[2025年03月] 更新されたのはNCLEX NCLEX-RN問題集PDFオンラインエンジン
NCLEX-RN.PDFで問題解答PDFサンプル問題は信頼され続ける
NCLEX-RNは、米国の認可された登録看護師になろうとしている個人の知識と能力をテストするために設計された認定試験です。この試験は、国家評議会の看護委員会（NCSBN）によって作成および管理されており、50州すべての看護能力の標準的な尺度として認識されています。
質問 # 430
A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?
- A. Discontinue the medication if nausea occurs.
- B. Restrict foods that contain salt or sodium.
- C. Regular foods should be eaten, including those that contain salt, such as bacon, ham, V-8 juice, and tomato juice.
- D. Restrict fluids to 1000 mL/day.
正解：C
解説：
(A) This answer is correct. A balanced diet with adequate salt intake is necessary. (B) This answer is incorrect. The client must drink six to eight full glasses of fluid per day (2000-3000 mL/day). (C) This answer is incorrect. The client should be instructed to avoid fluctuations of sodium intake. Diet should be balanced, with an adequate salt intake. (D) This answer is incorrect. Nausea is a frequent side effect that can be minimized with administration of drug with meals or after eating food.
質問 # 431
A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:
- A. Rolling from his back to his tummy
- B. Sucking his thumb
- C. Falling asleep
- D. Crying
正解：D
解説：
(A) A child with a subdural hematoma has increased ICP. Crying may significantly increase this pressure. (B) Adequate sleep is essential, but it is important that the child can be aroused from sleep after head injury. (C) This child is free to roll from his back to his abdomen. (D) Thumb-sucking serves to reduce anxiety and should not be prevented at this time.
質問 # 432
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
- A. Deep tendon reflexes are absent
- B. Respirations are>16 breaths/min
- C. Urine output is 20 mL/hr
- D. MgSO4serum levels are>15 mg/dL
正解：B
解説：
Explanation
(A) MgSO4is a central nervous system depressant. Loss of reflexes is often the first sign of developing toxicity. (B) Urinary output at <25 mL/hr or 100 mL in 4 hours may result in the accumulation of toxic levels of magnesium. (C) The therapeutic serum range for MgSO4is 6-8 mg/dL. Higher levels indicate toxicity. (D) Respirations of>16 breaths/min indicate that toxic levels of magnesium have not been reached. Medication administration would be safe.
質問 # 433
The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?
- A. Patience by the child when wearing soiled diapers
- B. The age at which the child's siblings were trained
- C. Communicating the urge to defecate or urinate
- D. The child awakening wet from his naps
正解：C
解説：
Section: Questions Set D
Explanation:
(A) Children experience impatience with soiled diapers when readiness for training is apparent. They often desire to be changed immediately. (B) A child must be able to use verbal or nonverbal skills to communicate needs. (C) A readiness indicator would be awaking dry from naps. (D) The age at which a sibling was toilet trained has no implications for training this child.
質問 # 434
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. Phone a rape counselor to begin working with the victim as soon as she enters the hospital.
- B. Do not leave the victim alone to collect her thoughts.
- C. Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.
- D. Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.
正解：C
解説：
Explanation
(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 # 435
An expected response to sodium polystyrene sulfonate (Kayexalate) is:
- A. Increase in serum magnesium
- B. Decrease in serum calcium
- C. Decrease in serum potassium
- D. Increase in serum HCO3
正解：C
解説：
(A) Sodium polystyrene sulfonate administration will not increase serum magnesium. Hypermagnesemia is virtually unknown except for clients in renal failure. (B) Sodium polystyrene sulfonate administration is not known to increase serum bicarbonate. (C) Decrease in serum potassium, the expected response of sodium polystyrene sulfonate, is secondary to the binding of this drug and potassium in the colon, and potassium is removed through the feces. (D) Serum calcium may actually increase with sodium polystyrene sulfonate administration, especially if calcium chloride is administered concurrently with this drug.
