NCLEX NCLEX-RN最新問題集[2025]高得点を掴み取れ
NCLEX-RN問題集PassTest100%合格率保証
質問 # 122
A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?
- A. A decreased blood sugar level
- B. An increased blood sugar level
- C. Fluctuating levels with a predawn increase
- D. A normal blood sugar level
正解：B
解説：
(A) Blood sugar levels increase when the body responds to stress and illness. (B) Blood sugar levels increase when the body responds to stress and illness. (C) Hyperglycemia occurs because glucose is produced as the body responds to the stress and illness of cellulitis. (D) Blood sugar levels remain elevated as long as the body responds to stress and illness.
質問 # 123
A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:
- A. Create a sense of well-being and self-worth
- B. Promote normal growth and development
- C. Establish an effective, habitual breathing pattern
- D. Help him overcome respiratory infections
正解：C
解説：
Explanation
(A) Regular exercise does promote a sense of well-being and selfworth, but this is not the ultimate goal of exercise for this client. (B) Regular chest physiotherapy, not exercise per se, helps to prevent respiratory infections. (C) Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern. (D) Along with adequate nutrition and minimization of pulmonary complications, exercise does help promote normal growth and development. However, exercise is promoted primarily to help establish a habitual breathing pattern.
質問 # 124
To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:
- A. Rinse the mouth and gargle with warm water after each use of the inhaler
- B. Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day
- C. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection
- D. Rinse the mouth before each use to eliminate colonization of bacteria
正解：A
解説：
Section: Questions Set B
Explanation:
(A) It is sufficient to rinse the plastic holders with warm water at least once per day. (B) It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity. (C) Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. "Neutralizing" the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. (D) Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler.
質問 # 125
An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?
- A. A family member who is having marital problems and is regularly abusing alcohol
- B. A person with adequate communication and coping skills who is employed by the family
- C. A lifelong friend of the client who is often confused
- D. A friend of the family who wants to help but is minimally competent
正解：A
解説：
Explanation
(A) This answer is correct. Two risk factors are identified in this answer. (B) This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. (C) This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. (D) This answer is incorrect. This individual has a vested interest in providing care.
質問 # 126
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. Diabetes insipidus
- B. Water satiety
- C. Thirst
- D. Edema
正解：C
解説：
Explanation/Reference:
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 # 127
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day.
During a recent clinic visit, she says to the nurse, "I can't stay still at night. I toss and turn and can't fall asleep." The nurse suspects that she may be experiencing:
- A. Akinesia
- B. Dystonia
- C. Akathisia
- D. Opisthotonos
正解：C
解説：
Section: Questions Set G
Explanation:
(A) Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. (B) Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. (C) Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. (D) Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heels are bent backward while the body is bowed forward, is an example of EPS.
質問 # 128
The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:
- A. Keeping a careful account of the amount of pancreatic enzymes ingested
- B. Carefully recording amounts and types of foods ingested
- C. Keeping a strict account of the number of calories ingested
- D. Careful monitoring of weight loss or gain
正解：D
解説：
Explanation
(A) Consistent weight gain, even if it is slow, is an indication that the child is eating and digesting sufficient calories. (B) Recording how much the child eats is useful, but it is not an indicator of how well his body is using the foods consumed. (C) Counting calories will indicate how much he is eating, but it will not reflect whether or not the foods are properly digested. (D) Keeping track of the enzyme intake will indicate compliance with medication but not whether the child is getting sufficient calories.
質問 # 129
After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well- baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?
- A. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn's eyes.
- B. The nurse counts the instruments and sponges with the scrub nurse.
- C. The nurse makes sure the mother and her newborn have been tagged with identical bands.
- D. The physician verifies the exact time of birth.
正解：C
解説：
Explanation/Reference:
Explanation:
(A) The delivery room personnel are responsible for verifying time of birth. (B) The scrub and circulating nurses count sponges and instruments. (C) This intervention is done in the nursery. (D) Tagging the mother and infant with identical bands is of utmost importance. The mother wears one band, and the newborn wears two. Identical numbers on the three bands provide identification for the newborn and the birth mother. Every time the newborn is brought to the mother after delivery, those bands are checked to be sure that the numbers are identical.
