[2024年12月]に更新されたNCLEX Certification NCLEX-RN試験練習テスト問題集豪華セット！
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NCLEX-RN（登録看護師のための全国評議会免許試験）は、米国で看護を実践するためのライセンスを取得するために、すべての看護卒業者が合格しなければならない標準化された試験です。この試験は、国家評議会の看護委員会（NCSBN）によって開発および管理されています。 NCLEX-RN試験では、安全で効果的な看護実践に不可欠な知識、スキル、能力を測定します。
質問 # 395
A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:
- A. Respiratory alkalosis
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Metabolic acidosis
正解：D
解説：
Explanation
(A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3.(D) Metabolic acidosis is determined by low pH and HCO3.
質問 # 396
A 4 days postpartum client who is gravida 3, para 3, isexamined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client's lochia as:
- A. Rosa
- B. Alba
- C. Rubra
- D. Serosa
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Lochia rubra is bloody with clots and occurs 1-3 days postpartum. (B) There is no such term as lochia rosa. (C) Lochia serosa is a pink-brown discharge with a serosanguineous consistency that occurs 4-9 days postpartum. (D) Lochia alba is yellow to white in color and occurs approximately 10 days postpartum.
質問 # 397
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, "Nurse, the baby is coming." As the nurse responds to her call, which one of the following observations should the nurse make first?
- A. Prepare a sterile area for delivery.
- B. Inspect the perineum.
- C. Time the contractions.
- D. Auscultate for fetal heart rate (FHR).
正解：B
解説：
Explanation
(A) The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. (B) Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. (C) If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. (D) Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.
質問 # 398
A 33-year-old client was brought into the emergency room unconscious, and it is determined that surgery is needed. Informed consent must be obtained from his next of kin. The sequence in which the next of kin would be asked for the consent would be:
- A. Parent, spouse, sibling, adult child
- B. Spouse, adult child, parent, sibling
- C. Spouse, parent, sibling, adult child
- D. Parent, spouse, adult child, sibling
正解：B
解説：
Explanation
(A) Spouse and adult child would be asked before a parent. (B) The order of kin relationship for an adult, as determined from legal intestate succession, is usually spouse, adult child, parent, sibling. (C) Parent and sibling would be asked after adult child. (D) Spouse and adult child would be asked before parent. Sibling would be asked last.
質問 # 399
A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
- A. Roast beef, baked potato, and diced carrots
- B. Chicken breast, rice, and green beans
- C. Tuna casserole, noodles, and spinach
- D. Pork chop, baked acorn squash, brussel sprouts
正解：D
解説：
Section: Questions Set B
Explanation:
(A) Both acorn squash and brussels sprouts are potassium-rich foods. (B) None of these foods is considered potassium rich. (C) Only the baked potato is a potassium-rich food. (D) Spinach is the only potassium-rich food in this option.
質問 # 400
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
- A. High risk for infection
- B. Ineffective airway clearance
- C. Altered oral mucous membrane
- D. Activity intolerance
正解：B
解説：
Section: Questions Set D
Explanation:
(A) The laryngectomy client should be able to gradually increase activities without difficulty. (B) The laryngectomy client may have copious amounts of secretions and require suctioning for the first 24-48 hours.
The cannula will require cleaning even after the first 24 hours because mucus collects in it. (C) The client does have a potential for infection, but it is not a more importantnursing priority than the ineffective airway clearance.
(D) This problem is not a more important nursing priority than ineffective airway clearance. The client's mouth may become dry, but good oral care should take care of the dryness.
質問 # 401
Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 οF. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose "just 5 more lb." Her symptoms are consistent with:
- A. Anorexia nervosa
- B. Pregnancy
- C. Gastritis
- D. Bulimia
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Presenting behaviors collectively are inconsistent with depression. (B) A preillness weight loss of 30%, lanugo, and cessation of menses are inconsistent with bulimia. (C) Symptoms and vital signs do not indicate the presence of infection. (D) All symptoms and vital signs are consistent with anorexia nervosa.
