[2025年03月20日]NCLEX-RN問題集完全版問題、試験学習ガイド
NCLEX Certification無料認定試験材料PassTestからの865問題
NCLEX-RN試験は、アメリカ合衆国でライセンスを取得するためにRNにとって重要なステップです。試験に合格することは、50州、コロンビア特別区、および米国領土全てでRNとして実践するための要件です。試験は一年中提供され、受験者は一年中いつでも試験をスケジュールすることができます。試験の費用は州によって異なり、$200から$500まで範囲があります。
質問 # 95
The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, "It's not so easy for me to just go right to the hospital like that." After acknowledging her feelings, which of these approaches by the nurse would probably be best?
- A. Repeat the physician's reasons for advising immediate hospitalization.
- B. Explore with the client her perceptions of why she is unable to go to the hospital.
- C. Explain to the client that she is ultimately responsible for her own welfare and that of her baby.
- D. Stress to the client that her husband would want her to do what is best for her health.
正解：B
解説：
Explanation
(A) This answer does not hold the client accountable for her own health. (B) The nurse should explore potential reasons for the client's anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization. (C) Repeating the physician's reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. (D) The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the client's potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice?
質問 # 96
The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?
- A. Ringer's lactate
- B. D5 in water
- C. Normal saline
- D. D5 with Ringer's lactate
正解：C
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 # 97
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. Altered oral mucous membrane
- B. High risk for infection
- C. Ineffective airway clearance
- D. Activity intolerance
正解：C
解説：
(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 # 98
Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders?
- A. The disorder is always carried on the X chromosome.
- B. Heterozygotes are affected.
- C. Two affected parents always have affected children.
- D. Only females are affected.
正解：C
解説：
Explanation
(A) The term heterozygote refers to an individual with one normal and one mutant allele at a given locus on a pair of homologous chromosomes. An individual who is heterozygous for the abnormal gene does not manifest obvious symptoms. (B) Disorders carried on either the X or Y sex chromosome are referred to as sex-linked recessive. (C) Either sex may be affected by autosomal recessive genetic disorders because the responsible allele can be on any one of the 46 chromosomes. (D) If both parents are affected by the disorder and are not just carriers, then all their children would manifest the same disorder.
質問 # 99
In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle?
- A. Proliferative phase
- B. Menstrual phase
- C. Ischemic phase
- D. Secretory phase
正解：D
解説：
Explanation
(A) Menses occurs during the menstrual phase, during which levels of both estrogen and progesterone are decreased. (B) The ovarian hormone responsible for the proliferative phase, during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone responsible for the secretory phase is progesterone, which is secreted by the corpus luteum and causes marked swelling in the uterine endometrium.
(D) The corpus luteum begins to degenerate in the ischemic phase, causing a fall in both estrogen and progesterone.
質問 # 100
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Hemolytic transfusion reaction
- B. Allergic transfusion reaction
- C. Circulatory overload
- D. Febrile transfusion reaction
正解：B
解説：
Explanation/Reference:
Explanation:
(A) A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. (B) Fever, chills, and headaches are indicative of a febrile transfusion reaction. (C) Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. (D) Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
質問 # 101
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. Metabolic acidosis
- B. Respiratory alkalosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
正解：A
解説：
Section: Questions Set C
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 # 102
A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:
- A. Monitor for visual disturbances, a side effect of digoxin
- B. Take the apical pulse for a full minute
- C. Not give the digoxin if the pulse is_100
- D. Not give the digoxin if the pulse is_60
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Digoxin should not be given to adults with an apical pulse < 60 bpm. (B) Digoxin should be given to children with an apical pulse > 100 bpm. With a pulse < 100 bpm, the medication should be withheld and the physician notified. (C) Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. (D) Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.