質問 # 436
The child with iron poisoning is given IV deferoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:
- A. Stop the medication, and begin a normal saline infusion
- B. Take all vital signs, and report to the physician
- C. Assess urinary output, and if it is 30 mL an hour, maintain current treatment
- D. Discontinue the IV
正解：A
解説：
Section: Questions Set A
Explanation:
(A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child's obvious allergic reaction.
質問 # 437
The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is:
- A. Hypertensive crisis
- B. Tardive dyskinesia
- C. Oculogyric crisis
- D. Orthostatic hypotension
正解：A
解説：
(A) Oculogyric crisis, involuntary upward deviation and fixation of the eyeballs, is usually associated with either postencephalitic parkinsonian or drug-induced extrapyramidal symptoms (EPS). (B) Hypertensive crisis is a potentially life-threatening side effect. This may occur if the client ingests foods, beverages, or medications containing tyramine. (C) Orthostatic hypotension, a drop in blood pressure resulting from a rapid change of body position, can occur with the administration of antidepressants. (D) Tardive dyskinesia, characterized by slow, rhythmical, automatic or stereotyped muscular movements, usually is associated with the administration of certain antipsychotic medications.
質問 # 438
To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?
- A. Increase in balance of myocardial O2 supply and demand
- B. Negative chronotropic therapy
- C. Afterload reduction therapy
- D. Positive inotropic therapy
正解：D
解説：
Section: Questions Set A
Explanation:
(A) Inotropic therapy will increase contractility, which will increase myocardial O2 demand. (B) Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. (D) Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand.
質問 # 439
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4" and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
- A. Assess vital signs
- B. Assign her to a room with someone her own age
- C. Obtain an accurate weight
- D. Search the client's purse for pills
正解：A
解説：
Explanation
(A) On admission, vital signs are the highest priority. Weight is not a vital sign. (B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a high priority. (C) Vital signs are a high priority when working with selfdestructive clients. (D) Room assignment is of low priority.
質問 # 440
A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?
- A. "Perhaps you and I can discover what produces your anxiety."
- B. "Don't worry, everything will be all right on your visit with your parents."
- C. "Why do you feel this way?"
- D. "Tell me about your dislike for your parents."
正解：A
解説：
Section: Questions Set E
Explanation:
(A) Asking the client to provide an explanation for her feelings is often intimidating. (B) This response is probing and may make the client feel used and valued only for the information she can provide. (C) This underrates the client's feelings and belittles her concerns. It may cause the client to stop sharing feelings for fear that they will be ridiculed. (D) The emphasis is on working with the client. It shows that there is hope for change through collaboration.
質問 # 441
A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?
- A. Murphy's sign
- B. Cullen's sign
- C. Turner's sign
- D. Rebound tenderness
正解：A
解説：
Explanation/Reference:
Explanation:
(A) This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. (B) This sign indicates areas of inflammation within the peritoneum, such as with appendicitis.
It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. (C) This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. (D) This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.
質問 # 442
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
- A. Serum glucose level of 180
- B. Serum potassium level of 3.7
- C. Urine output 22 mL/hr for 2 hours
- D. Small T wave of ECG
正解：C
解説：
Section: Questions Set G
Explanation
Explanation:
(A) Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. (B) Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. (C) A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate over infusion of potassium and hyperkalemia. (D) Glucose levels of <200 are desirable.
質問 # 443
The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?
- A. Normal saline
- B. Ringer's lactate
- C. D5 with Ringer's lactate
- D. D5 in water
正解：A
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 # 444
As a nurse works with an adolescent with cystic fibrosis, the nurse begins to notice that he appears depressed and talks about suicide and feelings of worthlessness. This is an important factor to consider in planning for his care because:
- A. It may be a bid for attention and an indication that more diversionary activity should be planned for him
- B. He needs to be observed carefully for signs that his depression has been relieved
- C. He needs to be confronted with his feelings and forced to work through them
- D. No threat of suicide should be ignored or challenged in any way
正解：D
解説：
Explanation
(A) Threats of suicide should always be taken seriously. (B) This client has a life-threatening chronic illness.
He may be concerned about dying or he may actually be contemplating suicide. (C) Sometimes clients who have made the decision to commit suicide appear to be less depressed. (D) Forcing him to look at his feelings may cause him to build a defense against the depression with behavioral or psychosomatic disturbances.