質問 # 130
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
- A. Decreased cardiac output
- B. Fluid volume deficit
- C. Severe hypotension
- D. Fluid volume excess
正解：D
解説：
Explanation
(A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D) Hypertension is the result of hypervolemia.
質問 # 131
A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to "fatigue," and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:
- A. Psychotic depression
- B. Severe anxiety
- C. Severe depression
- D. Deep depression
正解：C
解説：
(A) A client in deep depression would have been brought to the mental health center and would not be physically able to seek help for herself. (B) She is not manifesting psychotic symptoms in her behaviors. (C) The client's symptoms are more indicative of depression than anxiety. (D) Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed.
質問 # 132
A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training?
- A. Take two or three favorite toys with the child.
- B. Show disapproval if she does not void or defecate.
- C. Explain to the child she is going to "void" and "defecate."
- D. Have a child-sized toilet seat or training potty on hand.
正解：D
解説：
Explanation
(A) Giving her toys will distract her and interfere with toilet training because of inappropriate reinforcement.
(B) A child-sized toilet seat or training potty gives a child a feeling of security. (C) She should use words that are age appropriate for the child. (D) Children should be praised for cooperative behavior and/or successful evacuation.
質問 # 133
The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:
- A. "I know it was my fault that it happened, because I shouldn't have been out so late."
- B. "I know my date just had so much passion he couldn't handle me saying 'no.' "
- C. "If I had not worn that sexy dress that night, he wouldn't have raped me."
- D. "I know now that it was not my fault, but I want to continue counseling after my discharge."
正解：D
解説：
(A) This response does not show any insight; the client falsely assumes that she is responsible for the rape. (B) The client continues to falsely assume responsibility for the rapist's behavior. (C) The client believes falsely that rape is an act of passion, rather than one of violence, control, and domination. (D) The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.
質問 # 134
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:
- A. Provide nutritious finger foods several times a day.
- B. Order a high-calorie diet with supplements.
- C. Insist that she remain at the table and eat a balanced diet.
- D. Offer to go to the dining room with her and allow her to open the food and inspect what she eats.
正解：A
解説：
Section: Questions Set D
Explanation:
(A) The client is not able to sit for long periods. Forcing her to remain at the table will increase her anxiety and cause her to become hostile. (B) This action will not ensure that the client eats what is ordered. Dietary orders are not within the nurse's scope of practice. (C) Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating "on the run." (D) These clients are not suspicious of the food or insecure in moving about the unit alone.
質問 # 135
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. Eaten construction chalk
- B. Inhaled gasoline fumes
- C. Lead poisoning
- D. Ingested a caustic alkali
正解：D
解説：
Section: Questions Set G
Explanation:
(A, C, D) These agents would not cause ulcerations on mouth and lips. (B) Strong alkali or acids will cause burns and ulcerations on the mucous membranes.
質問 # 136
The following medications were noted on review of the client's home medication profile. Which of the medications would most likely potentiate or elevate serum digoxin levels?
- A. KCl
- B. Quinidine
- C. Theophylline
- D. Thyroid agents
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Hypokalemia can cause digoxin toxicity. Administration of KCl would prevent this. (B) Thyroid agents decrease digoxin levels. (C) Quinidine increases digoxin levels dramatically. (D) Theophylline is not noted to have an effect on digoxin levels.
質問 # 137
A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in onehalf normal saline infusing at 125 mL/hr and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. She last voided 51/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would:
- A. Provide food and fluids at the client's request
- B. Report to the surgeon if the client is unable to void within 8 hours of surgery
- C. Maintain IV, increasing the rate hourly until the client voids
- D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. (B) Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. (C) The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine.
The client may need catheterization or medication. The physician must provide orders for both as necessary. (D) Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.
質問 # 138
A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is
130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
- A. Maternal weight
- B. Previous birth of an infant weighing>9 lb
- C. Age >25 years
- D. Family history of heart disease
正解：B
解説：
Section: Questions Set F
Explanation:
(A) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. (B) The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. (C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. (D) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy.
