試験科目：National Council Licensure Examination(NCLEX-RN)
問題と解答：全865問 NCLEX-RN 対策
NO.1 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures
should be included in the postoperative care?
A. Encourage the child to cough up blood if present.
B. Give warm clear liquids when fully alert.
C. Have child gargle and do toothbrushing to remove old blood.
D. Observe for evidence of bleeding.
(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.2 The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for
tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?
A. Vitamin C
B. Vitamin A
C. Vitamin B1
D. Vitamin D
(A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. (B)
Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and
is essential for normal functioning of nervous tissue. (C) Vitamin D regulates absorption of calcium
and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the
formation and maintenance of skin and mucous membranes. It is also essential for normal growth
and development of bones and teeth.
NO.3 A violent client remains in restraints for several hours. Which of the following interventions is
most appropriate while he is in restraints?
A. Measure vital signs at least every 4 hours.
B. Assess skin integrity and circulation of extremities before applying restraints and as they are
C. Release restraints every 2 hours for client to exercise.
D. Give fluids if the client requests them.
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or
refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly
while the client is restrained, not only before restraints are applied and
after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains
agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D)
Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle
tone, skin and joint integrity, and circulation.
NO.4 A female client has just died. Her family is requesting that all nursing staff leave the room. The
family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the
room, requesting that only family members be present. The nurse assigned to the client should
perform the appropriate nursing action, which might include:
A. Tell the family that they may conduct their ceremony in the client's room; however, the nurse
B. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms
C. Respect the client's family's wishes.
D. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be
brought to the morgue.
(A) It is rare that a hospital has a specific policy addressing this particular issue. If the statement is
true, the nurse should show evidence of the policy to the family and suggest alternatives, such as the
hospital chapel. (B) Refusal to leave the room demonstrates a lack of understanding related to the
family's need to grieve in their own manner. (C) The nurse should leave the room and allow the
family privacy in their grief. (D) The family's wish to conduct a religious ceremony in the client's room
is part of the grief process. The request is based on specific cultural and religious differences dictating