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試験科目：「National Council Licensure Examination(NCLEX-RN)」
NO.1 A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The
client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of
diabetes when she is pregnant, she is classified as having:
A. Insulin-dependent diabetes
B. Gestational diabetes mellitus
C. Type II diabetes mellitus
D. Type I diabetes mellitus
(A) Insulin-dependent diabetes mellitus, also known as type I diabetes, usually appears before the
age of 30 years with an abrupt onset of symptoms requiring insulin for management. It is not related
to onset during pregnancy. (B) Non-insulin-dependent diabetes (type II diabetes) usually appears in
older adults. It has a slow onset and progression of symptoms. (C) This type of diabetes is the same as
insulin-dependent diabetes. (D) Gestational diabetes mellitus has its onset of symptoms during
pregnancy and usually disappears after delivery. These symptoms are usually mild and not life
threatening, although they are associated with increased fetal morbidity and other fetal
NO.2 Which one of the following is considered a reliable indicator for assessing the adequacy of
fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her
B. Bulging fontanelle
D. Urine output
(A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid
resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid
resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury.
(C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age.
NO.3 In client teaching, the nurse should emphasize that fetal damage occurs more frequently with
ingestion of drugs during:
A. Third trimester
B. First trimester
C. Second trimester
D. Every trimester
(A) Organogenesis occurs in the first trimester. Fetus is most susceptible to malformation during this
period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete
by this time. (D) The dangerous period for fetal damage is the first trimester, not the entire
NO.4 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures
should be included in the postoperative care?
A. Have child gargle and do toothbrushing to remove old blood.
B. Encourage the child to cough up blood if present.
C. Observe for evidence of bleeding.
D. Give warm clear liquids when fully alert.
(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.