PDF問題（2024年最新）実際のNCLEX NCLEX-RN試験問題
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質問 # 501
The nurse provides a male client with diet teaching so that he can help prevent constipation in the future.
Which food choices indicate that this teaching has been understood?
- A. Bagel with cream cheese
- B. Omelette and hash browns
- C. Pancakes and syrup
- D. Cooked oatmeal and grapefruit half
正解：D
解説：
Section: Questions Set B
Explanation:
(A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation.
(B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk.
質問 # 502
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. Rust colored
- B. Bright red with streaks
- C. Green colored
- D. Pink-tinged and frothy
正解：A
解説：
Explanation
(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 # 503
A male client has experienced low back pain for several years. He is the primary support of his wife and six children. Although he would qualify for disability, he plans to continue his employment as long as possible.
His back pain has increased recently, and he is unable to control it with non-steroidal anti-inflammatory agents. He refuses surgery and cannot take narcotics and remain alert enough to concentrate at work. His physician has suggested application of a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following is an appropriate rationale for using a TENS unit for relief of pain?
- A. TENS units have an ultrasonic effect that relaxes muscles, decreases joint stiffness, and increases range of motion.
- B. TENS units work on the gate-control theory of pain; biostimulation therapy of large fibers block painful stimuli.
- C. TENS units produce endogenous opioids that affect the central nervous system with analgesic potency comparable to morphine.
- D. TENS units prevent muscle spasms, decrease the potential for further injury, and minimize pressure on joints.
正解：B
解説：
Explanation
(A) TENS units do not have this effect, but whirlpool therapy does. (B) TENS units do not produce endogenous opioids, only the body can do that. (C) TENS units do work based on the gatecontrol theory of pain control. (D) TENS units do not have this effect, but possibly changing the client's position would.
質問 # 504
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. 1.13 mEq
- C. Not enough information to calculate
- D. 2 mEq
正解：D
解説：
Section: Questions Set C
Explanation:
(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 # 505
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. Puppets
- B. Books with colorful pictures
- C. Riding toys
- D. Music
正解：A
解説：
Explanation/Reference:
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 # 506
Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax?
- A. Mediastinal tissue and organ shifting
- B. Hypoxemia and respiratory acidosis
- C. Decreased tidal volume and tachypnea
- D. Ventilation-perfusion (V./Q.) mismatch
正解：A
解説：
Explanation/Reference:
Explanation:
(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 # 507
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. Eat small, frequent bland meals.
- C. Restrict fluid intake.
- D. Use Alka-Seltzer as necessary.
正解：B
解説：
Explanation/Reference:
Explanation:
(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 # 508
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
- A. Denial
- B. Regression
- C. Projection
- D. Displacement
正解：B
解説：
Explanation
(A) Denial is the disowning of consciously intolerable thoughts. (B) Displacement is the referring of a feeling or emotion from one person, object, or idea to another. (C) Regression is returning to an earlier stage of development. (D) Projection is attributing one's own thoughts, feelings, or impulses to another person.
質問 # 509
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
- A. Prolongs the client's third stage of labor
- B. Decreases the overall time of the labor process
- C. Prolongs the client's first stage of labor
- D. Decreases the time of the client's first stage of labor
正解：C
解説：
Explanation
(A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an anterior position.
Pressure on the sacral nerves is increased, and it takes the fetus a longer time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the larger diameter of the fetal head enters the pelvis first, it will have a more difficult time accommodating to the pelvis; therefore, it will take a longer time for the fetus to move through the pelvis. (C) It will increase the time of labor because the larger diameter of the fetal head will have a more difficult time accommodating to the pelvic inlet and thus will move through the pelvis slower. (D) In the third stage of labor the placenta is delivered; therefore, the infant has been delivered.
質問 # 510
A 55-year-old client is unconscious, and his physician has decided to begin tube feeding him using a smallbore silicone feeding tube (Keofeed, Duo-Tube). After the tube is inserted, the nurse identifies the most reliable way to confirm appropriate placement is to:
- A. Place the tip of the tube under water and observe for air bubbles
- B. Auscultate air insufflated through the tube
- C. Obtain a chest x-ray
- D. Aspirate gastric contents
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Aspiration of gastric contents is usually a reliable way to verify tube placement. However, if the client has dark respiratory secretions from bleeding, tube feedings could be mistaken for respiratory secretions; in other words, aspirating an empty stomach is less reliable in this instance. In addition, it is common for small-bore feeding tubes to collapse when suction pressure is applied. (B) Insufflation of air into large-bore nasogastric tubes can usually be clearly heard. In small-bore tubes, it is more difficult to hear air, and it is difficult to distinguish between air in the stomach and air in the esophagus. (C) A chest x-ray is the most reliable means to determine placement of small-bore nasogastric tubes. (D) Observing for air bubbles when the tip is held under water is an unreliable means to determine correct tube placement for all types of nasogastric tubes. Air may come from both the respiratory tract and the stomach, and the client who is breathing shallowly may not force air out of the tube into the water.
