NCLEX-PN 形式の練習問題（LPN/LVN）：直前対策パック

A goal states: "The patient will report pain of 3/10 or less within one hour of analgesia." After one hour the patient reports 6/10. What should the nurse do?

1. ARecord the goal as met, as the pain has gone down
2. BWait until the next day to evaluate again
3. CChange the goal to 6/10 or less so that it counts as met
4. DRecord the goal as not met and review the plan

During medicines reconciliation, the patient says they take an anticoagulant at home, but it has not been prescribed in hospital. What should the nurse do?

1. AGive the patient's own supply without telling anyone
2. BTell the patient to stop it for good
3. CInform the prescriber so the omission can be reviewed
4. DIgnore it, as the hospital doctor knows best

患者の胸部の一部に帯状疱疹があり、免疫は正常で、病変は完全に覆うことができます。通常、どの予防策が必要ですか？

1. A陽圧の防護環境
2. B病変を覆った標準予防策
3. C飛沫予防策のみ
4. D陰圧室での空気予防策

A nurse has a needlestick from a patient with hepatitis B. The nurse finished the vaccine series and has a documented protective antibody level. Which statement is correct?

1. AHepatitis B immune globulin and a complete new vaccine series are both needed at once
2. BNo hepatitis B treatment is needed, but the injury is still reported and followed up
3. CNo reporting is needed because the nurse is immune
4. DThe nurse must stop all patient care for six months

予測されず、速やかなフォローアップが必要な所見はどれですか？

1. Aヘパリンを点滴中の患者に、新たな黒いタール状の便が出た
2. B腹腔鏡下胆嚢手術の 1 日後の患者が、右肩の痛みを訴えている
3. C長年の COPD の患者が樽状胸郭を呈している
4. D肝硬変が知られている患者の黄色い皮膚が、変わっていない

START 法のトリアージで、歩けない成人が 1 分間に 28 回呼吸し、橈骨動脈の脈を触れず、毛細血管再充満時間が 4 秒です。どの区分になりますか？

1. A呼吸数が 30 回/分未満なので、黄（待機可能）
2. B黒（救命困難）
3. C赤（最優先）
4. D緑（軽症）

心臓のリズムにとって最も危険な電解質異常は？

1. Aナトリウムの低下
2. Bカリウムの高すぎや低すぎ
3. Cクロールの上昇
4. Dリン酸の低下

During a general anaesthetic, a patient develops a rapidly rising temperature, muscle rigidity and rising carbon dioxide levels. What should be suspected?

1. AMalignant hyperthermia
2. BA normal response to surgery
3. CNeuroleptic malignant syndrome from antipsychotics
4. DPostoperative infection

A patient receiving chemotherapy has an ANC of 300/µL and a new temperature of 38.3 °C (100.9 °F). What should the nurse do first?

1. ARemove extra blankets and offer a tepid sponge bath
2. BEncourage oral fluids and record the fever in the chart
3. CReport it at once so cultures and antibiotics start quickly
4. DGive acetaminophen (paracetamol) and recheck the temperature in 4 hours

The nurse teaches a patient with thrombocytopenia (platelets 25 × 10³/µL) about home safety. Which statement shows a need for further teaching?

1. A"I'll take aspirin if I get a headache"
2. B"I'll use an electric razor to shave"
3. C"I'll use a soft-bristled toothbrush"
4. D"I'll blow my nose gently, not forcefully"

After naloxone reverses an opioid overdose, why must the patient be watched closely?

1. ANaloxone itself causes respiratory depression at high doses
2. BNaloxone makes the opioid stay longer in the body
3. CNaloxone may wear off before the opioid does, so breathing can slow again
4. DNaloxone often causes severe low blood glucose a few hours after the dose

A patient with an epidural infusion of local anaesthetic becomes hypotensive. What is the most likely mechanism?

1. AThe epidural catheter has caused heavy bleeding
2. BBlockade of sympathetic nerves causes vasodilation
3. CThe local anaesthetic causes a severe allergic reaction
4. DThe drug increases urine output and causes dehydration

Why must inspired air be humidified for a patient with a tracheostomy?

1. ADry air is needed to stop secretions forming in the trachea
2. BThe nose and upper airway, which warm and moisten air, are bypassed
3. CHumidification prevents the cuff from deflating
4. DHumidified air contains more oxygen than dry air at the same flow

After an anaphylactic reaction to a bee sting that responded to adrenaline (epinephrine), a patient asks to go home immediately. Which advice is most appropriate?

1. AStay in hospital for at least two weeks on daily intravenous antihistamines
2. BStay for observation, then go home with an adrenaline auto-injector and teaching
3. CGo home straight away, because anaphylaxis never recurs once adrenaline has worked
4. DGo home and take antihistamines only if the throat swells

During continuous bladder irrigation, 3200 mL drains out in a shift. 2500 mL of irrigation fluid was put in. What is the true urine output?

