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. AChange the goal to 6/10 or less so that it counts as met
2. BRecord the goal as not met and review the plan
3. CRecord the goal as met, as the pain has gone down
4. DWait until the next day to evaluate again

Under the Mental Capacity Act 2005 (England and Wales), a patient with capacity makes a decision staff think is unwise. What follows?

1. AAn unwise decision on its own proves that the person lacks capacity
2. BStaff may override any decision they think is unwise
3. CThe family must be asked to make the decision instead
4. DAn unwise decision alone does not mean the person lacks capacity

A nurse has just given an intramuscular injection with a safety needle. What should the nurse do next with the needle?

1. ALay it on the medication tray and discard it later
2. BActivate the safety device and drop it into a sharps container at once
3. CRecap it carefully with both hands and dispose of it after the drug round
4. DBend the needle to make it unusable, then discard it

無菌的な中心静脈カテーテルのドレッシング交換中に、同僚が開いた滅菌野の上に腕を伸ばしてテープを手渡しました。看護師はどうすべきですか？

1. A滅菌野は汚染されたとみなし、新しく準備し直す
2. B同僚は滅菌物に触れていないので、続ける
3. C滅菌タオルで滅菌野を覆い、その上で続ける
4. D腕が上を通った場所に最も近い物だけを取り除く

An arterial blood gas shows pH 7.28, PaCO₂ 40 mmHg (5.3 kPa) and HCO₃⁻ 16 mEq/L (mmol/L). How should the nurse interpret it?

1. AMetabolic alkalosis
2. BRespiratory acidosis
3. CMetabolic acidosis
4. DRespiratory alkalosis

肺炎の高齢の患者が、新たに錯乱しています。最初に行うことはどれですか？

1. A頓用の鎮静薬を投与する
2. Bこれが患者にとって普通のことかどうか、家族に尋ねる
3. C酸素飽和度とほかのバイタルサインを確認する
4. D患者が点滴を引っ張らないよう、手首を抑制する

A patient on peritoneal dialysis notices the drained fluid has become cloudy and has abdominal pain. What is likely?

1. ANormal dialysis fluid
2. BConstipation
3. CPeritonitis
4. DA urinary tract infection

A patient with severe ulcerative colitis develops abdominal distension, fever and tachycardia, and the number of stools falls. What complication should be suspected?

1. AToxic megacolon
2. BConstipation from dehydration
3. CCoeliac disease
4. DRecovery from the colitis

肝硬変の患者のアルブミンが 2.2 g/dL（22 g/L）です。最も関連しそうな所見はどれですか？

1. A尿量の増加
2. B浮腫と腹水
3. C高カリウム血症
4. D高血圧

A patient recovering from acute tubular necrosis now passes 4–5 L of urine a day. Which electrolyte changes should the nurse watch for?

1. ALow potassium and low sodium from urine losses
2. BNo changes, because the kidneys are now normal
3. CHigh potassium and high sodium from retention
4. DHigh calcium and high phosphate from bone loss

While giving medicines, a patient says, "That pill looks different from the one I usually take." What should the nurse do?

1. AStop and recheck the order and the medicine before giving it
2. BReassure the patient and give the pill anyway
3. CExplain that only the staff decide which medicines are given
4. DGive the pill and check the chart afterwards

A nurse gives 2 mg from a 4 mg ampoule of morphine. What should happen to the remaining 2 mg?

1. AIt is given to the next patient who needs morphine
2. BIt is poured down the sink without telling anyone
3. CIt is discarded in front of a witness, and both sign the record
4. DIt is kept labelled in the patient's drawer for the next dose

During airway suctioning, when should suction be applied?

1. AContinuously for at least 30 seconds
2. BOnly while withdrawing the catheter
3. CBefore the catheter enters the airway
4. DOnly while inserting the catheter

A nurse teaches a patient who has a new permanent pacemaker. Which statement shows a need for further teaching?

1. A"I will tell staff about the device before any MRI scan."
2. B"I will keep my mobile phone in my shirt pocket over the device."
3. C"I will keep my follow-up appointments for device checks."
4. D"I will carry my pacemaker identification card with me at all times."

腹膜透析液は、使用前にどのように温めますか？

1. A専用の乾熱式ウォーマーで
2. B熱い水道水を張ったボウルで
3. C冷蔵庫から出して冷たいまま使う
4. D電子レンジで

The nurse has four renal patients. Which one needs to be seen first?

