NCLEX 形式の優先順位の決定と委任：直前対策パック

Which patient with diabetes should the nurse see first?

1. ANeeds foot care teaching before discharge tomorrow
2. BGlucose 48 mg/dL (2.7 mmol/L), sweating and confused
3. CGlucose 210 mg/dL (11.7 mmol/L) after a large lunch, feels well
4. DHbA1c result of 8.2%, asking about diet

A nurse teaches a patient to inject enoxaparin at home. Which statement shows a need for further teaching?

1. A“I will change the injection site each time.”
2. B“I will tell my doctor if I notice unusual bruising or bleeding.”
3. C“I will rub the area after the injection to help it absorb.”
4. D“I will inject into the fat of my abdomen, away from the navel.”

A patient has a very low platelet count. Which safety measure is appropriate?

1. AUse a firm toothbrush and a safety razor
2. BUse a soft toothbrush and an electric razor
3. CFloss hard each day to keep the gums healthy
4. DTake rectal temperatures for accuracy

An audit shows poor hand hygiene compliance on a ward. Which plan is most likely to improve it?

1. AA combined approach with education, hand rub at every bedside, regular audits and feedback
2. BDisciplining staff who are seen not cleaning their hands, with no other change
3. CA single poster about hand hygiene placed in the staff room
4. DRemoving all sinks so staff must use hand rub

A patient on a heparin infusion has an aPTT below the target range on the protocol. What should the nurse do?

1. AAdjust the rate as the protocol directs and recheck as scheduled
2. BStop the infusion and give protamine sulfate as quickly as possible
3. CContinue the same rate and recheck the aPTT in a few days
4. DSwitch the infusion to oral warfarin without a prescription

心不全の患者が、リシノプリル、スピロノラクトン、カリウム補充薬を服用しています。今日のカリウムは 6.0 mEq/L です。最も考えられる説明はどれですか？

1. Aカリウムを上げる複数の薬が、一緒に服用されている
2. Bスピロノラクトンは、カリウムの喪失を起こす
3. Cリシノプリルは、カリウムを下げる
4. Dカリウム補充薬は、血清濃度に影響しない

心臓のリズムにとって最も危険な電解質異常は？

1. Aナトリウムの低下
2. Bカリウムの高すぎや低すぎ
3. Cリン酸の低下
4. Dクロールの上昇

A patient has a blood pressure of 220/130 mmHg with headache, confusion and visual disturbance. Why is the blood pressure lowered in a controlled way rather than as fast as possible?

1. ARapid lowering causes hyperglycaemia
2. BBlood pressure cannot be lowered with drugs
3. CA sudden drop can reduce blood flow to the brain, heart and kidneys
4. DRapid lowering always causes the hypertension to come back much worse

A patient has chest pain at rest in the early morning with brief ST elevation that resolves. Coronary arteries are later found to be clear. Which condition is most likely?

1. AAortic stenosis
2. BStable exertional angina from a fixed plaque
3. CVasospastic (Prinzmetal) angina
4. DAcute pericarditis

A patient with pneumonia has a temperature of 39 °C, pain and a sinus tachycardia of 122/min. BP is normal. What is the best way to manage the heart rate?

1. AGive a beta-blocker to bring the heart rate below 100/min
2. BArrange urgent electrical cardioversion to restore a normal rate
3. CGive IV adenosine
4. DTreat the fever, pain and possible dehydration, then reassess

Why is IV calcium gluconate given in severe hyperkalaemia?

1. AIt moves potassium into the cells
2. BIt removes potassium through the kidneys
3. CIt protects the heart from arrhythmias
4. DIt binds potassium in the gut

Two days after an ileal conduit was formed, the stoma is dark purple and dry. What should the nurse do?

1. AApply a warm compress to improve the colour of the stoma
2. BRecord it as normal for a new stoma
3. CReport it urgently, because the stoma may be ischaemic
4. DChange the bag and check again next week

上部消化管出血の患者で、尿素がクレアチニンよりずっと大きく上昇することがあるのはなぜですか？

1. A尿素が出血している胃粘膜で作られるから
2. B消化された血液がタンパク質負荷となり、尿素を上昇させるから
3. Cクレアチニンが嘔吐物とともに体外に失われるから
4. D出血が必ず腎尿細管を直接傷めるから

高悪性度リンパ腫の化学療法を開始した2日後、患者の尿量が減り、カリウムは6.4 mmol/L、リンは高く、カルシウムは低くなっています。看護師は何を疑い、どうすべきですか？

1. Aアレルギー反応で、抗ヒスタミン薬を投与して通常どおり続ける
2. B予想される化学療法の副作用で、次のサイクルまで対応は不要
3. C単純な脱水で、経口水分を促し、来週に血液検査を再確認する
4. D腫瘍崩壊症候群。上申し、心電図モニタリングを開始し、静注輸液を見込む