NCLEX-RN無料問題集「NCLEX National Council Licensure Examination(NCLEX-RN)」

質問 1

A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism.
He reports that the last time he drank was 3 days ago, and that now he is starting to "feel kind of shaky." Based on the information given above, nursing care goals for this client will initially focus on:

（A）Physiological stabilization

（B）Ineffective coping skills

（C）Self-concept problems

（D）Interpersonal issues

正解：A 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 2

A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks' gestation, all of the following observations are made. Which would require intervention?

（A）Weight gain of 2 kg in 4 weeks

（B）Subjective data: shortness of breath after showering

（C）Blood pressure of 128/78

（D）Ankle edema reported present in late afternoon and evenings

正解：B 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 3

A male client tells his nurse that he has had an ulcer in the past and is afraid it is "flaring up again." The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:

（A）Melena

（B）Pain in the middle of the night

（C）A bowel movement every 3-5 days

（D）Episodes of nausea and vomiting

正解：A 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 4

A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?

（A）Assess color and odor of fluid.

（B）Assess fetal heart rate (FHR).

（C）Document on fetal monitor strip and chart.

（D）Assess quantity of fluid.

正解：B 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 5

A client at 9 weeks' gestation comes for an initial prenatal visit. On assessment, the nurse discovers this is her second pregnancy. Her first pregnancy resulted in a spontaneous abortion. She is 28 years old, in good health, and works full-time as an elementary school teacher. This information alerts the nurse to which of the following:

（A）An increased risk for subsequent abortions

（B）The need for teaching regarding family planning

（C）An increased risk in maternal adaptation to pregnancy

（D）The need for anticipatory guidance regarding the pregnancy

正解：D 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 6

A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as part of discharge planning?

（A）Keep exercise at a minimum to reduce stress.

（B）Give oral iron medication every day.

（C）Have the child's blood pressure monitored every week.

（D）Know the signs and symptoms of iron overload.

正解：D 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 7

A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.
Teaching related to skin care for the client would include which of the following?

（A）Encourage her to avoid direct sunlight on the area being treated.

（B）Teach her to cover broken skin in the treated area with a medicated ointment.

（C）Teach her to completely clean the skin to remove all ointments and markings after each treatment.

（D）Encourage her to wear a tight-fitting vest to support her scapula.

正解：A 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 8

A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that:

（A）He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds.Milk intake should be limited to 1 qt/day

（B）It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily

（C）Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods

（D）Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices

正解：A 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 9

A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, "This is too much trouble. I would rather just have a Foley.'' An appropriate response for the RN teaching him would be:

（A）"OK. I'll ask your physician if we can replace the Foley.''

（B）"You need to learn this because your doctor ordered it.''

（C）"It is not too much trouble. This is the best way to manage urination.''

（D）"I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.''

正解：D 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 10

The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:

（A）Give her good perineal care after each diaper change

（B）Leave the door open to her room

（C）Give her a small soft blanket to hold

（D）Pick her up when she cries

正解：D 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 11

Nursing care of the infant prior to surgical closure of a meningomyelocele would include:

（A）Cover sac with saline-soaked sterile dressing

（B）Aspirate any fluid from sac

（C）Do not apply dressing; keep sac open to air

（D）Cover sac with dry sterile dressing

正解：A 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 12

The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release?

（A）Propranolol (Inderal)

（B）Dobutamine (Dobutrex)

（C）Epinephrine (Adrenalin)

（D）Norepinephrine (Levophed)

正解：C 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 13

A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

（A）Bed flat on operative side

（B）Head of bed elevated 30 degrees on nonoperative side

（C）Bed flat on nonoperative side

（D）Head of bed elevated 30 degrees on operative side

正解：C 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 14

A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely.
The first intervention the RN should initiate is to:

（A）Assess the client to see if she is having vaginal bleeding

（B）Help the client to a sitting position

（C）Obtain the client's vital signs immediately

（D）Place the examining table in the Trendelenburg position

正解：B 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 15

Newborns are routinely screened for phenylketonuria. The nursery nurse ensures that this screening test is performed:

（A）At 2-3 days of age regardless of amount of milk feedings

（B）At 1 month, because the biochemical buildup of phenylalanine takes 1 month to detect

（C）Immediately after birth, because the most accurate result is obtained at this time

（D）After 2-3 days of milk ingestion

正解：D 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 16

The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:

（A）Increases venous return and cardiac output by normalizing fluid status

（B）Covers burn scars and decreases the psychological impact during recovery

（C）Decreases hypertrophic scar formation

（D）Assists with ambulation

正解：C 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

質問 17

A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:

（A）Respiratory alkalosis

（B）Metabolic acidosis

（C）Metabolic alkalosis

（D）Respiratory acidosis

正解：C 解答を投票する

解説: (JPNTest メンバーにのみ表示されます)

NCLEX-RN 無料問題集「NCLEX National Council Licensure Examination(NCLEX-RN)」

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