1. AA patient with mild itching from uraemia who wants a cream
2. BA patient with CKD asking about their phosphate binder
3. CA patient with a creatinine slightly above their usual level
4. DA patient with a potassium of 6.8 mmol/L who reports palpitations

Which risk is particularly linked with tramadol?

1. AHigh blood pressure that needs emergency treatment in most patients
2. BSevere stomach ulcers in all patients
3. CRapid liver failure at normal doses
4. DSerotonin syndrome with some antidepressants, and seizures

On day 2 of nasogastric feeding, a severely malnourished patient becomes weak and breathless with ankle swelling. Phosphate is 0.4 mmol/L. What is most likely?

1. AToo little calorie intake
2. BRefeeding syndrome
3. CAn allergy to the feed formula
4. DNormal adjustment to the new feed

Which is a common sign of iron deficiency anaemia in pregnancy?

1. ATiredness, pallor and breathlessness
2. BHigh blood pressure and headache
3. CWeight gain and ankle swelling
4. DIncreased appetite and frequent urination

A woman with a previous caesarean is having a trial of labour. Which induction agent should the nurse question?

1. AAmniotomy
2. BMisoprostol
3. COxytocin used per protocol
4. DA balloon catheter

Which injury in an infant is most suggestive of physical abuse?

1. AA bruise on the shin of a walking toddler
2. BPosterior rib fractures
3. CA greenstick fracture of the forearm after a fall from a slide
4. DA scraped knee in a 3-year-old

A 2-year-old has had three febrile urinary tract infections. Which underlying condition should be considered?

1. ANephrotic syndrome
2. BHypospadias
3. CTesticular torsion on both sides
4. DVesicoureteral reflux

A patient intoxicated with phencyclidine (PCP) is agitated and has nystagmus and high blood pressure. Which nursing approach is best?

1. ATry to talk the patient down by discussing his feelings in detail
2. BPut him in a busy area so that staff can watch him more easily
3. CProvide a quiet, low-stimulation environment and keep staff and patient safe
4. DEncourage him to walk around the ward and join in activities to help burn off the drug

On a mental health ward, which task is most appropriate for the nurse to delegate to a healthcare assistant?

1. AAccompanying a stable patient to the dining room and recording his food intake
2. BEvaluating whether a PRN medicine given an hour ago has worked
3. CTeaching a patient about the side effects of lithium
4. DCarrying out the full admission suicide risk assessment of a newly admitted patient

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）。 滴下速度の計算結果は 145.735 gtt/min です。 この練習問題のルールは「滴下速度は、最も近い整数の滴数に丸める」です。記録する値 x はいくつですか。

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）。 維持輸液が 120 mL/h で休みなく続いています。24時間で何リットル V を投与しますか。

体重 21 kg の子どもに、2 mg/kg の薬が処方されています。原液は 10 mg/mL を含みます。用量を吸い上げます：何 mL V を投与しますか？

処方は 250 マイクログラムです。アンプルは 1 mg/mL を含みます。1 mL の注射器に用量を吸い上げます：何 mL V を投与しますか？

10 滴/mL の輸液セットで 500 mL を 4 時間かけて投与します。滴下速度 R を 1 分あたりの滴数で求めなさい。 最も近い整数に丸めてください。

点滴が 60 滴/mL のセットで 30 滴/分で落ちています。バッグには 400 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 8 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）。 1000 mL のバッグをポンプで 75 mL/h で投与しています。16:00 の時点で 500 mL がすでに投与されています。バッグが空になるまであと何時間 t ですか？ 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）。 練習用の患者をブレーデンスケールで評価します：知覚の認知: かなり制限されている; 湿潤: ときどき湿っている; 活動性: 座位可能; 可動性: やや制限されている; 栄養状態: 非常に良好; 摩擦とずれ: 明らかな問題なし。ブレーデンスケールの合計 B を求めてください。

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）。 次の観察結果に NEWS2 チャート（SpO₂ スケール1）を使います：呼吸数 16/分、SpO₂ 97%（室内気吸入）、血圧 92/56 mmHg、脈拍 82/分、意識清明、体温 39.6 °C。この患者はどの臨床的リスク群に入りますか。クリックしてください。

1. 1低
2. 2低～中
3. 3中
4. 4高