[2022年更新]合格できるNCLEX NCLEX-RN試験最新865問題 [Q104-Q125]

質問104、 A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:

質問105、 A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the “tension-building phase,” the nurse might expect the client to describe which of the following?

質問106、 What is the most effective method to identify early breast cancer lumps?

質問107、 A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?

質問108、 The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2°F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician’s orders should the RN question?

質問109、 Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities

質問110、 A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?

質問111、 A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?

質問112、 On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking “the blue pill” (haloperidol) in the morning and evening, and “the white pill” (benztropine) right before bedtime. The nurse might suggest to the client that she try:

質問113、 An obstructing stone in the renal pelvis or upper ureter causes:

質問114、 A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?

質問115、 The most commonly known vectors of Lyme disease are:

質問116、 A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?

質問117、 The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?

質問118、 A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to
other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?

質問119、 A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:

質問120、 A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February
17, 18, and 19. The nurse calculates her expected date of delivery to be:

質問121、 As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:

質問122、 A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience?

質問123、 Which of the following nursing care goals has the highest priority for a child with epiglottitis?

質問124、 An 8-year-old child comes to the physician’s office complaining of swelling and pain in the knees. His mother says, “The swelling occurred for no reason, and it keeps getting worse.” The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history?

質問125、 A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be: