NCLEX NCLEX-RN 問題集

質問 1：
Nursing assessment of early evidence of septic shock in children at risk includes:
A. Normal pulses, hypotension, and oliguria
B. Fever, tachycardia, and tachypnea
C. Elevated blood pressure, hyperventilation, and thready pulses
D. Respiratory distress, cold skin, and pale extremities
正解：B
解説: (Topexam メンバーにのみ表示されます)

質問 2：
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
A. Release restraints every 2 hours for client to exercise.
B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
C. Give fluids if the client requests them.
D. Measure vital signs at least every 4 hours.
正解：A
解説: (Topexam メンバーにのみ表示されます)

質問 3：
The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage.
These signs and symptoms would include:
A. Eye pain and itching
B. Blurred vision and dizziness
C. Feeling of eye pressure and headache
D. Eye discharge and hemoptysis
正解：A
解説: (Topexam メンバーにのみ表示されます)

質問 4：
A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:
A. "It's not appropriate for you to try to manipulate the staff into granting your wishes."
B. "Okay, missing one meal won't hurt."
C. "You'll have to eat lunch, or we'll force-feed you."
D. "We will not allow you to starve yourself. You may choose to eat voluntarily or be fed."
正解：D
解説: (Topexam メンバーにのみ表示されます)

質問 5：
A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
A. 100 gtt/min
B. 50 gtt/min
C. 5 gtt/min
D. 1 gtt/min
正解：B
解説: (Topexam メンバーにのみ表示されます)

質問 6：
Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client?
A. Furosemide 20 mg/PO for decreased urine output
B. Magnesium salicylate to decrease inflammation
C. Nifedipine 10 mg SL for B/P 140/90
D. Nitroglycerin gr 1/150 for chest pain
正解：C
解説: (Topexam メンバーにのみ表示されます)

質問 7：
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. Alba
B. Rubra
C. Rosa
D. Serosa
正解：D
解説: (Topexam メンバーにのみ表示されます)

質問 8：
Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders?
A. Two affected parents always have affected children.
B. The disorder is always carried on the X chromosome.
C. Heterozygotes are affected.
D. Only females are affected.
正解：A
解説: (Topexam メンバーにのみ表示されます)

質問 9：
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
A. She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time.
B. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
C. She places her infant on her right side after feeding her.
D. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.
正解：A
解説: (Topexam メンバーにのみ表示されます)