質問 # 402
A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:
- A. Respiratory alkalosis
- B. Metabolic alkalosis
- C. Metabolic acidosis
- D. Respiratory acidosis
正解：D
解説：
Explanation
(A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3.
(D) Metabolic acidosis is determined by low pH and HCO3.
質問 # 403
Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
- A. Vomiting, impaired consciousness, decreased blood pressure
- B. Fine hand tremor, headache, mental dullness
- C. Polyuria, polydipsia, edema
- D. Gastric irritation, nausea, diarrhea
正解：A
解説：
Explanation/Reference:
Explanation:
(A) These symptoms are acute, common, and usually harmless central nervous system side effects of lithium. (B) These symptoms of lithium toxicity are usually dose related. (C) These symptoms are acute, common, and usually harmless renal side effects of lithium. (D) These symptoms are acute, common, and usually harmless gastrointestinal side effects of lithium.
質問 # 404
A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?
- A. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.
- B. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
- C. Advise the client to discontinue the drug at the first sign of dizziness.
- D. Instruct the client in Valsalva's maneuver to equalize middle ear pressure and to prevent hearing loss.
正解：B
解説：
(A) The first nursing measure is to instruct the client in which drug side effects to report. (B) Discontinuing the drug is not an independent nursing intervention and may compromise client care. (C) Audiometric testing will detect hearing loss, but it does not indicate a potential cause. (D) Equalizing middle ear pressure will not prevent hearing loss.
質問 # 405
A behavioral modification program is recommended by the multidisciplinary team working with a 15-year- old client with anorexia nervosa. A nursing plan of care based on this modality would include:
- A. Encouraging her to verbalize her feelings concerning food and food intake
- B. Role playing the client's eating behaviors
- C. Restriction to the unit until she has gained 2 lb
- D. Provision for a high-calorie, high-protein snack between meals
正解：C
解説：
Explanation/Reference:
Explanation:
(A) This answer is incorrect. Role playing is based on learning but is not based on the behavioral modification model. (B) This answer is correct. The behavioral modification model is based on negative and positive reinforcers to change behavior. (C) This answer is incorrect. Verbal catharsis is not an intervention based on behavioral modification. (D) This answer is incorrect. Although an acceptable nursing intervention, it is not based on behavioral modification.
質問 # 406
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
- A. Evidence of perineal irritation
- B. Pulse increased from 96 to 102
- C. Temperature rose to 102_F rectally
- D. Pulse fell from 102 to 96
正解：C
解説：
(A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. (B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. (C) This rise in pulse rate is probably not significant, but it is important to monitor for continued change. (D) This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
質問 # 407
An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?
- A. Immerse both legs in cool water.
- B. Apply ice packs to both legs.
- C. Apply Silvadene cream (silver sulfadiazine).
- D. Begin debridement by removing all charred clothing from wound.
正解：A
解説：
Explanation
(A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound first. This creates further tissue damage. Debridement is not the first nursing action. (C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection. (D) Emergency care of a thermal burn is immersing both legs in cool water.
Cool water permits gradual temperature change and prevents further thermal damage.
質問 # 408
A 48-year-old client is in the surgical intensive care unit after having had three-vessel
coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician?
- A. Serum osmolality is elevated indicating hemoconcentration. The nurse should increase IV fluid rate.
- B. Serum sodium is low. The nurse should change IV fluids to normal saline.
- C. Blood urea nitrogen is subnormal. The nurse should increase the protein in the client's diet as soon as possible.
- D. Serum potassium is low. The nurse should administer KCl as ordered.
正解：D
解説：
(A)
An elevated serum osmolality poses no immediate danger and is not corrected rapidly.
(B)
A low serum sodium alone does not warrant changing IV fluids to normal saline. Other assessment parameters, such as hydration status, must be considered. (C) A low serum blood urea nitrogen is not necessarily indicative of protein deprivation. It may also be the result of overhydration. (D)A low serum potassium potentiates the effects of digitalis, predisposing the client to dangerous arrhythmias. It must be corrected immediately.
