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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. Have child gargle and do toothbrushing to remove old blood.
C. Observe for evidence of bleeding.
D. Give warm clear liquids when fully alert.
Answer: C
Explanation:
(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 primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed
toward:
A. Providing pain relief
B. Preventing infection
C. O2 therapy
D. Maintaining an adequate level of hydration
Answer: D

NCLEX-RN試験問題解説集
Explanation:
(A) Maintaining the hydration level is the focus for nursing intervention because dehydration
enhances the sickling process. Both oral and parenteral fluids are used. (B) The pain is a result of the
sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of
the pain will be resolved with hydration. (C) Serious bacterial infections may result owing to splenic
dysfunction. This is true at all times, not just during the acute period of a crisis. (D) O2 therapy is used
for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary
intervention to alleviate the dehydration that enhances the sickling process.

NO.3 Three weeks following discharge, a male client is readmitted to the psychiatric unit for
depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse
admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am
just no good." Which response by the nurse is most appropriate at this time?
A. "I don't think you are worthless. I'm glad to see you, and we will help you."
B. "Don't you think this is a sign of your illness?"
C. "You've been feeling sad and alone for some time now?"
D. "I know with your wife and new baby that you do have a lot to live for."
Answer: C
Explanation:
(A)
This response does not acknowledge the client's feelings.
(B)
This is a closed question and does not encourage communication.
(C)
This response negates the client's feelings and does not require a response from the client. (D) This
acknowledges the client's implied thoughts and feelings and encourages a response.

NO.4 A 24-year-old client presents to the emergency department protesting "I am God." The nurse
identifies this as a:
A. Hallucination
B. Conversion
C. Illusion
D. Delusion
Answer: D

NCLEX-RN試験感想
Explanation:
(A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory
experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion
is the expression of intrapsychic conflict through sensory or motor manifestations.

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NCLEX-RN試験番号:NCLEX-RN 試験対策
試験科目:「National Council Licensure Examination(NCLEX-RN)」
最近更新時間:2016-10-11
問題と解答:865

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