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NCLEX-RN試験は、米国の州立看護評議会（NCSBN）によって実施されています。コンピュータ適応型テストであり、問題の難易度は受験者の回答能力に合わせて調整されます。試験は、単純な看護タスクから複雑なものまで、受験者の能力レベルを評価するように設計されています。試験は、全国の各テストセンターで実施され、受験者は試験に登録し、資格をNCSBNに提出する必要があります。
NCLEX-RN試験は、米国で登録看護師になるための重要なステップです。試験に合格することは、国内のどの州でも看護師免許を取得するために必須です。試験では、看護知識、批判的思考、意思決定能力が評価されます。試験に合格するためには、最新の看護実践を熟読し、熱心な準備と学習が必要です。
NCLEX-RN（National Council Licensure Examination for Registered Nurses）は、入門レベルの看護実践のための看護卒業生の能力を評価する標準化された試験です。この試験は、National Council of State Boards of Nursing（NCSBN）によって開発・実施され、米国とカナダで看護を実践したいすべての看護師に必要です。NCLEX-RN試験は、安全で効果的な看護実践に必要な看護の知識、スキル、能力をテストするよう設計されています。NCLEX-RN試験に合格することは、看護免許を取得し、登録看護師になるための要件です。
質問 # 295
On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
- A. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
- B. Withhold her lithium, and report her symptoms to the physician.
- C. Administer her next dosage of lithium, and then call the physician.
- D. Contact the lab and request a lithium level in 30 minutes, and call the physician.
正解：B
解説：
(A) The client has lithium toxicity, and the nurse must withhold further dosages. (B) Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level. (C) Ensuring adequate intake of sodium chloride will promote excretion of lithium and will assist in managing the client's lithiumtoxicity. (D) A lithium blood level must be drawn immediately to determine the seriousness of the toxicity and to provide the physician with data for medical orders.
質問 # 296
A 68-year-old man was recently diagnosed with endstage renal disease. He has not yet begun dialysis but is experiencing severe anemia with associated symptoms of dyspnea on exertion and chest pain. Which statement best describes the management of anemia in renal failure?
- A. The renal secretion of erythropoiesis is decreased. The bone marrow requires erythropoietin to mature red blood cells.
- B. Transfusion is often begun as early as possible to prevent complications of anemia such as dyspnea and angina.
- C. Anemia in renal failure is frequently caused by low serum iron and ferritin and corrected by oral iron and ferritin replacement therapy.
- D. Hematocrit levels usually remain slightly below normalin clients with renal failure.
正解：A
解説：
(A) Clients in renal failure typically have very low hematocrits, often in the range of 16-22%. (B) Transfusion is avoided unless the client exhibits acute symptoms such as dyspnea, chest pain, tachycardia, and extreme fatigue. When the client is given a transfusion, the bone marrow adjusts by producing less red blood cells. (C) Anemia in renal failure is caused primarily by decreased erythropoietin. Low serum iron and ferritin may aggravate the anemia and require treatment. (D) Decreased secretion of erythropoietin by the kidney is the primary cause of anemia. The bone marrow requires this hormone to mature red blood cells. Treatment is with replacement therapy.
質問 # 297
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
解説：
Explanation
(A) Tubular support, such as that received with a Jobst garment, applies tension of 10-20 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 6-12 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status.
質問 # 298
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. 132/78 to 124/76
- B. 140/90 to 148/98
- C. 114/70 to 140/88
- D. 136/88 to 144/93
正解：C
解説：
(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 # 299
Which of the following ECG changes would be seen as a positive myocardial stress test response?
- A. Prolongation of the PR interval
- B. ST-segment depression
- C. Pathological Q wave
- D. Hyperacute T wave
正解：B
解説：
Explanation
(A) Hyperacute T waves occur with hyperkalemia. (B) Prolongation of the P R interval occurs with first-degree AV block. (C) Horizontal ST-segment depression of>1 mm during exercise isdefinitely a positive criterion on the exercise ECG test. (D) Patho-logical Q waves occur with MI.
質問 # 300
A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include:
- A. Administering analgesics as ordered
- B. Having the child turn, cough, and deep breathe every 1-2 hours
- C. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position
- D. Remaining with the child and keeping as calm and quiet as possible
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Allowing the client to remain in the position of comfort will not resolve the atelectasis. This position, if left unchanged, over time may actually increase the atelectasis. (B) Analgesics will not resolve the atelectasis and may contribute to it if proper nursing actions are not taken to help resolve the atelectasis.
(C) Having the client turn, cough, and deep breathe every 1-2 hours will aid in resolving the atelectasis.
Surgery clients are at risk for postoperative respiratory complications because pulmonary function is reduced as a result of anesthesia and surgery. (D) Remaining with the client and keeping him calm and quiet will not affect the client's anxiety, restlessness, or help to resolve the atelectasis. The cause (atelectasis) needs to be treated, not the symptoms (anxiety and restlessness).
質問 # 301
The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?
- A. D5 with Ringer's lactate
- B. Normal saline
- C. Ringer's lactate
- D. D5 in water
正解：B
解説：
Explanation
(A) Phenytoin will precipitate if mixed with Ringer's lactate and should not be administered. (B, C) Phenytoin will precipitate if mixed with D5 in Ringer's lactate and should not be administered. (D) Phenytoin is compatible only with normal saline and should be mixed only with normal saline for administration.