質問 # 409
A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
- A. Intubation of the right mainstem bronchus
- B. A left hemothorax
- C. An inadequate mechanical ventilator
- D. A right hemothorax
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Although a left hemothorax could cause diminished and distant breath sounds, it is irrelevant to this situation. (B) A right hemothorax will not cause diminished and distant breath sounds on the left side of the chest. (C) The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left. (D) An inadequate mechanical ventilator has no relationship to this situation.
質問 # 410
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
- A. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
- B. Fluid volume deficit secondary to alteration in skin integrity
- C. Alteration in comfort secondary to alteration in skin integrity
- D. Alteration in sensation secondary to third-degree burn
正解：A
解説：
(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48-72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
質問 # 411
A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant.
The best time to immunize her is:
- A. After the first trimester
- B. At 28 weeks' gestation
- C. In the immediate postpartum period
- D. Within 72 hours postpartum
正解：C
解説：
Explanation/Reference:
Explanation:
(A) The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. (B) Rubella infection during the second trimester may result in permanent hearing loss for the fetus. (C) RhoGam is the drug generally administered at 28 weeks' gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. (D) RhoGam is the drug administered within 72 hours postpartum to Rh- negative women to prevent the development of antibodies to fetal cells.
質問 # 412
What is the most effective method to identify early breast cancer lumps?
- A. Yearly checkups performed by physician
- B. Monthly breast self-examination
- C. Ultrasounds every 3 years
- D. Mammograms every 3 years
正解：B
解説：
Explanation
(A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective forwomen older than 40. (B) Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self-examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. (D) Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.
質問 # 413
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. "It sounds like you're intellectualizing your drinking problem."
- B. "Your grandfather and father were both alcoholics?"
- C. "Risk factors can often be controlled by self-responsibility."
- D. "That might be a problem. Tell me more about them."
正解：C
解説：
Explanation/Reference:
Explanation:
(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 # 414
A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child's case manager knows that treatment has been effective when:
- A. The child's father is arrested for child abuse
- B. The child's parents can identify appropriate behaviors for children in his age group
- C. The child's parents identify the ways in which he is different from the rest of the family
- D. The child is removed from the home and placed in foster care
正解：B
解説：
Section: Questions Set G
Explanation:
(A) Removing an abused child from the home and placement in a foster home are not the desired outcome of treatment. (B) Children who are perceived as "different" from the rest of the family are more likely to be abused. (C) Although legal action may be taken against abusive parents, it is not an indicator of an effective treatment program. (D) Identification of age-appropriate behaviors is essential to the role of parents, because misunderstanding children's normal developmental needs often contributes to abuse or neglect.
質問 # 415
An 18-month-old child has been playing in the garage. His mother brings him to a nurse's home complaining of his mouth being sore. His lips and mouth are soapy and white, with small ulcerated areas beginning to form. The child begins to vomit. His pulse is rapid and weak. The nurse suspects that the child has:
- A. Lead poisoning
- B. Ingested a caustic alkali
- C. Eaten construction chalk
- D. Inhaled gasoline fumes
正解：B
解説：
Explanation/Reference:
Explanation:
(A, C, D) These agents would not cause ulcerations on mouthand lips. (B) Strong alkali or acids will cause burns and ulcerationson the mucous membranes.
質問 # 416
A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being "bugged." Her diagnosis is schizophrenia.
One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:
- A. Protect her from suicide
- B. Supervise her medication regimen
- C. Involve her in groups for social interaction
- D. Enable her to develop trust
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Suicide is a greater risk in depression than in schizophrenia. (B) The client is suspicious and needs help to develop trust, which is basic to her improvement. (C) Although she will be taking medication, drug therapy would not necessitate consistency in the nurses assigned. (D) A suspicious client should have limited exposure to groups, because group participation increases discomfort.
質問 # 417
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