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NCLEX-RN試験は、十分な準備が必要な厳しい試験です。受験者は、テストの内容を確認し理解し、コンピュータベースのフォーマットに慣れ、タイムドセッティングで問題に回答する練習をする必要があります。レビューコース、学習ガイド、模擬試験、オンラインリソースなど、NCLEX-RN試験に備えるためのいくつかのリソースがあります。十分な準備と試験内容の徹底的な理解により、RNはNCLEX-RN試験に合格し、アメリカで看護実践のライセンスを取得することができます。
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パフォーマンスに基づいています。この試験には、選択肢の全てを選択する、空欄を埋める、順番を指定するなどの、複数の選択形式の問題が含まれます。この試験は、解剖学と生理学、薬理学、看護手順、患者ケアなど、幅広い看護知識をテストするように設計されています。
質問 # 54
A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:
- A. Digoxin (Lanoxin) 0.25 mg po every day
- B. Furosemide (Lasix) 40 mg po every morning
- C. Nitroglycerin (Nitrol) 1 inch topically every 4 hours
- D. O22 L/min via nasal cannula
正解：A
解説：
(A) Digoxin is a cardiac glycoside given to clients in heart failure to improve their myocardial contractility. (B) Furosemide is a loop diuretic given to clients in heart failure to promote diuresis. (C) O2is given to clients in heart failure to increase oxygenation and to prevent or treat hypoxemia. (D) Nitroglycerin is a nitrate given to clients in heart failure to increase their cardiac output by decreasing the peripheral resistance that the left ventricle must pump against.
質問 # 55
A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the:
- A. Tip of the nose to the ear lobe to the xiphoid process or midepigastric area
- B. Tip of the nose to the lower lip to the umbilicus
- C. End of the tube to the first measurement line on the tube
- D. Lower lip to the shoulder to the upper sternum
正解：A
解説：
(A) This measurement is _50 cm (48-49 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (B) This measurement is _50 cm (47-48 cm). Fifty centimeters is considered the lengthnecessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (C) This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-earxiphoid). (D) This is the correct measurement of 50 cm from the tip of the client's nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.
質問 # 56
A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be:
- A. "Yes, increase your insulin by 1 U for each hour of practice because exercise causes the body to need more insulin."
- B. "No, do not increase your insulin, but eating a snack prior to practice exercise will make insulin more effective and move more glucose into the cells."
- C. "You should ask your doctor about this."
- D. "No, do not increase your insulin. Exercise will not affect your insulin needs."
正解：B
解説：
(A) A nurse can give this information to a client. (B) Exercise makes insulin more efficient in moving more glucose into the cells. No more insulin is needed. (C) Exercise makes insulin more efficient unless the diabetes is poorly controlled. (D) Exercise makes insulin more efficient in moving more glucose into the cells.
質問 # 57
A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:
- A. Protect the child from infection
- B. Protect the family from curious visitors
- C. Isolate the child from other clients and the nursing staff
- D. Provide the child with privacy
正解：A
解説：
(A) The child no longer has normal white blood cells and is extremely susceptible to infection. (B) There are more appropriate ways to provide privacy, and there is no need to protect the child from healthy visitors. (C) Visitors and visiting hours may be at the client's and/or family's request without regard to the isolation precaution. (D) The child may have strong positive relationships with other clients or staff. As long as proper precautions are observed, there is no reason to isolate her from them.
質問 # 58
A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to:
- A. Sit and rest
- B. Clean his inhaler with warm water and soak it in a 10% bleach solution
- C. Drink a glass of water
- D. Use his bronchodilator inhaler
正解：C
解説：
(A) Inhalers should be cleaned once a day. They should be taken apart, washed in warm water, and dried according to manufacturer's instructions. Soaking in bleach is inappropriate. (B) A common side effect of inhaled steroid preparations is oral candidal infection. This can be prevented by drinking a glass of water or gargling after using a steroid inhaler. (C) There is nothing wrong with sitting and resting after using a steroid inhaler, but it is not necessary. (D) If a person is using a steroid inhaler as well as a bronchodilator inhaler, the bronchodilator shouldalways be used first. The reason for this is that the bronchodilator opens up the person's airways so that when the steroid inhaler is used next, there will be better distribution of medication.
