NCLEX-RN 試験解説問題、NCLEX-RN テスト難易度


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試験科目:National Council Licensure Examination(NCLEX-RN)
問題と解答:全865問 NCLEX-RN 過去問題

>> NCLEX-RN 過去問題


NO.1 Three weeks following discharge, a male client is readmitted to the psychiatric unit for
depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse
admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am
just no good." Which response by the nurse is most appropriate at this time?
A. "You've been feeling sad and alone for some time now?"
B. "Don't you think this is a sign of your illness?"
C. "I know with your wife and new baby that you do have a lot to live for."
D. "I don't think you are worthless. I'm glad to see you, and we will help you."
Answer: A

NCLEX-RN 問題数   NCLEX-RN 知識   
This response does not acknowledge the client's feelings.
This is a closed question and does not encourage communication.
This response negates the client's feelings and does not require a response from the client. (D) This
acknowledges the client's implied thoughts and feelings and encourages a response.

NO.2 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures
should be included in the postoperative care?
A. Give warm clear liquids when fully alert.
B. Encourage the child to cough up blood if present.
C. Have child gargle and do toothbrushing to remove old blood.
D. Observe for evidence of bleeding.
Answer: D

NCLEX-RN 体験記   NCLEX-RN ソフト   
(A) The nurse should discourage the child from coughing, clearing the throat, or putting objects in his
mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert.
Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to
distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous
toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual, may occur.
The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright
red blood, continuous swallowing, and changes in vital signs.

NO.3 A 24-year-old client presents to the emergency department protesting "I am God." The nurse
identifies this as a:
A. Illusion
B. Conversion
C. Delusion
D. Hallucination
Answer: C
(A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory
experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion
is the expression of intrapsychic conflict through sensory or motor manifestations.

NO.4 An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his
left leg that started approximately 20 minutes ago. When performing the admission assessment, the
nurse would expect to observe which of the following:
A. Both lower extremities cyanotic when placed in a dependent position
B. Both lower extremities warm to touch with 2_pedal pulses
C. The left leg warmer to touch than the right leg
D. Decreased or absent pedal pulse in the left leg
Answer: D

NCLEX-RN 正確率   
(A) This statement describes a normal assessment finding of the lower extremities. (B) This
assessment finding reflects problems caused by venous insufficiency. (C) Decreased or absentpedal
pulses reflect a problem caused by arterial insufficiency. (D) The leg that is experiencing arterial
insufficiency would be cool to touch due to the decreased circulation.

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