質問 # 103
The nurse is planning a reality orientation program for a group of clients with organic brain syndrome at the mental health center. Props that could be used for this program are:
- A. A library of biographical books
- B. Large maps and posters depicting area of current residence
- C. A litter of kittens for the clients to pet
- D. Month-old magazines that are provided by volunteers
正解：B
解説：
(A) This answer is incorrect. Current magazines would be appropriate. (B) This answer is correct. Maps of the state and town and posters that depict current events in the area are appropriate props. (C) This answer is incorrect. Kittens would be appropriate for pet therapy, not reality therapy. (D) This answer is incorrect. Biographies depict a past, not a present, orientation.
質問 # 104
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
- A. Bladder spasms
- B. Clot formation
- C. Prostatic infection
- D. Scrotal edema
正解：B
解説：
Section: Questions Set F
Explanation:
(A) The purpose of bladder irrigation is not to prevent bladder spasms, but to drain the bladder and decrease clot formation and obstruction. (B) A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage. (C) Scrotal edema seldom occurs after TURP. Bladder irrigation will not prevent this complication.
(D) Prostatic infection seldom occurs after TURP. Bladder irrigation will not prevent this complication.
質問 # 105
A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.
What tests should the nurse anticipate?
- A. Aspartate transaminase, alanine transaminase
- B. Lactic dehydrogenase, CPK
- C. Sedimentation rate, WBC count
- D. Reticulocyte count, creatinine phosphokinase (CPK)
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury. (C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.
質問 # 106
A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:
- A. Attempts to direct the client's attention to the here and now
- B. Exhibits sincere interest in the delusional voices
- C. Encourages the client to discuss the voices
- D. Gives the medication as necessary for the acting-out behavior
正解：A
解説：
(A) This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. (B) This answer is correct. The nurse should appropriately present reality. (C) This answer is incorrect. Showing interest would reinforce the delusional system. (D) This answer is incorrect. The statement only indicates that the client is hearing voices. It does not state that the client is acting out.
質問 # 107
While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to
her. The nurse will handle this effectively if she:
- A. Leaves the room in order to compose herself
- B. Ignores the remarks and hopes he will not try it again
- C. Politely tells the client, "Keep your hands off "
- D. Confronts the remarks but attempts not to reject the client
正解：D
解説：
(A)
This response does not recognize normal feelings of attraction and rejects the client.
(B)
By ignoring the situation, the nurse has not set limits to discourage other remarks or perhaps more sexually aggressive behavior. (C) By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship. (D) Leaving the room does not deal with setting limits for future interactions.
質問 # 108
A 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client's:
- A. Thought processes
- B. Mood and affect
- C. Level of insight
- D. Abstracting abilities
正解：B
解説：
Section: Questions Set G
Explanation:
(A) Assessing the client's level of insight is an important part of the mental status exam (MSE), but it does not reflect suicide potential. (B) Assessing the client's thought processes is an important part of the MSE, but it does not reflect suicide potential. (C) Assessing the client's mood and affect is an important part of the MSE, and it can be a very valuable indicator of suicide potential. Frequently a client who has decided to proceed with suicide plans will exhibit a suddenly improved mood and affect. (D) Assessing a client's abstracting abilities is an important part of the MSE, but it does not reflect suicide potential.
質問 # 109
MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:
- A. Vasoconstrictive
- B. Antiemetic
- C. Hypertensive
- D. Vasodilative
正解：D
解説：
(A) An anticonvulsant effect is the goal of drug therapy for PIH. However, we would not
want to increase the vasoconstriction that is already present. This would make the symptoms more severe. (B) An anticon-vulsant effect and vasodilation are the desired outcomes when administering this drug. (C) An anticonvulsant effect is the goal of drug therapy for PIH; however, hypertensive drugs would increase the blood pressure even more. (D) An anticonvulsant effect is the goal of drug therapy for PIH. MgSO4is not classified as an antiemetic. Antiemetics are not indicated for PIH treatment.
