NCLEX 形式の優先順位の決定と委任：直前対策パック

A patient had a colostomy formed yesterday. Which stoma appearance should be reported straight away?

1. ASlightly swollen
2. BDark purple or black
3. CA little bleeding when cleaned
4. DMoist and pink-red

看護助手に委任せず、RN が自ら行うのが最も適切な業務はどれですか？

1. A患者の口腔ケアを手伝うこと
2. B手術後 3 日目の安定した患者を、廊下で歩かせること
3. C手術後、初めて患者をベッドから起こすこと
4. D心不全の患者の体重を毎朝測定すること

錠剤を渡す前に、患者が「この薬はいつもの薬と見た目が違う」と言いました。看護師はどうすべきですか？

1. A半分だけ渡して、異常な作用がないか観察する
2. B投与前に手を止めて、指示と薬を再確認する
3. C患者を安心させて錠剤を渡す
4. D病院ではどの薬も見た目が違うものだと患者に説明する

看護師が、同僚が手指衛生をせずに患者から次の患者へ移るのを目にしました。最善の対応はどれですか？

1. Aすぐに同僚へ丁寧に注意を促す
2. B次回はするかどうか様子を見る
3. Cチーム内の対立を避けるため、何も言わない
4. D1か月後に匿名で管理者に報告する

A patient has a hot, swollen big toe. The serum uric acid is normal. Which statement is correct?

1. AGout can only be diagnosed with a CT scan of the foot
2. BGout is certain, as a normal urate proves the diagnosis
3. CGout is still possible, as urate can be normal in an attack
4. DGout is ruled out, as uric acid is always high in an attack

A patient with blood pressure that is hard to control has a potassium of 2.9 mEq/L, a sodium of 144 mEq/L and a raised serum bicarbonate, without taking a diuretic. Which condition is most likely?

1. ACentral diabetes insipidus
2. BPrimary adrenal insufficiency
3. CPrimary hyperaldosteronism
4. DSyndrome of inappropriate ADH

アナフィラキシーの第一選択薬は？

1. A静注のアセトアミノフェン
2. B吸入ステロイド
3. Cアドレナリンの筋肉注射
4. Dセチリジンなどの経口抗ヒスタミン薬

Why is morphine more likely to cause toxicity in a patient with severe kidney impairment?

1. AIts active metabolites build up because the kidneys excrete them
2. BKidney disease makes the opioid receptors disappear
3. CKidney failure makes the stomach absorb more morphine
4. DThe kidneys normally activate morphine, so more of it becomes active

A patient with stable angina is afraid nicotine patches will harm their heart. Which reply is most accurate?

1. ANicotine patches are much more harmful to the heart than cigarettes
2. BPeople with angina must stop smoking without any help
3. CNicotine replacement is much safer than smoking and is recommended
4. DNicotine replacement only works if smoking continues

A patient with severe chronic kidney disease needs therapeutic anticoagulation for a DVT. Why might unfractionated heparin be chosen instead of a low-molecular-weight heparin?

1. AUnfractionated heparin is taken by mouth
2. BLMWH cannot be given to anyone over 60
3. CUnfractionated heparin has no bleeding risk at all
4. DLMWH is cleared by the kidneys and can accumulate

How does the nurse test the facial nerve (VII)?

1. ATouch the forehead, cheek and chin with cotton wool
2. BShine a light in each eye and check the pupil response
3. CAsk the patient to stick out the tongue and move it from side to side
4. DAsk them to raise the eyebrows, shut the eyes tightly and smile

A patient received IV insulin and glucose for hyperkalaemia an hour ago. What must the nurse monitor over the next few hours?

1. AUrine colour, for blood in the urine
2. BCapillary glucose, for hypoglycaemia
3. CSkin, for a drug rash
4. DPupils, for raised intracranial pressure

Which drug class is used to reduce the risk of a first variceal bleed in cirrhosis?

1. ACalcium supplements
2. BNon-selective beta-blockers
3. CProton pump inhibitors
4. DThiazide diuretics

A sacral wound has heavy exudate, and the surrounding skin is white, soft and wrinkled. What should the nurse do?

1. AUse a dressing that adds even more moisture
2. BApply a tight plastic film directly over the wound
3. CLeave the same dressing in place for a week so the wound is not disturbed
4. DProtect the skin edges and use a more absorbent dressing