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National Council Licensure Examination(NCLEX-RN)問題集を今すぐダウンロード

質問 39
A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:

  • A. Within 72 hours postpartum
  • B. After the first trimester
  • C. In the immediate postpartum period
  • D. At 28 weeks' gestation

正解: C

解説:
Section: Questions Set F
Explanation:
(A) The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. (B) Rubella infection during the second trimester may result in permanent hearing loss for the fetus. (C) RhoGam is the drug generally administered at 28 weeks' gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. (D) RhoGam is the drug administered within 72 hours postpartum to Rh-negative women to prevent the development of antibodies to fetal cells.

 

質問 40
A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child's case manager knows that treatment has been effective when:

  • A. The child is removed from the home and placed in foster care
  • B. The child's parents can identify appropriate behaviors for children in his age group
  • C. The child's parents identify the ways in which he is different from the rest of the family
  • D. The child's father is arrested for child abuse

正解: B

解説:
(A) Removing an abused child from the home and placement in a foster home are not the desired outcome of treatment. (B) Children who are perceived as "different" from the rest of the family are more likely to be abused. (C) Although legal action may be taken against abusive parents, it is not an indicator of an effective treatment program. (D) Identification of age-appropriate behaviors is essential to the role of parents, because misunderstanding children's normal developmental needs often contributes to abuse or neglect.

 

質問 41
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?

  • A. Alteration in comfort secondary to alteration in skin integrity
  • B. Alteration in sensation secondary to third-degree burn
  • C. Fluid volume deficit secondary to alteration in skin integrity
  • D. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity

正解: D

解説:
(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48-72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.

 

質問 42
The nurse would assess the client's correct understanding of the fertility awareness methods that enhance conception, if the client stated that:

  • A. "My sexual partner and I should have intercourse when my cervical mucosa is thick and cloudy."
  • B. "At ovulation, my basal body temperature should rise about 0.5F."
  • C. "I should douche immediately after intercourse."
  • D. "My sexual partner and I should have sexual intercourse on day 14 of my cycle regardless of the length of the cycle."

正解: B

解説:
(A)
At ovulation, the cervical mucus is increased, stretchable, and watery clear. (B) Under the influence of progesterone, the basal body temperature increases slightly after ovulation.
(C)
To enhance fertility, measures should be taken that promote retention of sperm rather than removal. (D) Ovulation, the optimal time for conception, occurs 14+2 days before the next menses; therefore, the date of ovulation is directly related to the length of the menstrual cycle.

 

質問 43
A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?

  • A. Listening to a story about the Muppets
  • B. Watching Sesame Street on television
  • C. Assembling a puzzle with large pieces
  • D. Being taken for a wheelchair ride

正解: C

解説:
Section: Questions Set F
Explanation:
(A) A 2-year-old child is in the stage of autonomy, according to Erikson. Assembling a puzzle with large pieces enables her to "do it herself." (B) A wheelchair ride would probably be fun, but it is not directed toward helping the child to achieve autonomy. (C) Listening to a story may be fun and educational, but it is not directed toward helping the child to achieve autonomy. (D) Watching television may be a favorite activity, but it does not foster autonomy.

 

質問 44
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