完全版NCLEX-RN練習テスト865特別な問題と解答が待ってます！
NCLEX Certification問題集でNCLEX-RN試験完全版問題で試験学習ガイド
NCLEX-RN試験は、看護の実践、クライアントの必要性、および看護プロセスの候補者の知識を評価する多肢選択問題から構成されています。これらの問題は包括的で、薬理学、解剖学および生理学、看護プロシージャを含む幅広いトピックをカバーする場合があります。試験はコンピュータ適応型であり、問題の難易度は候補者の知識レベルに適応します。
質問 # 504
A complication for which the nurse should be alert following a liver biopsy is:
- A. Ascites
- B. Jaundice
- C. Hepatic coma
- D. Shock
正解：D
解説：
(A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. (B) Jaundice may occur due to increased bilirubin levels, not due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver.
質問 # 505
Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual functioning?
- A. "A transurethral resection does not usually cause impotence."
- B. "Many men experience impotence following TURP."
- C. "Check with your doctor about resuming sexual activity."
- D. "You may resume sexual intercourse in 2 weeks."
正解：A
解説：
Section: Questions Set F
Explanation:
(A) Sexual activity should be delayed until cleared by the client's physician. (B) Although many men experience retrograde ejaculation following prostate surgery, potency is seldom affected. (C) Although the client may experience retrograde ejaculation, it will not limit his ability to engage in sexual intercourse. (D) Although the client should obtain clearance from his physician before resuming sexual activity, this statement does not give the client any information or reassurance about future sexual activity or potency that could decrease his anxiety.
質問 # 506
A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?
- A. A large toy with movable parts to improve pincer grasp
- B. A pull toy to encourage locomotion
- C. Various large colored blocks to teach visual discrimination
- D. A mobile to improve hand-eye coordination
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Increased locomotive skills make push-pull toys appropriate for the energetic toddler. (B) Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 6-12 months of age to help visual stimulation.
質問 # 507
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
(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 # 508
As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, "I know I must come to the hospital, but what do I do next?" You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?
- A. Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.
- B. Phone a rape counselor to begin working with the victim as soon as she enters the hospital.
- C. Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.
- D. Do not leave the victim alone to collect her thoughts.
正解：A
解説：
(A) Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel "dirty" after rape, and their first instinct is to take care of personal hygiene before facing anyone. (B) This action is of lesser importance at this time. (C) Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. (D) Once the victim enters the emergency room, it is important not to leave her alone.
質問 # 509
A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
- A. Auscultate the site for a bruit
- B. Assess the site for bruising or hematoma
- C. Assess the site for leakage of blood or fluids
- D. Inspect the site for color, warmth, and sensation
正解：A
質問 # 510
A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:
- A. Bradycardia
- B. Thready pulse
- C. Tachycardia
- D. Irregular pulse
正解：A
解説：
Section: Questions Set F
Explanation:
(A) A thready pulse is indicative of hypotension and excessive blood loss and is often rapid. (B) Pulse irregularities or dysrhythmias do not occur in the normal postpartal woman. (C) Tachycardia occurs less frequently than bradycardia and is related to increased blood loss or prolonged difficult labor and/or birth. (D) Puerperal bradycardia with rates of 50-70 bpm commonly occurs during the first 6-10 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.
質問 # 511
The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?
- A. Abstract thinking
- B. Memory
- C. Ability to focus and concentrate thoughts
- D. Judgment
正解：C
解説：
(A) This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. (B) This answer is
correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. (C) This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. (D) This answer is incorrect. In testingmemory, the nurse would attempt to get the client either to recall recent events or to think about past events.
質問 # 512
Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low-tyramine diet. Which of the following are foods that she should avoid?
- A. Fresh fruit such as apples and oranges
- B. Fresh vegetables
- C. Pickled, aged, smoked, and fermented foods
- D. Broiled fresh fish and fowl
正解：C
解説：
(A) These foods may produce elevation in blood pressure when consumed during MAO inhibition therapy. (B) These foods have not been pickled, fermented, smoked, or aged. They contain very little, if any, tyramine or tryptophan. (C) As long as the meat has not been aged or smoked, it is within the dietary regimen. (D) Fresh fruits can be consumed as desired. However, the consumption of bananas is limited.
質問 # 513
Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?
- A. Increased rate and depth of respirations
- B. Increased perception of pain
- C. Increased peripheral vasodilation
- D. Increased level of consciousness
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. (B) The side effects of morphine sulfate include respiratory depression. (C) Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. (D) Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.
質問 # 514
Clinical manifestations seen in left-sided rather than in right-sided heart failure are:
- A. Decreased peripheral perfusion and rales
- B. Hypotension and hepatomegaly
- C. Elevated central venous pressure and peripheral edema
- D. Dyspnea and jaundice
正解：A
解説：
Section: Questions Set A
Explanation:
(A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. (D) Clinical manifestations of left- sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales.
質問 # 515
The nurse would assess the client's correct understanding of the fertility awareness methods that enhance conception, if the client stated that:
- A. "My sexual partner and I should have intercourse when my cervical mucosa is thick and cloudy."
- B. "I should douche immediately after intercourse."
- C. "At ovulation, my basal body temperature should rise about 0.5F."
- D. "My sexual partner and I should have sexual intercourse on day 14 of my cycle regardless of the length of the cycle."