質問 # 59
The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include:
- A. Larger number of alveoli, diaphragmatic breathing
- B. Rounded shape of chest, smaller volume of air
- C. Diaphragmatic breathing, larger volume of air
- D. Fewer alveoli, slower respiratory rate
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. (B) Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. (C) The adult has a larger number of alveoli than a child. (D) The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.
質問 # 60
A client experiencing delusions states, "I came here because there were people surrounding my house that wanted to take me away and use my body for science." The best response by the nurse would be:
- A. "I need more information on why you think others want to use your body for science."
- B. "I know that must be frightening for you; let the staff know when you are having thoughts that trouble you."
- C. "There were no people surrounding your house, your relatives brought you here, and no one really wants your body for science."
- D. "Describe the people surrounding your house that want to take you away."
正解：B
解説：
Explanation
(A) Focusing on the delusional content does not reinforce reality. (B) Pursuing details or more information on the delusion reinforces the false belief and further distances the client from reality. (C) Challenging the client's delusional system may force the client to defend it, and you cannot change the delusion through logic. (D) Focusing on the feeling can reinforce reality and discourage the false belief. Seeking out staff when thoughts are troublesome can help to decrease anxiety.
質問 # 61
A client has begun to exhibit signs of alcohol withdrawal. Her blood pressure has risen from 120/60 to 190/100, pulse is increased from 88 to 110 bpm, and she is irritable and agitated and has gross motor tremors of the hands. The nurse notifies the doctor. The nurse can anticipate that the doctor will order which of the following?
- A. A benzodiazepine such as chlordiazepoxide (Librium)
- B. An opiate such as propoxyphene napsylate (Darvocet)
- C. A tricyclic antidepressant such as amitriptyline (Elavil)
- D. A phenothiazine such as chlorpromazine (Thorazine)
正解：A
解説：
Section: Questions Set D
Explanation:
(A) This answer is incorrect. Benzodiazepines are drugs of choice for alcohol withdrawal. (B) This answer is correct. The drug has a sedative effect, is safe, and has an anticonvulsant effect.(C) This answer is incorrect.
Amitriptyline is an antidepressant. (D) This answer is incorrect. Chlorpromazine is most effective in psychotic disorders.
質問 # 62
Goal setting for a client with Meniere's disease should include which of the following?
- A. Prevention of a fall injury
- B. Frequent ambulation
- C. Prevention of infection
- D. Consumption of three meals per day
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. (B) Vertigo resulting in balance problems is one of the most common manifestations of Meniere's disease. (C) Adequate nutrition is important, but the emphasis in Meniere's disease is not the number of meals per day but a decrease in intake of sodium. (D) Infection is not an anticipated problem.
質問 # 63
A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:
- A. A soft relaxed abdomen
- B. A rigid, boardlike abdomen
- C. Hypertonicity of the uterus
- D. Uterine atony
正解：A
解説：
Explanation
(A) A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. (B) A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. (C) The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. (D) In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.
質問 # 64
A 12-year-old girl has been diagnosed with insulindependent diabetes mellitus. Which of these principles would best guide her nutritional management?
- A. Concentrated sweets are taken during increased activity.
- B. Fat requirements are increased owing to the possibility of ketoacidosis.
- C. Food restriction is imposed to reduce weight.
- D. Caloric distribution should be calculated to fit activity patterns.
正解：D
解説：
(A) Concentrated sweets are eliminated from diet planning. Complex carbohydrates may be taken at the time of increased activity. (B) Food restriction is not used for diabetic control of growing children. Caloric restriction may be imposed for weight control if necessary. (C) Total caloric intake and proportions of basic nutrients should be consistent from day to day. Distribution of these calories should fit the activity pattern. Extra food is needed for increased activity. A balance of food, exercise, and insulin should be maintained. (D) Because of the increased risk of atherosclerosis, the fat percentage of the total caloric intake is reduced.
