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NCLEX-RN試験はコンピュータ適応型であり、問題の難易度は受験者の回答によって決定されます。試験は受験者のスキルレベルに合わせて適応し、受験者が正解すると問題が難しくなり、不正解の場合は簡単になります。この形式により、各受験者は個別の能力に合わせたユニークな試験を受けることができます。
質問 # 149
Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?
- A. Neurovascular checks every 2 hours
- B. Elevate legs on pillows
- C. No smoking
- D. Arteriogram in the morning
正解：B
解説：
(A) Neurovascular checks are a routine part of assessment with clients having this diagnosis. (B) Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. (C) Arteriogram is a routine diagnostic order. (D) Smoking is highly correlated with this disorder.
質問 # 150
A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:
- A. Walk between contractions
- B. Relax during contractions
- C. Hyperventilate during contractions
- D. Push during contractions
正解：D
解説：
(A) The second stage of labor is characterized by uterine contractions, which cause the client to bear down. (B) Slow, deep, rhythmic breathing facilitates the laboring process. Hyperventilation is abnormal breathing resulting from loss of pain control. (C) The client should remain on bed rest during labor. (D) Contractions result in discomfort.
質問 # 151
Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?
- A. 114/70 to 140/88
- B. 136/88 to 144/93
- C. 132/78 to 124/76
- D. 140/90 to 148/98
正解：A
解説：
Explanation/Reference:
Explanation:
(A) These blood pressure changes reflect only an 8 mm Hg systolic and a 5 mm Hg diastolic increase, which is insufficient for blood pressure changes indicating PIH. (B) These blood pressure changes reflect a decrease in systolic pressure of 8 mm Hg and diastolic pressure of 2 mm Hg; these values are not indicative of blood pressure increases reflecting PIH. (C) The definition of PIH is an increase in systolic blood pressure of 30 mm Hg and/or diastolic blood pressure of 15 mm Hg. These blood pressures reflect a change of 26 mm Hg systolically and 18mm Hg diastolically. (D) These blood pressures reflect a change of only 8 mm Hg systolically and 8 mm Hg diastolically, which is insufficient for blood pressure changes indicating PIH.
質問 # 152
Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with:
- A. Dystonia and akathisia
- B. Akathisia and parkinsonism
- C. Neuroleptic malignant syndrome
- D. Parkinsonism and dystonia
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Stiff neck is consistent with a dystonic reaction, but the client has no symptoms of drooling, shuffling gait, or pill-rolling movements characteristic of parkinsonism. (B) Stiff neck is consistent with a dystonic reaction, and inability to sit still with varying degrees of psychomotor agitation is characteristic of akathisia.
(C) The client has symptoms of dystonia but not of parkinsonism. (D) The client has none of the characteristic symptoms of neuroleptic malignant syndrome: hyperpyrexia, generalized muscle rigidity, mutism, obtundation, agitation, sweating, increased blood pressure and pulse.
質問 # 153
Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
- A. Cover sac with dry sterile dressing
- B. Do not apply dressing; keep sac open to air
- C. Cover sac with saline-soaked sterile dressing
- D. Aspirate any fluid from sac
正解：C
解説：
(A) A dry, sterile dressing would adhere to the sac, causing tissue damage. (B) A saline-soaked sterile dressing protects the sac from contamination by air and prevents drying. (C) A sac open to air causes drying and potential for contamination. (D) This intervention is not an independent nursing action.
質問 # 154
At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?
- A. Lie down after eating.
- B. Use Alka-Seltzer as necessary.
- C. Restrict fluid intake.
- D. Eat small, frequent bland meals.
正解：D
解説：
(A) At least eight glasses of fluid per day are encouraged to help dilute stomach contents, thereby decreasing irritation. (B) Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should be avoided. (C) Small, frequent bland meals help to decrease gastric pressure and to prevent reflux. (D) Lying down after meals may cause gastric reflux and prevents optimal gastric emptying.
質問 # 155
A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20-year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?
- A. Lifting heavy objects
- B. Ingestion of barbiturates
- C. Walking briskly
- D. Ingestion of antacids
正解：A
解説：
Explanation
(A) Lifting heavy objects will increase intrathoracic pressure, thus placing the client at risk for rupturing esophageal varices. (B, C, D) This activity will not cause an increase in intrathoracic pressure.
質問 # 156
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Febrile transfusion reaction
- B. Hemolytic transfusion reaction
- C. Allergic transfusion reaction
- D. Circulatory overload
正解：C
解説：
Explanation
(A) A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. (B) Fever, chills, and headaches are indicative of a febrile transfusion reaction. (C) Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. (D) Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
質問 # 157
During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:
- A. Enhanced detoxification of drugs
- B. A loss of phagocytic activity
- C. Faulty processing of bilirubin
- D. The formation of collateral circulation
正解：C
解説：
Explanation
(A) A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases the susceptibility to infections. (B) The faulty processing of bilirubin produces bilesalts, which are irritating to the skin. (C) The detoxification of drugs is impaired with cirrhosis of the liver. (D) Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caput medusae.
質問 # 158
A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate.
Which nursing diagnosis should have priority?
- A. Decreased cardiac output related to ineffective pumping action of the heart
- B. Altered growth and development related to decreased intake of food
- C. Altered nutrition: less than body requirements related to inability to take in adequate calories
- D. Activity intolerance related to imbalance between oxygen supply and demand
正解：A
解説：
Section: Questions Set G
Explanation:
(A) Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. (B) The decreased intake occurs due to fatigue from the altered cardiac output. (C) Fatigue occurs due to the decreased cardiac output. (D) The ineffective action of the myocardium leads to inadequate O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development.
質問 # 159
A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?
- A. Hold the child's discharge for 1 hour.
- B. Administer an antiemetic as necessary.