正解：C
解説：
Explanation/Reference:
Explanation:
(A) At ovulation, the cervical mucus is increased, stretchable, and watery clear. (B) Under the influence of progesterone, the basal body temperature increases slightly after ovulation. (C) To enhance fertility, measures should be taken that promote retention of sperm rather than removal. (D) Ovulation, the optimal time for conception, occurs 14+2 days before the next menses; therefore, the date of ovulation is directly related to the length of the menstrual cycle.
質問 # 516
A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby's condition. The nurse knows that the pediatrician has discussed the baby's condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first?
- A. Tell the mother that this condition has been successfully treated with exercises, casts, and/or braces.
- B. Tell the mother that this is not a serious condition.
- C. Call the orthopedist and request that he come to see the baby now.
- D. Question the mother and find out what the pediatrician has told her about the baby's condition.
正解：D
解説：
(A) The nurse should call the orthopedist after assessing the mother's knowledge. (B) The nurse must first assess the knowledge of the parent before attempting any explanation. (C) The nurse should assess the mother's knowledge of the baby's condition as the first priority. (D) This answer is correct, but the priority is B.
質問 # 517
While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?
- A. Encourage the client to take warm sitz baths.
- B. Have the client expose the area to air.
- C. Apply ice to the perineum.
- D. Inform the physician.
正解：A
解説：
Explanation
(A) The area is bruised and painful. This action would do nothing to help with the healing process of the perineum or to provide comfort. (B) Ice is effective immediately after birth to reduce edema and discomfort, but not on the 2nd postpartum day. (C) Sitz baths are useful if the perineum has been traumatized, because the moist heat increases circulation to the area to promote healing, relaxes tissue, and decreases edema. (D) The physician is not notified of bruising, but if a hematoma is present, then the physician is notified.
質問 # 518
Hematotympanum and otorrhea are associated with which of the following head injuries?
- A. Frontal lobe fracture
- B. Epidural hematoma
- C. Basilar skull fracture
- D. Subdural hematoma
正解：C
解説：
Explanation
(A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage.
質問 # 519
Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:
- A. Ventricular septal defect
- B. Patent ductus arteriosus
- C. Tetralogy of Fallot
- D. Transposition of the great arteries
正解：C
解説：
Section: Questions Set D
Explanation:
(A) Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood the reach the systemic circulation. (B) A VSD alone creates a left-to-right shunt.
The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the systemic circulation. (C) In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. (D) Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.
質問 # 520
A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis - Alteration in comfort, pain related to:
- A. Increased blood flow through the coronary arteries
- B. Decreased stimulation of the sympathetic nervous system
- C. Decreased secretion of catecholamines secondary to anxiety
- D. Increased excretion of lactic acid due to myocardial hypoxia
正解：D
解説：
Section: Questions Set G
Explanation:
(A) Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. (B) Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed toward increasing the blood flow through coronary arteries. (C) Chest pain causes an increase in the stimulation of the sympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. (D) Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasing the workload of the heart.
質問 # 521
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
- A. Call the physician and notify the physician of this finding.
- B. Use a Doppler to determine presence and strength of these pulses.
- C. Palpate these pulses again in 15 minutes.
- D. Document the finding that the pulses are not palpable.
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler. (D) The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler.
質問 # 522
A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?
- A. Position on side or abdomen.
- B. Maintain elbow restraints in place unless she is being directly supervised.
- C. Offer pacifier when she cries.
- D. Clean suture line every shift.
正解：B
解説：
(A) Placing the infant on her abdomen may allow for injury to the suture line. (B) Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. (C) The suture line is cleaned as often as every hour to prevent crusting and scarring. (D) Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring.
質問 # 523
An obstructing stone in the renal pelvis or upper ureter causes:
- A. Urinary frequency and dysuria
- B. Radiating pain into the urethra with labia pain experienced in females or testicular pain in males
- C. Dull, aching, back pain
- D. Severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor
正解：D
解説：
Section: Questions Set D
Explanation:
(A) Radiating pain in the urethra in both sexes, extending into the labia in females and into the testicle or penis in the male, indicates a stone in the middle or lower segment of the ureter. (B) Urinary frequency and dysuria are caused by a stone in the terminal segment of the ureter withinthe bladder wall. (C) An obstructing stone in the renal pelvis or upper ureter causes severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor. (D) Dull and aching pain may indicate early stages of hydronephrosis. Also, a stone in the renal pelvis or upper ureter causes severe flank and abdominal pain.
質問 # 524
Which of the following nursing orders has the highest priority for a child with epiglottitis?
- A. Specific gravity every shift
- B. Vital signs every shift
- C. Tracheostomy set at bedside
- D. Intake and output
正解：C
解説：
Section: Questions Set G
Explanation:
(A) Because of the possibility of fever or respiratory failure, vital signs should be done more often than every eight hours. (B) If the epiglottitis worsens, the edema and laryngospasm may close the airway and an emergency tracheostomy may be necessary. (C) Although intake and output are a part of the nursing care of a child with epiglottitis, it is not as important as the safety measure of keeping the tracheostomy set at the bedside. (D) Specific gravity will indicate hydration status, but it is not as important as keeping the tracheostomy set at the bedside.
質問 # 525
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