質問 # 445
A 48-year-old client presents with a long history of severedepression unrelieved by medication. He is admitted to the hospital for electroconvulsive therapy. Familymembers are very concerned about this therapy and are requesting information about aftereffects of the treatment. The nurse informs the family that he will:
- A. Be alert and oriented immediately after the treatment
- B. Require no special care after the procedure
- C. Have insomnia for the first few days
- D. Have transient memory loss, confusion, andheadache
正解：D
解説：
Explanation
(A) This answer is correct. The client will be confused and have a memory loss, which is usually temporary, after electroconvulsive shock therapy. (B) This answer is incorrect. The client will experience transient memory loss, look bewildered, and be confused initially. (C) This answer is incorrect. The client will sleep immediately following the treatment. (D) This answer is incorrect. Vital signs are taken at least hourly after treatment. The client is monitored for hypotension, tachycardia, respiratory problems, and possible seizure activity.
質問 # 446
A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:
- A. "The quality of my voice will be excellent after surgery."
- B. "I know I will need special swallowing training after my surgery."
- C. "I may also have to have a radical neck dissection done."
- D. "I will have very little difficulty swallowing after surgery."
正解：D
解説：
Section: Questions Set D
Explanation:
(A) A client with a supraglottic (horizontal partial) laryngectomy would require special swallowing training, not a vertical partial laryngectomy. (B) The quality of the client's voice will be altered but adequate for communication. (C) The client will have minimal difficulty swallowing. (D) A radical neck dissection may be done with a total laryngectomy, but not with a partial laryngectomy.
質問 # 447
Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?
- A. Administration of hypo-osmolar fluids
- B. Decreased serum osmolality
- C. Increased core body temperature
- D. Decreased PaCO2
正解：D
解説：
Explanation
(A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema.
(D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known.
質問 # 448
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. Dobutamine (Dobutrex)
- B. Epinephrine (Adrenalin)
- C. Norepinephrine (Levophed)
- D. Propranolol (Inderal)
正解：B
解説：
(A) Norepinephrine's side effects are primarily related to safe, effective care environment and include decreased peripheral perfusion and bradycardia. (B) Dobutamine's side effects include increased heart rate and blood pressure, ventricular ectopy, nausea, and headache. (C) Propranolol's side effects include elevated blood urea nitrogen, serum transaminase, alkaline phosphatase, and lactic dehydrogenase. (D) Epinephrine increases serum glucose levels by increasing glycogenolysis and inhibiting insulin release. Prolonged use can elevate serum lactate levels, leading to metabolic acidosis, increased urinary catecholamines, false elevation of blood urea nitrogen, and decreased coagulation time.
質問 # 449
A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:
- A. Hyperoxygenate before and after suctioning
- B. Suction for a maximum of 20 seconds
- C. Maintain clean technique during suctioning
- D. Suction for a maximum of 30 seconds
正解：A
解説：
Section: Questions Set D
Explanation:
(A) The maximum time for suctioning is 10-15 seconds. (B) Supplemental O2should be administered before and after suctioning to reduce hypoxia. (C) The maximum time for suctioning is 10-15 seconds. (D) Strict sterile technique should be used during suctioning.
質問 # 450
A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia?
- A. Klebsiellapneumonia
- B. Pneumococcal pneumonia
- C. Escherichia colipneumonia
- D. Legionella pneumophilapneumonia
正解：B
解説：
Explanation/Reference:
Explanation:
(A)Klebsiellapneumonia is caused by gram-negative bacteria. (B) Pneumococcal pneumonia is caused by gram-positive bacteria. (C)Legionella pneumophilapneumonia is a nonbacterial pneumonia. (D)E.
colipneumonia is caused by gram-negative bacteria.
質問 # 451
......
NCLEX NCLEX-RN問題集PDFのベストを目指すなら問題集を使おう 目指そう高得点：https://www.passtest.jp/NCLEX/NCLEX-RN-shiken.html
NCLEX Certification NCLEX-RN試験と認定テストエンジン：https://drive.google.com/open?id=1Wr1zJjsMwfFYSSqibenTjLFQ9yrDYCat