- C. Discharge the child as the physician ordered.
- D. Notify the physician immediately.
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Holding the child's discharge alone does not address the client's problem. (B) Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should benotified immediately so that a serum theophylline level can be ordered. Theophylline dose should be withheld until the physician is notified. (C) The child must be evaluated for theophylline toxicity before any discharge. (D) Cause of the nausea should be investigated before the administration of an antiemetic.
質問 # 160
A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
- A. Document on fetal monitor strip and chart.
- B. Assess color and odor of fluid.
- C. Assess quantity of fluid.
- D. Assess fetal heart rate (FHR).
正解：D
解説：
Explanation
(A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well-being, but it does not take priority over assessment of FHR. (B) Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.
質問 # 161
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. No urinary output, tachycardia, and restlessness
- B. Marked elevation in blood pressure, respirations, and pulse
- C. Decreased systolic pressure, cold skin, and anuria
- D. Rapid pulse; narrowed pulse pressure; cool, moist skin
正解：D
解説：
Section: Questions Set D
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 # 162
The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
- A. Photosensitivity
- B. Dryness of the mouth
- C. Excessive appetite
- D. Hypotension
正解：A
解説：
(A) A decrease in blood pressure sometimes occurs with chlorpromazine. It would not be a factor influenced by a picnic in the park. (B) Protection from the sun is important in clients taking phenothiazines because they burn easily and severely. (C) An appetite increase sometimes occurs with chlorpromazine. It would not be affected by a picnic. (D) Dryness of the mouth may occur at any time and is not affected by the picnic outing.
質問 # 163
Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax?
- A. Mediastinal tissue and organ shifting
- B. Ventilation-perfusion (V./Q.) mismatch
- C. Hypoxemia and respiratory acidosis
- D. Decreased tidal volume and tachypnea
正解：A
解説：
(A, B, D) These occur in both tension pneumothorax and open pneumothorax. (C) The tension pneumothorax acts like a one- way valve so that the pneumothorax increases with each breath. Eventually, it occupies enough space to shift mediastinal tissue toward the unaffected side away from the midline. Tracheal deviation, movement of point of maximum impulse, and decreased cardiac output will occur. The other three options will occur in both types of pneumothorax.
質問 # 164
A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?
- A. A sore throat
- B. Complaints of muscle aches
- C. Respiratory rate of 16 breaths/min
- D. Pulse rate of 80 bpm
正解：A
解説：
Explanation
(A) A respiratory rate of 16 breaths/min is normal and is not a cause for alarm. (B) A pulse rate of 80 bpm is normal and is not a cause for alarm. (C) Complaints of muscle aches are unrelated to her receiving chemotherapy. There may be other causes related to her hospital stay or the disease process. (D) A sore throat is an indication of a possible infection. A client receiving chemotherapy is at risk of neutropenia. An infection in the presence of neutropenia can result in a life-threatening situation.
質問 # 165
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's parents can identify appropriate behaviors for children in his age group
- B. The child's parents identify the ways in which he is different from the rest of the family
- C. The child is removed from the home and placed in foster care
- D. The child's father is arrested for child abuse
正解：A
解説：
Explanation
(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 # 166
A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:
- A. Low-grade fever
- B. Hypertension
- C. Disorientation
- D. Diarrhea
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Disorientation is the first sign of sepsis in burn children. (B) Low-grade fever is not indicative of sepsis.
(C) Diarrhea is not indicative of sepsis. (D) Hypertension is not indicative of sepsis.
質問 # 167
Which of the following findings would be abnormal in a postpartal woman?
- A. Chills shortly after delivery
- B. Urinary output of 3000 mL on the second day after delivery
- C. An oral temperature of 101F (38.3C) on the third day after delivery
- D. Pulse rate of 60 bpm in morning on first postdelivery day
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (12-24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000-3000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious process.
質問 # 168
A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is:
- A. Circulatory overload
- B. Hypokalemia
- C. Air embolus
- D. Hypocalcemia
正解：D
解説：
Explanation
(A) Air embolism is a potential complication of blood administration, but it is fairly rare and can be prevented by using good IV technique. (B) Circulatory overload is a potential complication of blood administration, but because this client is actively bleeding, she is not at high risk for overload. (C) Hypocalcemia is a potential complication of blood administration that occurs in situations where massive transfusion has occurred over a short period of time. It occurs because the citrate in stored blood binds with the client's calcium. Another potential complication for which this client is especially at risk is hypothermia, which can be prevented by using a blood warmer to administer the blood. (D) Hypokalemia is not a complication of blood administration.
質問 # 169
A 26-year-old client is diagnosed with an astrocytoma, a benign brain tumor. From the nurse's knowledge of the central nervous system, the nurse knows that benign tumors:
- A. Grow more rapidly than malignant tumors
- B. Do not warrant concern because they do not become malignant tumors
- C. Can be removed surgically
- D. Can be just as dangerous as malignant tumors
正解：D
解説：
(A) Both a benign and a malignant tumor can displace or destroy nearby structures or increase intracranial pressure. (B) Benign or malignant brain tumors grow at different rates depending on the type of tumor. (C) Some benign tumors do become malignant tumors. (D) Whether or not a tumor is operable depends on its location and the amount of damage its removal will cause.
質問 # 170
The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most the etiology?
- A. Hypernatremia
- B. Hypocalcemia
- C. Hypokalemia
- D. Hypomagnesemia
正解：C
解説：
(A) A deficit in sodium concentration results in muscular weakness and lethargy. (B) Muscle fatigue and hypotonia are caused by hypercalcemia. (C) Muscle weakness and fatigue are classic signs of hypokalemia. (D) Hypermagnesemia can cause muscle weakness, paralysis, and coma.
質問 # 171
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