NCLEX 形式の優先順位の決定と委任：直前対策パック

One day after surgery, a patient walked safely with the RN this morning. The RN now asks a nursing assistant to walk her again. Which instruction is most important?

1. A“Make sure she wears her own slippers if she has them.”
2. B“Walk her to the end of the corridor and back twice before lunch.”
3. C“Try to finish the walk before the lunch trays arrive.”
4. D“Stop and call me at once if she feels dizzy or short of breath.”

Two patients on the unit have the same surname. What should the nurse do before giving a medication?

1. AAsk a nursing assistant which patient is which
2. BAsk the patient, “Are you Mr Smith?” and give the drug once he says yes
3. CCheck two identifiers against the wristband and the medication record
4. DUse the room number as the main identifier

滅菌野を準備している最中に、看護師が質問に答えるためそこから背を向けました。正しいのはどれですか？

1. A滅菌野は汚染されたとみなされ、準備し直す必要がある
2. Bその間誰も触れていないので、滅菌野は滅菌のままである
3. C後でカバーをすれば使用できる
4. D看護師に近い物だけを交換すればよい

A nurse calls a provider using SBAR about a patient with falling blood pressure. Which statement is the “Recommendation”?

1. A“I think he needs to be assessed now. Can you come within the next 15 minutes?”
2. B“I am calling about Mr. Jansen in room 12, who is hypotensive.”
3. C“His blood pressure has fallen from 130/80 to 88/50 over the last two hours.”
4. D“He is 72 and had a bowel resection yesterday.”

A healthy patient's result is slightly outside the laboratory reference range, and all other results are normal. Which statement best explains why this can happen?

1. ARanges cover about 95% of healthy people, so some fall outside
2. BAny result outside the range always means disease is present
3. CReference ranges are the same in every laboratory worldwide
4. DReference ranges include every healthy person without exception

A child with sickle cell disease and a recent viral illness is pale and tired. The hemoglobin has fallen sharply, and the reticulocyte count is very low. What is the most likely problem?

1. AA normal finding in sickle cell disease
2. BIron deficiency from a poor diet over months
3. CA vaso-occlusive pain crisis in the bones
4. DAn aplastic crisis, often caused by parvovirus B19

患者に疝痛性の腹痛、腹部膨満、嘔吐があり、2 日間排便も排ガスもありません。考えられる問題は？

1. A過敏性腸症候群
2. B胃腸炎
3. C合併症のない虫垂炎
4. D腸閉塞

Several hours after thyroid surgery, a patient has increasing neck swelling, stridor and difficulty breathing. What is most likely?

1. ANormal postoperative swelling
2. BA thyroid storm
3. CA haematoma compressing the airway
4. DHypocalcaemia from parathyroid damage

After repair of an abdominal aortic aneurysm, which regular assessment helps detect a blocked graft or clots in the legs?

1. ATesting the gag reflex every four hours after surgery
2. BChecking the pupils' response to light
3. CChecking leg pulses, colour, warmth and sensation
4. DMeasuring the blood glucose every hour through the night

A patient regains a pulse after a ventricular fibrillation arrest that was probably caused by a heart attack. Which investigation is most urgent?

1. ASpirometry
2. BA lumbar puncture
3. CA 12-lead ECG
4. DAn abdominal ultrasound

Before checking a capillary glucose, why should the patient wash their hands with soap and water?

1. AWashing prevents all infection from the lancet
2. BSoap makes the blood flow faster from the finger
3. CWashing lowers the glucose in the blood
4. DSugar on the skin can give a falsely high reading

高齢の2型糖尿病患者の血糖が48 mmol/L、浸透圧が365 mOsm/kgで、有意なケトンはなく、錯乱があります。最優先は何ですか？

1. A治療中の低血糖を予防するための、経口ブドウ糖
2. B浸透圧、ナトリウム、血糖の綿密な確認を伴う、慎重な静注輸液
3. C1時間以内に血糖を正常化するための、大量のインスリン静注ボーラス
4. D脳浮腫を避けるための、厳格な水分制限

オピオイドに対する耐性を最もよく表す記述はどれですか？

1. A患者がその薬をもっと欲しいという強迫的な渇望を持つこと
2. B同じ効果を得るために、時間とともに高い用量が必要になること
3. C患者がその薬に対するアレルギーを起こしたこと
4. Dその薬がもう便秘を起こさなくなること

During preoperative assessment, a patient says their brother had a "very high fever" during an anaesthetic. What is the most important action?

1. AReassure the patient that fevers after anaesthesia are always harmless
2. BInform the anaesthetist, as malignant hyperthermia may run in the family
3. CGive paracetamol before surgery to prevent fever
4. DRecord it as a family allergy to paracetamol