1. A2500 mL
2. B700 mL
3. C5700 mL
4. D3200 mL

A 66-year-old smoker has had two episodes of painless red urine. Urine cultures are negative. Which plan is most appropriate?

1. AAnother course of antibiotics for a UTI
2. BAdvise more fluids and review in a year
3. CUrgent referral for cystoscopy and imaging
4. DReassure him, because the blood has stopped

During the first infusion of a monoclonal antibody such as rituximab, which problem is most important to watch for?

1. AAn infusion reaction, such as fever, rigors or breathlessness
2. BSudden hair loss during the infusion
3. CSevere constipation within the first hour of starting the infusion
4. DA rise in platelet count above normal

After surgery, a patient says they have "no pain" but grimaces, breathes shallowly and refuses to move or cough. What should the nurse do?

1. AAccept the statement and record a pain score of 0
2. BTell the patient firmly that they must stop hiding their pain from staff
3. CInsist they walk without any analgesia
4. DExplore their beliefs and explain how analgesia aids recovery

Why is indomethacin generally not used as a tocolytic after about 32 weeks?

1. AIt triggers maternal hypoglycaemia
2. BIt causes severe maternal hypertension
3. CIt stimulates stronger contractions late in pregnancy
4. DIt can close the fetal ductus arteriosus too early

Which finding is a sign that the placenta is separating in the third stage of labour?

1. AThe uterus becomes soft and wide
2. BSudden severe abdominal pain
3. CA gush of blood and lengthening of the cord
4. DImmediate fall in maternal blood pressure

Why is the Lund and Browder chart preferred over the adult "rule of nines" for estimating burn size in children?

1. AIt counts the number of blisters on the body
2. BIt is mainly used for small burns of the hands, feet and face in children
3. CIt measures the depth of the burn rather than its area
4. DIt adjusts for the larger head and smaller legs of young children

Several family members, including the children, have had headaches, nausea and drowsiness all winter. They feel better when away from home. What should the nurse suspect?

1. ASeasonal influenza
2. BFood poisoning
3. CMigraine that runs in the family
4. DCarbon monoxide poisoning

将来の自殺の最も強い予測因子の 1 つはどれですか？

1. A強い宗教的信仰があること
2. B結婚していること
3. C以前の自殺企図
4. D安定した仕事があること

MAOI を服用中の患者が、パーティーから戻ると、後頭部の激しい頭痛、首のこわばり、動悸を訴えます。看護師が最初にすべきことは何ですか？

1. A血圧を測定し、処方者に緊急に連絡する
2. B頭痛のために濃いコーヒーを 1 杯与える
3. C横になって寝てやり過ごすよう助言する
4. D次の MAOI の服用を早めて与える

練習問題（数値は架空のもので、臨床上の指針ではありません）。 ある患者の体温は 100.2 °F です。°C = (°F − 32) × 5/9 を使って摂氏 T に換算してください。小数第1位に丸めてください。

練習問題（数値は架空のもので、臨床上の指針ではありません）。 ある点滴は 3 mcg/min を投与します。この投与速度 D を mg/h で表してください。

バイアルに粉末 500 mg が入っています。ラベルには「注射用水 1.8 mL を加えると全量 2 mL になる」とあります。処方は 375 mg です。溶解した溶液を何 mL V 投与しますか？

患者の体重は 198 lb です。処方は 1 回量として 2 mg/kg で、原液は 1 mL 中に 40 mg を含みます。1 kg = 2.2 lb として、何 mL V 投与しますか？

40 mL/h での輸液が指示されていますが、ポンプがありません。15 滴/mL の輸液セットを使って自然落下で投与します。滴下速度 R を 1 分あたりの滴数で求めなさい。

点滴が 20 滴/mL のセットで 30 滴/分で落ちています。バッグには 750 mL 残っています。あと何時間 t で空になりますか？ 小数第 1 位まで四捨五入してください。

練習問題（数値は架空のもので、臨床上の指針ではありません）。 記録は、ある患者の 12 時間勤務帯 1 回分の摂取量と排泄量を示しています。点滴は勤務帯の間ずっと表示の流量で投与されました。水分出納 B = 摂取量 − 排泄量 を mL で求めてください（負の答えは正味の喪失を意味します）。 氷片は体積の半分として数えます。

練習問題（数値は架空のもので、臨床上の指針ではありません）。 500 mL のバッグを 06:00 に開始し、ポンプで 80 mL/h で投与しています。07:30 の時点でバッグには何 mL V 残っていますか？

練習問題（数値は架空のもので、臨床上の指針ではありません）。 練習用のチャートに GCS 5、E2、V2 と記録されています。記録された運動反応のスコア M はいくつで、どの反応を表していますか。数字で答えてください。

練習問題（数値は架空のもので、臨床上の指針ではありません）。 ある成人の体重は 69 kg、身長は 158 cm です。BMI を計算し、WHO の体重区分をクリックしてください。

1. 1低体重（やせ）
2. 2普通体重
3. 3過体重
4. 4肥満クラスI
5. 5肥満クラスII
6. 6肥満クラスIII