質問 # 302
A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery:
- A. Has too many valves
- B. Takes more time to remove
- C. Is smaller in diameter
- D. Has a greater risk of becoming reoccluded
正解：B
解説：
Section: Questions Set D
Explanation:
(A) It does take more time to remove the internal mammary artery, and this is one reason why some physicians do not use it. (B) There is not a greater risk of reocclusion. In fact, it may actually stay patent longer. (C) The internal mammary artery is actually larger in diameter than the saphenous vein. (D) The internal mammary artery does not have too many valves.
質問 # 303
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. Edema
- B. Water satiety
- C. Diabetes insipidus
- D. Thirst
正解：D
解説：
(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 # 304
Before completing a nursing diagnosis, the nurse must first:
- A. Plan interventions
- B. Perform an assessment
- C. Perform evaluation
- D. Write goals and objectives
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Goals and objectives are based on a nursing assessment and diagnosis. (B) Assessment is the first step of nursing process. (C) Interventions are nursing actions to meet goals and objectives. (D) Evaluation process follows nursing interventions.
質問 # 305
A child receiving chemotherapeutic drugs experiences a loss of appetite directly related to the therapy. Which of the following strategies should be most effective in encouraging the child to eat?
- A. Provide a well-balanced diet at usual times, and restrict dessert if the child fails to eat well.
- B. Schedule procedures immediately after eating so that the child will not be tired or in pain at mealtime.
- C. Offer the child smaller meals more frequently than usual, and include as many of her favorite foods as possible.
- D. Offer the child a diet with a wider variety of foods and with more seasoning than her usual diet.
正解：C
解説：
(A) Because the child's appetite is capricious at best, regular servings may be overwhelming. Praise the child for what is eaten. (B) The child will soon learn that procedures follow meals and may play with food rather than eat it to avoid or delay the procedure. (C) Young children usually do not like highly seasoned foods and may need the security of usual foods. Such a change may actually increase anorexia. (D) Small servings appear more achievable to the child, and the inclusion of favorite foods can add a sense of security.
質問 # 306
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to:
- A. Promote rapid protein catabolism
- B. Protect the myocardium from the effects of hypokalemia
- C. Drive potassium from the serum back into the cells
- D. Remove the potassium from the body by renin exchange
正解：C
解説：
(A) Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. (B) Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. (C) Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. (D) The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.
質問 # 307
A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:
- A. The elevated blood pressure causes photophobia.
- B. External stimuli are annoying to the client with PIH.
- C. The client is restless.
- D. Noise or bright lights may precipitate a convulsion.
正解：D
解説：
(A)
The client may be anxious and hyperresponsive to stimuli but not necessarily restless.
(B)
This is not a physiological response to an elevated blood pressure in PIH. (C) The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. (D) External stimuli might induce a convulsion but are not annoying to the client with PIH.
質問 # 308
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
- A. The nurse has placed the suction catheter in the esophagus.
- B. This is a normal finding.
- C. The feeding is infusing into the trachea.
- D. The client aspirated tube feeding.
正解：D
解説：
Explanation
(A) Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding. (B) Because the trachea provides direct access to a client's airway, it would not be possible to place the catheter in the esophagus. (C) Blue-colored sputum is never considered a normal finding and should be reported and documented. (D) The nurse confirmed placement of the feeding tube in the stomach prior to initiating the tube feeding; therefore, it is highly unlikely that the feeding tube would be located in the trachea.
質問 # 309
A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting
20 seconds, every time the fetus moves. The nurse explains that:
- A. Further testing is needed
- B. The fetus is distressed
- C. The test is inconclusive and should be repeated
- D. The test is normal and the fetus is reacting appropriately
正解：D
解説：
Explanation/Reference:
Explanation:
(A) The test results were normal, so there would be no need to repeat to determine results. (B) There are no data to indicate further tests are needed, because the result of the NST was normal. (C) An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a 15-minute period. (D) The NST results were normal, so there was no fetal distress.
質問 # 310
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
- A. Crackles or rales on the affected side
- B. Increased breath sounds on the affected side
- C. Bradypnea and bradycardia
- D. Shortness of breath and sharp pain on the affected side
正解：D
解説：
Section: Questions Set E
Explanation:
(A) With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. (B) With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. (C) Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. (D) With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).
質問 # 311
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
- A. 30 weeks
- B. 10 weeks
- C. 20 weeks
- D. 16 weeks
正解：C
解説：
Section: Questions Set E
Explanation:
(A) At 10 weeks, the fundus is located slightly above the symphysis pubis. (B) At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. (C) At 20 weeks, the fundus is located approximately at the umbilicus. (D) At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
質問 # 312
During his hospitalization, a 3-year-old child has become unusually aggressive in his play activities. His parents report this change in behavior to the primary nurse. How could the nurse explain the child's change in behavior?
- A. Deep-seated feelings of hostility
- B. A coping response
- C. A lack of interest in socializing
- D. Usual behavior for this child
正解：B
解説：
Section: Questions Set D
Explanation:
(A) Unusually aggressive behavior does not indicate a deepseated problem. (B) A lack of social interest results in poor participation in play activities with peers. Aggression would not be an expected behavior. (C) The aggressive behavior was newly developed and not a routine behavior. (D) Play provides the child with opportunities for coping and adaptation. Aggression during the play activities would indicate a coping response.
質問 # 313
A couple is planning the conception of their first child.
The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day:
- A. 14+2 days
- B. 20+2 days
- C. 22+2 days
- D. 16+2 days
正解：B
解説：
(A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days. (B) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 16). (C) Ovulation occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 22).
質問 # 314
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