質問 # 110
A female client is admitted to the emergency department complaining of severe right-sided abdominal pain and vaginal spotting. She states that her last menstrual period was about 2 months ago. A positive pregnancy test result and ultrasonography confirm an ectopic pregnancy. The nurse could best explain to the client that her condition is caused by:
- A. A distended or ruptured fallopian tube
- B. Abnormal development of the embryo
- C. A congenital abnormality of the tube
- D. A malfunctioning of the placenta
正解：A
解説：
Explanation/Reference:
Explanation:
(A) The embryo itself may develop normally in the first several weeks of an ectopic pregnancy. (B) An ectopic pregnancy in the fallopian tube causes severe pain owing to the size of the growing embryo within the narrow lumen of the tube, causing distention and finally rupture within the first 12 weeks of pregnancy.
(C) The Fallopian tube may either be normal or contain adhesions caused by a history of pelvic inflammatory disease or tubal surgeries, neither of which are congenital causes. (D) An ectopic pregnancy does not involve a dysfunctional placenta, but the implantation of the blastocyst outside the uterus.
質問 # 111
The nurse enters the room of a client on which a "do not resuscitate" order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, "please save her!" The nurse's action would be:
- A. Call a code and proceed with cardiopulmonary resuscitation.
- B. Call the physician and inform him that the client has expired.
- C. Remind the husband that the physician wrote an order not to resuscitate.
- D. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts.
正解：A
解説：
Section: Questions Set G
Explanation:
(A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
質問 # 112
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. A full bladder
- B. Normal involution
- C. An infection pain
- D. A hemorrhage
正解：A
解説：
Explanation/Reference:
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 # 113
A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?
- A. He is euphoric for about an hour after each injection.
- B. He asks for pain medication although his blood pressure and pulse rate are normal.
- C. The client requests pain medicine every 4 hours.
- D. He is asleep 30 minutes after receiving the IV morphine.
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. (B) Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. (C) A person may be in pain even with normal vital signs. (D) A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain.
質問 # 114
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Reporting any signs of crepitus immediately to the physician
- B. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
- C. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
- D. Avoiding manipulation of the tracheostomy including cuff deflation
正解：D
解説：
Explanation/Reference:
Explanation:
(A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. (D) The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
質問 # 115
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. Thirst
- B. Edema
- C. Diabetes insipidus
- D. Water satiety
正解：A
解説：
Section: Questions Set C
Explanation:
(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 # 116
In an interview for suspected child abuse, the child's mother openly discusses her feelings.
She feels her husband is too aggressive in disciplining their child. The child's father states,
"Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child." Based on this remark, the nurse would make the following nursing diagnosis:
- A. Fear related to retaliation by the father
- B. Ineffective coping
- C. Actual injury related to poor impulse control by the father
- D. Altered family process related to physical abuse
正解：D
解説：
(A) There is no evidence of fear as the child is unable to communicate. (B) There is actual injury, but the parents have not yet admitted causing the child's injuries. (C) This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. (D) Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.
質問 # 117
When assessing the client 6 hours postpartum, the fundus is found to be U +3, displaced to the right of midline, and slightly boggy. The nurse would first:
- A. Grasp the uterus and massage vigorously
- B. Increase the IV oxytocin drip rate
- C. Give methergine IM
- D. Assess for a full bladder
正解：B
解説：
(A)Oxytocin may not be necessary if the bladder is emptied and if the uterus remains firm, midline, and at about U11 after massage. (B) The same rationale as for answer "A" applies.
(C)A full bladder is the most common cause of uterine atony. If the bladder is full, it should be emptied and the uterus reassessed before further intervention. (D) If the bladder is full, the uteruswill not stay contracted or return to a normal position. Overly vigorous massage also encourages uterine atony.
質問 # 118
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NCLEX-RN試験は、複数選択肢問題からなり、看護知識、批判的思考、意思決定能力、問題解決能力を評価することを目的としています。問題数や試験時間は、受験者のパフォーマンスによって異なり、最小問題数は75問、最大問題数は265問です。試験内容は最新の看護実践に基づいており、現在の看護職に関連しています。
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。
NCLEX-RN試験の問題集簡単まとめ：https://www.passtest.jp/NCLEX/NCLEX-RN-shiken.html
リアルNCLEX-RNは100% カバー率リアル試験問題を使おう：https://drive.google.com/open?id=1Wr1zJjsMwfFYSSqibenTjLFQ9yrDYCat