公式集、全トピックの解法の要点、14 問の演習問題。完全な解答は巻末にあります。
A parent of a child with influenza talks with the nurse. Which statement shows a need for further teaching?
An infant with pyloric stenosis has repeated projectile vomiting. Which acid-base imbalance is most likely?
A patient with a respiratory infection has a raised procalcitonin level. What does this most suggest?
A patient in a vest restraint has slid down in bed, and the vest is pressing against the neck. What should the nurse do first?
A patient had a total gastrectomy. Which long-term therapy is needed to prevent anemia?
A patient taking isoniazid for latent TB reports nausea, loss of appetite and dark urine. The ALT is five times the upper limit of normal. What is the best action?
Which of these is one of the "4 Hs", the reversible causes of cardiac arrest?
Which nursing measure helps reduce raised intracranial pressure?
A patient on furosemide has a serum potassium of 3.0 mmol/L (3.0 mEq/L). Which symptoms may this cause?
A patient with end-stage COPD has severe breathlessness at rest despite optimal treatment and wants comfort-focused care. Which measure is recognised to help?
How does bladder training help urge incontinence?
手術後、患者の尿量が3時間にわたって15 mL/時で、脈拍110/分、血圧96/58 mmHg、粘膜が乾燥しています。尿量低下の最も考えられる原因はどれですか？
大手術の後の最初の数日間、「必要時」の投与より定期的（スケジュール化）な鎮痛が好まれることが多いのはなぜですか？
Two days after surgery, a patient on regular ibuprofen has a low urine output and a rising creatinine, and intake has been poor. What should the nurse do?
答え: D · “I will give my child aspirin to bring the fever down.”
Aspirin in children with viral illnesses such as influenza or chickenpox is linked to Reye syndrome. Fluids, rest at home and reporting breathing trouble are correct.
答え: D · Metabolic alkalosis
Repeated vomiting of stomach contents loses hydrochloric acid, causing metabolic alkalosis, often with low chloride and potassium. Fluids and electrolytes are corrected before surgery.
答え: C · A bacterial rather than a viral infection
Procalcitonin rises mainly in bacterial infections and much less in viral ones. It is used with clinical judgement to help decide when antibiotics are needed or can be stopped.
答え: D · Release the restraint at once and reposition the patient
Patients have died from strangulation when vest restraints moved up to the neck. The nurse frees the patient immediately, checks breathing and repositions them, then reassesses whether the restraint is needed at all.
答え: A · Lifelong vitamin B12 replacement
Intrinsic factor from the stomach is needed to absorb vitamin B12 in the ileum. After a total gastrectomy, B12 must be replaced for life, usually by injection, to prevent macrocytic anemia and nerve damage.確認に用いた資料: Vitamin B12 or folate deficiency anaemia - Causes · NHS (2023); Vitamin B12 deficiency anemia · MedlinePlus (NIH) (2026)
答え: A · Hold the isoniazid and report the findings to the prescriber at once
Isoniazid can cause hepatitis, which may be severe. Symptoms such as nausea, loss of appetite and dark urine with a markedly raised ALT mean the drug should be held and the prescriber informed. Patients are taught to avoid alcohol and report these symptoms early.
答え: A · Hypoxia
The 4 Hs are hypoxia, hypovolaemia, hypo- or hyperkalaemia and other metabolic causes, and hypothermia. The 4 Ts are thrombosis, tension pneumothorax, tamponade and toxins.
答え: B · Raising the head of the bed to about 30° with the head kept midline
Head elevation and a midline neck position help venous drainage from the brain. Neck flexion, tight tube ties, coughing, straining and unnecessary suctioning can all raise intracranial pressure.
答え: C · Muscle weakness, cramps and an irregular pulse
The adult reference range is about 3.5–5.0 mmol/L, so 3.0 mmol/L is low. Hypokalaemia causes weakness, cramps, constipation and arrhythmias, with flattened T waves and U waves on the ECG. Tingling lips and hand spasm suggest low calcium.
答え: C · A low-dose opioid with a hand-held fan and calm positioning
Low-dose oral opioids can ease refractory breathlessness in advanced disease. A fan blowing air across the face, upright positioning, breathing techniques and anxiety management also help. Oxygen is used only if it relieves symptoms or corrects hypoxaemia.
答え: D · The time between voids is slowly increased
In bladder training, the patient follows a schedule and gradually lengthens the time between voids while using urge-suppression techniques. Over weeks, bladder capacity and control improve. Very low fluid intake makes urine concentrated and irritating.
答え: A · 循環血液量減少による腎前性AKI
頻脈、低血圧、粘膜の乾燥は、腎臓への灌流を減らす循環血液量減少を示唆します。看護師はカテーテルが開通していることを確認して上申します。チームは通常、輸液負荷を処方し、出血や大量の喪失などの原因を探します。
答え: B · 薬の濃度が安定し、激しい痛みのピークを防げるから
予測できる持続的な術後の痛みは、定期的な多角的鎮痛（例えばパラセタモールと、安全な場合はNSAID）で管理し、突出痛には頓用の用量を併用するのが最善です。痛みと副作用は引き続き定期的にアセスメントします。
答え: A · Withhold the next dose and report to the prescriber
NSAIDs can cause acute kidney injury, particularly with hypovolaemia, older age or other nephrotoxic drugs. The nurse withholds and reports, and fluid status and other analgesia are reviewed.
これは独自の練習教材です。ExamProblems はこの試験を実施する団体とは提携しておらず、その承認も受けていません。試験名は内容を説明するためにのみ使用しています。 NCLEX®, NCLEX-RN® and NCLEX-PN®はthe National Council of State Boards of Nursing, Inc. (NCSBN)の商標です。同団体はExamProblemsと提携しておらず、推奨も正確性の保証もしていません。
ExamProblems · examproblems.com/courses/nclex-style-prioritization-and-delegation