質問 # 65
A 6-year-old girl has been diagnosed with a urinary tract infection secondary to vesicoureteral reflux. Which statement by her mother indicates a need for further teaching?
- A. "I make sure she drinks plenty of fluids every day."
- B. "She tries to empty her bladder completely after she urinates, like I told her."
- C. "She enjoys wearing nylon panties, but I make her change them everyday."
- D. "I have taught her to wipe from front to back after urinating."
正解：C
解説：
Explanation
(A) Wiping from front to back is wiping from an area of lesser contamination (urethra) to an area of greater contamination (rectum). (B) Generous fluid intake reduces the concentration of urine. (C) Cotton is a natural, absorbent fabric. Nylon often predisposes the client to urinary tract infections. Dark, warm, moist areas are excellent media for bacterial growth. (D) With vesicoureteral reflux, urine refluxes into the ureter(s) during voiding and then returns to the bladder (residual), which becomes a source for future infection.
質問 # 66
One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, "It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers." The nurse's best response would be:
- A. "That might be a problem. Tell me more about them."
- B. "Your grandfather and father were both alcoholics?"
- C. "It sounds like you're intellectualizing your drinking problem."
- D. "Risk factors can often be controlled by self-responsibility."
正解：D
解説：
(A) Focusing is an effective therapeutic strategy. This response, however, allows the client to "defocus" off the topic of learning how to accept responsibility for his behavior and future growth. (B) The nurse can educate the client about both the "genetic risk" for the development of alcoholism and ways to make long-term healthy lifestyle changes. (C) This response is inappropriately confrontational and condescending to the client. (D) Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here.
質問 # 67
A client delivered a stillborn male at term. An appropriate action of the nurse would be to:
- A. Discourage the parents from seeing the baby.
- B. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time.
- C. Reassure the parents that they can have other children.
- D. State, "You have an angel in heaven."
正解：B
解説：
Section: Questions Set G
Explanation:
(A) This is not a supportive statement. There are also no data to indicate the family's religious beliefs. (B) Seeing their baby assists the parents in the grieving process. This gives them the opportunity to say "good- bye." (C) Parents need time to get to know their baby. (D) This is not a comforting statement when a baby has died. There are also no guarantees that the couple will be able to have another child.
質問 # 68
The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:
- A. Teach parents appropriate safety precautions
- B. Reduce mother's sense of guilt
- C. Determine child's activity pattern
- D. Instruct parents in use of ipecac
正解：A
解説：
Explanation/Reference:
Explanation:
(A) This goal is not the most important. (B) There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. (C) Ipecac is not used for caustic alkali and acid ingestions. (D) Determining the parent's knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents.
質問 # 69
Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?
- A. "I should always take this medication with an antacid."
- B. "I would notify my physician immediately if I experience nausea, vomiting, and double vision."
- C. "I should only take the medication if my heart rate is greater than 100 bpm."
- D. "I could stop taking this medication when I begin to feel better."
正解：B
解説：
Section: Questions Set G
Explanation:
(A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. (B) The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. "Feeling better" indicates the drug is working and medication therapy must be continued. (C) Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. (D) Antacids decrease the effectiveness of digoxin.
質問 # 70
Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is:
- A. 40 mg/dL and 130 mg/dL
- B. 70 mg/dL and 120 mg/dL
- C. 90 mg/dL and 200 mg/dL
- D. 100 mg/dL and 200 mg/dL
正解：B
解説：
(A) The recommended range is 70-120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus.
質問 # 71
Prior to an amniocentesis, a fetal ultrasound is done in order to:
- A. Evaluate fetal lung maturity
- B. Ensure that the fetus is mature enough to perform the amniocentesis
- C. Locate the position of the placenta and fetus
- D. Evaluate the amount of amniotic fluid
正解：C
解説：
Section: Questions Set D
Explanation:
(A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for gestational dating, although it does not separately determine lung maturity. (B) Ultrasound can evaluate amniotic fluid volume, which may be used to determine congenital anomalies. (C) Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of pregnancy.
