A straw and cup
- D. Syringe
正解：D
解説：
Section: Questions Set C
Explanation:
(A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3-month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This minimizes the amount of sucking needed.
質問 # 144
In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:
- A. Increased pressure in the pulmonary veins and pulmonary edema
- B. Increased left ventricular systolic pressures and hypertrophy
- C. Decreased pulmonary blood flow and cyanosis
- D. Systemic venous engorgement
正解：B
解説：
Section: Questions Set A
Explanation/Reference:
Explanation:
(A) These signs are seen in pulmonic stenosis or in response to pulmonary congestion and edema and mitral stenosis. (B) These signs are seen primarily in mitral stenosis or as a late sign in aortic stenosis after left ventricular failure. (C) These signs are seen primarily in right-sided heart valve dysfunction. (D) Left ventricular hypertrophy occurs to increase muscle mass and overcome the stenosis; left ventricular pressures increase as left ventricular volume increases owing to insufficient emptying.
質問 # 145
A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?
- A. Explain what will take place and what she will see, feel, and hear.
- B. Remind her that she has had this procedure before and that it is nothing to be afraid of.
- C. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.
- D. Give her a big hug and tell her that she is a big girl now and that she will do just fine.
正解：A
解説：
(A)
Even though the child has had the procedure before, she will probably need additional explanations and emotional support. (B) The fact that the child has had the procedure before and possibly found it painful or uncomfortable may increase, not relieve, her stress.
(C)
This intervention does nothing to reassure the child and may well prevent her from expressing her feelings. (D) This does not prepare the child for the test and burdens her with the expectation that she act bigger and braver than she is.
質問 # 146
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?
- A. "If you forget to take your morning dose, double the night time dose."
- B. "Carry a medications alert card with you at all times."
- C. "You should take aspirin instead of acetaminophen (Tylenol) for headaches."
- D. "You should use a straight-edge razor when shaving your arms and legs."
正解：B
解説：
(A) Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. (B) Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. (C) Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. (D) An electric razor should be used to prevent accidental cutting, which can lead to bleeding.
質問 # 147
An 11-month-old infant is admitted with a possible diagnosis of pyloric stenosis. Which of the following best describes the characteristic clinical manifestations of pyloric stenosis?
- A. Pain, especially when eating
- B. Poor appetite and sucking reflex
- C. Increased frequency and quantity of stools
- D. Palpable olive-shaped mass in the epigastrium just right of the umbilical cord
正解：D
解説：
Explanation/Reference:
Explanation:
(A) There is no evidence of pain in infants with pyloric stenosis whether eating or not. (B) There are both good appetite and feeding habits in these children. (C) Because of regurgitation, there is usually decreased frequency and quantity of stools and also signs of dehydration and weight loss. (D) Along with upper abdominal distention, there is a characteristic palpable olive-shaped mass located to the right of the umbilicus.
質問 # 148
The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?
- A. "This will hurt only a little; try to be a big boy."
- B. "This is a terrible procedure, so don't look."
- C. "This is going to hurt a lot; close your eyes and hold my hand."
- D. "Some say this feels like a pinch or a bug bite. You tell me what it feels like."
正解：D
解説：
Section: Questions Set B
Explanation:
(A) Educating the child about the pain may lessen anxiety. The child should be prepared for a potentially painful procedure but avoid suggesting pain. The nurse should allow the child his own sensory perception and evaluation of the procedure. (B) The nurse should avoid absolute descriptive statements and allow the child his own perception of the procedure. (C) The nurse should avoid evaluative statements or descriptions and give the child control in describing his reactions. (D) False statements regarding a painful procedure will cause a loss of trust between the child and the nurse.
質問 # 149
A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
- A. Intubation of the right mainstem bronchus
- B. An inadequate mechanical ventilator
- C. A right hemothorax
- D. A left hemothorax
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Although a left hemothorax could cause diminished and distant breath sounds, it is irrelevant to this situation. (B) A right hemothorax will not cause diminished and distant breath sounds on the left side of the chest. (C) The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left. (D) An inadequate mechanical ventilator has no relationship to this situation.
質問 # 150
The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?
- A. Never use abdominal site for a rotation site.
- B. Pinch the skin up to form a subcutaneous pocket.
- C. Avoid applying pressure after injection.
- D. Change needles after injection.
正解：B
解説：
Explanation
(A) Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. (B) The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. (C) Massaging the site of injection facilitates absorption of the insulin. (D) Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3-7 days.
質問 # 151
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
- A. Alteration in comfort secondary to alteration in skin integrity
- B. Fluid volume deficit secondary to alteration in skin integrity
- C. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
- D. Alteration in sensation secondary to third-degree burn
正解：C
解説：
(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48-72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
質問 # 152
An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?
- A. Apply Silvadene cream (silver sulfadiazine).
- B. Begin débridement by removing all charred clothing from wound.
- C. Immerse both legs in cool water.
- D. Apply ice packs to both legs.
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound first. This creates further tissue damage.
Débridement is not the first nursing action. (C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection. (D) Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.
質問 # 153
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:
- A. Cheese omelette with ham and mushrooms, milk
- B. Waffles with butter and honey, orange juice
- C. Baked chicken, baked potato with bacon bits, milk
- D. Liver and onions, macaroni and cheese, tea with sugar
正解：B
解説：
Explanation
(A, B, D) These foods are high in protein, which needs to be restricted. (C) Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.