質問 # 511
When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill?
- A. Storytelling
- B. Play-acting out feelings in different roles
- C. Open discussion and understanding
- D. Drawing pictures
正解：B
解説：
Section: Questions Set G
Explanation:
(A) When dealing with grief, siblings are usually most comfortable initially with open discussion. (B) Assuming different roles allows children to act out their feelings without fear of reprisals and to gain insight and control.
(C) This method may be helpful, but having the child take an active part through role playing is more effective.
(D) This technique may be helpful, but being an active participant through role playing is more effective.
質問 # 512
A client on the infectious disease unit is discussing transmission of human immunodeficiency virus (HIV).
The nurse would need to provide more client education based on which client statement?
- A. "HIV is a virus transmitted by sexual contact."
- B. "HIV is a virus that is easily transmitted by casual contact."
- C. "HIV can be transmitted to an unborn infant."
- D. "Condoms reduce the transmission of HIV."
正解：B
解説：
Explanation
(A) HIV is transmitted through unprotected sexual contact. (B) Condoms are an effective barrier to prevent HIV transmission. (C) HIV is not easily transmitted by casual contact. (D) HIV can be transmitted intrauterinely at the time of delivery, and by breast-feeding.
質問 # 513
A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect:
- A. Compensated metabolic acidosis
- B. Compensated respiratory acidosis
- C. Uncompensated respiratory acidosis
- D. Compensated respiratory alkalosis
正解：B
解説：
Section: Questions Set C
Explanation:
(A) In compensated metabolic acidosis, the pH level is normal, the PCO2 level is decreased, and the HCO3 level is decreased. The client's primary alteration is an inability to remove excess acid via the kidneys. The lungs compensate by hyperventilating and decreasing PCO2. (B) In compensated respiratory acidosis, the pH level is normal, the PCO2 level is elevated, and the HCO3 level is elevated. The client's primary alteration is an inability to remove CO2 from the lungs, so over time, the kidneys increase reabsorption of HCO3 to buffer the CO2. (C) In compensated respiratory alkalosis, the pH level is normal, the PCO2 level is decreased, and the HCO3level is decreased. The client's primary alteration is hyperventilation, which decreases PCO2. The client compensates by increasing the excretion of HCO3 from the body. (D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2 level is increased, and the HCO3 level is normal. The client's primary alteration is an inability to remove CO2 from the lungs. The kidneys have not compensated by increasing HCO3 reabsorption.
質問 # 514
When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:
- A. In neurogenic shock, the skin is warm and dry
- B. In hypovolemic shock, there is a bradycardia
- C. In neurogenic shock, there is delayed capillary refill
- D. In hypovolemic shock, capillary refill is less than 2 seconds
正解：A
解説：
Section: Questions Set A
Explanation:
(A) Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia resulting from the lack of sympathetic balance to parasympathetic stimuli from the vagus nerve, and the loss of the ability to sweat below the level of injury. In neurogenic shock, the client is hypotensive but bradycardiac with warm, dry skin. (B) In hypovolemic shock, the client is hypotensive and tachycardiac with cool skin. (C) In hypovolemic shock, the capillary refill would be>5 seconds. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and peripheral flow is good.
質問 # 515
A hyperactive client is experiencing flight of ideas. The most therapeutic activity for him would be:
- A. Playing basketball in the gym
- B. Working a 1000-piece puzzle
- C. Doing crafts in occupational therapy
- D. Playing bridge with three other clients
正解：A
解説：
Explanation
(A) This activity requires motor skills and therefore would be difficult for a hyperactive client. (B) This activity would take too long, and the client would have difficulty concentrating owing to a limited attention span. (C) This client would not be able to concentrate enough to play card games. He would respond to all the stimuli in the area, become distracted, and leave the table. (D) This activity would allow the client to channel his energy in a positive way.
質問 # 516
When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
- A. Regular
- B. Long acting
- C. Human or pork
- D. NPH
正解：A
解説：
(A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. (C) Only regular insulin can be given IV.
質問 # 517
A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be exhibited by her:
- A. Twenty-four hours after the last drink
- B. Six to 8 hours after the last drink
- C. Two to 4 hours after the last drink
- D. Immediately on admission
正解：B
解説：
(A) This answer is incorrect. Alcohol withdrawal usually begins approximately 6-8 hours after the last drink. (B) This answer is correct. It takes approximately 6-8 hours for metabolism of alcohol. (C) This answer is incorrect. The alcohol is still in the system, as indicated by the high blood alcohol level. (D) This answer is incorrect. Symptoms of alcohol withdrawal usually begin within 6-8 hours of the last drink.
質問 # 518
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