質問 # 139
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
(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 # 140
A 10-year-old boy has been diagnosed with Legg-Calve Perthes disease. Which of the client's responses would indicate compliance during initial therapy?
- A. Not bearing weight on affected extremity
- B. Drinking large amounts of milk
- C. Putting self on weight reduction diet
- D. Walking short distances 3 times/day
正解：A
解説：
(A) This condition causes aseptic necrosis of the head of the femur in the acetabulum. Drinking large quantities of milk at this time cannot hasten recovery. (B) The aim of treatment is to keep the head of the femur in the acetabulum. Non-weight-bearing is essential. Activity causes microfractures of the epiphysis. (C) In addition to non-weightbearing, clients are often placed on bedrest, which helps to reduce inflammation. Later, active motion is encouraged. (D) Weight is not generally an issue with this disease. Slipped femoral capital epiphysis, which is most frequently observed in obese pubescent children, usually requires a weight reduction diet.
質問 # 141
After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?
- A. One centimeter above the ischial spines
- B. One centimeter below the ischial spines
- C. Located in the pelvic outlet
- D. Has not entered the pelvic inlet yet
正解：A
解説：
Explanation/Reference:
Explanation:
(A) The ischial spines are located on both sides of the midpelvis. These spines mark the diameter of the narrowest part of the pelvis that the fetus will encounter. They are not sharp protrusions that will harm the fetus. Station refers to the relationship between the ischial spines in the pelvis and the fetus. The ischial spines are designated at 0 station. If the presenting part of the fetus is located above the ischial spines, a negative number is assigned, noting the number of centimeters above the ischial spines. Therefore, 1 centimeter below the ischial spines is designated as +1 station. (B) See explanation in A One centimeter above the ischial spines is designated as +1 station. (C) The pelvic inlet is the first part of the pelvis that the fetus enters in routine delivery. The midpelvis is the second part of the pelvis to be entered by the fetus. The ischial spines are located on both sides of the midpelvis. (D) The pelvic outlet is the last part of the pelvis that the fetus will enter. When the fetus reaches this part of the pelvis, birth is near.
質問 # 142
The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?
- A. "This is going to hurt a lot; close your eyes and hold my hand."
- B. "This is a terrible procedure, so don't look."
- C. "Some say this feels like a pinch or a bug bite. You tell me what it feels like."
- D. "This will hurt only a little; try to be a big boy."
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Educating the child about the pain may lessen anxiety. The child should be prepared for a potentially painful procedure but avoid suggesting pain. The nurse should allow the child his own sensory perception and evaluation of the procedure. (B) The nurse should avoid absolute descriptive statements and allow the child his own perception of the procedure. (C) The nurse should avoid evaluative statements or descriptions and give the child control in describing his reactions. (D) False statements regarding a painful procedure will cause a loss of trust between the child and the nurse.
質問 # 143
The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?
- A. Never use abdominal site for a rotation site.
- B. Avoid applying pressure after injection.
- C. Pinch the skin up to form a subcutaneous pocket.
- D. Change needles after injection.
正解：C
解説：
Section: Questions Set B
Explanation:
(A) Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. (B) The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. (C) Massaging the site of injection facilitates absorption of the insulin. (D) Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3-7 days.
質問 # 144
Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?
- A. Erythema
- B. Exudate
- C. Crust
- D. Edema
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Exudate (moist, active drainage) is a clinical sign of wound infection. (B) Crust (dry, scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. (C) Edema (swelling) is a clinical sign of wound infection. (D) Erythema (redness) is a clinical sign of wound infection.
質問 # 145
......
100%合格率リアルNCLEX-RN試験成功を掴み取れ：https://www.passtest.jp/NCLEX/NCLEX-RN-shiken.html
プレミアム良質なNCLEX NCLEX-RNオンライン問題集：https://drive.google.com/open?id=1W0pRcXq9Nof08bMtVn7g5-10AZytmS7z