質問 # 154
A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
- A. Makes the procedure more comfortable for the client
- B. Reduces the possibility of hematoma formation
- C. Reduces the possibility of air embolism
- D. Allows the physician to visualize the subclavian vein
正解：C
解説：
Explanation/Reference:
Explanation:
(A) The subclavian vein is not visible during central line insertion regardless of the client's position. (B) The Trendelenburg position reduces the possibility of air embolism because it places slight positive pressure on the central veins. It also distends the veins, and distention facilitates insertion. (C) This response is untrue; it has no effect on hematoma formation. (D) This position is not necessarily more comfortable for the client, and many clients, especially those who may be short of breath, may find the position uncomfortable and difficult to maintain.
質問 # 155
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. Facilitate optimal development
- B. Provide a demanding and challenging educational program
- C. Provide respite care for the mother
- D. Prepare child to enter mainstream education
正解：A
解説：
(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 # 156
To facilitate maximum air exchange, the nurse should position the client in:
- A. Flat-supine
- B. Prone
- C. High Fowler
- D. Orthopneic
正解：D
解説：
Explanation
(A) The high Fowler position does increase air exchange, but not to the extent of orthopneic position. (B) The orthopneic position is a sitting position that allows maximum lung expansion. (C) The prone position places pressure on diaphragm and does not promote maximum air exchange. (D) The flat-supine position places pressure on diaphragm by abdominal organs and does not promote maximum air exchange.
質問 # 157
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
- A. Blood pressure
- B. Level of consciousness
- C. Fluid intake
- D. Skin turgor
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client. (D) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.
質問 # 158
A 28-year-old client comes to the clinic for her first prenatal examination. In relating her obstetrical history, she tells the nurse that she has been pregnant twice before. She had a "miscarriage" with the first pregnancy after 6 weeks. With the second pregnancy, she delivered twin girls at 31 weeks' gestation. One of the twins was stillborn and the other twin died at 4 days of age. Using a five-digit system, the nurse records her as being:
- A. 2-2-2-1-2
- B. 2-1-1-0-0
- C. 3-0-1-1-0
- D. 2-0-2-1-0
正解：C
解説：
Explanation
(A) The first digit represents the total number of pregnancies. This client has been pregnant 3 times including this pregnancy. The twin pregnancy counts as only one pregnancy, and because she delivered prior to 37 weeks' gestation, the third digit is recorded as 1. (B) The first digit represents the total number of pregnancies.
This client has been pregnant 3 times including this pregnancy. The second digit represents the total number of fullterm deliveries; she has lost two pregnancies before 37 weeks' gestation. At present, she has no living children, so the fifth digit is noted as 0. (C) The client is pregnant for the third time, and the first digit reflects the total number of pregnancies. She has had no full-term deliveries, because she delivered prior to 37 gestational weeks, so the second digit is recorded as 0. The third digit represents the number of preterm deliveries, and a twin pregnancy counts as only one delivery. She lost an earlier pregnancy prior to 20 gestational weeks, and the fourth digit reflects spontaneous or elective abortions. Lastly, the fifth digit indicates the number of children currently living, and she has no living children. (D) She is pregnant for the third time, and the first digit reflects the total number of pregnancies. In the previous two pregnancies, she delivered prior to 37 gestational weeks, thus having no full-term deliveries, which is indicated by the second digit. The fourth digit represents the total number of abortions, spontaneous or elective, and she reported a spontaneous abortion with her first pregnancy.
質問 # 159
A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, "Something is wrong. This is like my labor." Which reply by the nurse identifies the physiological response of the client?
- A. "The same hormone that is released in response to the baby's sucking, causing milk to flow, also causes the uterus to contract."
- B. "Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement."
- C. "There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it."
- D. "Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract."
正解：A
解説：
Explanation
(A) Mammary growth as well as milk production and maintenance in the breast occur in response to hormones produced primarily by the hypothalamus and the pituitary gland. (B) Prolactin stimulates the alveolar cells of the breast to produce milk. It is important in the initiation of breast-feeding. (C) Oxytocin, which is released by the posterior pituitary, stimulates the let-down reflex by contraction of the myoepithelial cells surrounding the alveoli. In addition, it causes contractions of the uterus and uterine involution. (D) Afterpains may occur with retained placental fragments. A boggy uterus and continued bleeding are other symptoms that occur in response to retained placental fragments.
質問 # 160
The nurse teaches a pregnant client that a high-risk symptom occurring at any time during pregnancy that needs to be reported immediately to a healthcare provider is:
- A. Constipation
- B. Urinary frequency
- C. Abdominal pain
- D. Breast tenderness
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Constipation is a result of decreased peristalsis due to smooth muscle relaxation related to changing progesterone levels that occur during pregnancy. (B) Urinary frequency is a common result of the increasing size of the uterus and the resulting pressure it places on the bladder. (C) With the increased vascularity and hypertrophy of the mammary alveoli due to estrogen and progesterone level changes, the breasts will increase in size and may become tender. (D) Abdominal pain may be an indication of early spontaneous abortion, preterm delivery, or a placental abruption.
質問 # 161
An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?
- A. Diabetes insipidus
- B. Edema
- C. Thirst
- D. Water satiety
正解：C
解説：
Explanation/Reference:
Explanation:
(A) If the client is experiencing water satiety, there is no more desire for water. (B) Absorption of saline into circulation rather than into amniotic sac increases serum sodium and desire for water. (C) Edema can be a late side effect caused by water intoxication. (D) Diabetes insipidus occurs as a result of deficient antidiuretic hormone.
質問 # 162
Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to:
- A. Act as an anesthetic
- B. Relieve anxiety
- C. Reduce secretions
- D. Relax muscles
正解：D
解説：
Explanation
(A) Succinylcholine chloride relaxes muscles and decreases the intensity of the seizure. (B) Succinylcholine chloride does not relieve anxiety. (C) Atropine is given to reduce secretions. (D) Thiamylal sodium (Surital) or other phenobarbital preparations are used as brief anesthetics.
質問 # 163
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