質問 # 72
A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her
7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high- risk prenatal clinic. The client's weight increase is most likely due to:
- A. Fluid retention
- B. Hypertension due to kidney lesions
- C. Obesity prior to conception
- D. Overeating and subsequent obesity
正解：A
解説：
Section: Questions Set B
Explanation
Explanation:
(A) Overeating can lead to obesity, but not to edema. (B) There is no indication of obesity prior to pregnancy.
PIH is more prevalent in the underweight than in the obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. (D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.
質問 # 73
An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following:
- A. Both lower extremities cyanotic when placed in a dependent position
- B. Decreased or absent pedal pulse in the left leg
- C. The left leg warmer to touch than the right leg
- D. Both lower extremities warm to touch with 2_pedal pulses
正解：B
解説：
Explanation
(A) This statement describes a normal assessment finding of the lower extremities. (B) This assessment finding reflects problems caused by venous insufficiency. (C) Decreased or absentpedal pulses reflect a problem caused by arterial insufficiency. (D) The leg that is experiencing arterial insufficiency would be cool to touch due to the decreased circulation.
質問 # 74
On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:
- A. Normal involution
- B. An infection pain
- C. A full bladder
- D. A hemorrhage
正解：C
解説：
Explanation
(A) Immediately after expulsion of the placenta, the fundus should be in the midline and remain firm. (B) A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus. (C) Symptoms of infection may include unusual uterine discomfort, temperature elevation, and foul-smelling lochia. The stem of this question does not address any of these factors. (D) While excessive bleeding is associated with a soft, boggy uterus, the stem of this question includes displacement of the uterus, which is more commonly associated with bladder distention.
質問 # 75
A 58-year-old client on a general surgery unit is scheduled for transurethral resection of the prostate (TURP) in
2 hours. The nurse explains to the client that this procedure means:
- A. Removal of the prostate tissue by way of a lower abdominal midline incision through the bladder and into the prostate gland
- B. Removal of prostate tissue by a resectoscope that is inserted through the penile urethra
- C. Removal of prostate tissue by an open surgical approach through a low horizontal incision, bypassing the bladder, to the prostate gland
- D. Removal of the prostate tissue by an open surgical approach through an incision between the ischial tuberosities, the scrotum, and the rectum
正解：B
解説：
Section: Questions Set D
Explanation:
(A) This describes a suprapubic (transvesical) prostatectomy procedure. (B) This is the correct description of a TURP procedure. (C) This describes a perineal prostatectomy procedure. (D) This describes a retropubic (extravesical) prostatectomy procedure.
質問 # 76
In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
- A. Counseling a client with post-traumatic stress disorder
- B. Teaching fifth-grade children the harmful effects of substance abuse
- C. Referring a client who has been on a detoxification unit to a rehabilitation center
- D. Crisis intervention with an intoxicated teenager whose mother just committed suicide
正解：B
解説：
Section: Questions Set F
Explanation:
(A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.
質問 # 77
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. Self-concept problems
- B. Interpersonal issues
- C. Ineffective coping skills
- D. Physiological stabilization
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Self-concept and self-esteem problems may emerge during the client's treatment, but these are not immediate concerns. (B) Interpersonal issues may become evident during the course of the client's treatment, but these are also not immediate areas of concern. (C) Improving individual coping skills is generally a primary focus in the treatment and nursing care of persons with substance abuse problems.
However, this is still not the immediate concern in this client situation. (D) Correction of fluid and electrolyte status and vitamin deficiencies, as well as prevention of delirium, is the immediate concern in the care of this client.
質問 # 78
A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?
- A. 0.06 mL
- B. 0.38 mL
- C. Information given insufficient to determine the amount of atropine to be administered
- D. 2.7 mL
正解：B
解説：
Section: Questions Set G
Explanation:
(A, C) Information was incorrectly placed in the formula, resulting in an incorrect answer. (B) The answer is correct.
0.4 mg = 1 mL:0.15 mg 5 = mL
0.4 x = 0.15
x = 0.15/0.4
x = 0.375 or 0.38 mL
(D) Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given.
質問 # 79
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