NCLEX 形式の優先順位の決定と委任：直前対策パック

看護助手が、患者の血圧が 168/98 mmHg（先ほどは 130/80）で、頭痛があると報告しました。RN はどうすべきですか？

1. A1 時間後に血圧を再測定して報告するよう助手に頼む
2. B頓用の降圧薬を今すぐ投与するよう助手に頼む
3. C値を記録し、与薬ラウンドを続ける
4. D患者をアセスメントし、血圧を再測定して、症状を調べる

Four laboratory results come back at once. Which one should the nurse report first?

1. APotassium 3.4 mEq/L in a patient on a diuretic
2. BHemoglobin 6.5 g/dL (65 g/L) in a patient with a GI bleed
3. CCreatinine 1.3 mg/dL in an older adult, unchanged from last week
4. DGlucose 180 mg/dL after a meal in a patient with diabetes

An order reads “Give potassium chloride by IV push.” What should the nurse do?

1. AGive half by IV push and the rest later
2. BDilute it in a small syringe and push it
3. CGive it slowly by IV push over two minutes while watching the cardiac monitor
4. DNot give it, and contact the prescriber, because it is never given by IV push

A visitor is receiving an electric shock from a faulty lamp and is still touching it. What should the nurse do first?

1. APull the visitor away from the lamp by the arm as quickly as possible
2. BSwitch off the power or unplug the lamp without touching the person
3. CThrow water over the lamp to stop the current
4. DStart chest compressions straight away

A patient with hyperkalemia is prescribed an oral potassium binder such as patiromer or sodium zirconium cyclosilicate. How does this drug lower potassium?

1. AIt protects the heart muscle against high potassium levels
2. BIt binds potassium in the gut so it leaves in the stool
3. CIt moves potassium into cells in the next few minutes
4. DIt stops the kidneys from absorbing water in the tubules

鉄欠乏性貧血に最も典型的な結果の組み合わせはどれですか？

1. A高ヘモグロビンと高ヘマトクリット
2. Bヘモグロビンの低下、大きな赤血球（高 MCV）、高フェリチン
3. Cヘモグロビンの低下、小さな赤血球（低 MCV）、低フェリチン
4. Dヘモグロビンは正常で、血小板数のみ高い

Why is continuous bladder irrigation used after a transurethral resection of the prostate (TURP)?

1. ATo stretch the bladder back to its normal size
2. BTo measure the patient's kidney function
3. CTo give antibiotics directly into the kidneys
4. DTo stop blood clots from blocking the catheter

Which task is most appropriate for a registered nurse to delegate to a trained healthcare assistant (unlicensed assistive personnel)?

1. ATeaching a patient to inject insulin for the first time
2. BAssessing a patient who has just reported new chest pain
3. CMeasuring and recording vital signs on a stable patient
4. DGiving a dose of intravenous antibiotic

After thrombolysis for a myocardial infarction, which complication is the nurse most concerned to detect?

1. AConstipation from bed rest
2. BA high blood glucose caused by the thrombolytic drug itself
3. CBleeding, including a sudden change in neurological status
4. DA skin rash appearing at the sites of the ECG electrodes

On a ventilated patient, the end-tidal CO₂ waveform suddenly drops to zero. What should the nurse suspect first?

1. AA sudden improvement in the patient's lung function
2. BNormal variation that needs no action
3. CTube displacement, disconnection or obstruction
4. DA rise in the patient's body temperature over the last hour

患者が自分で気道を守れないかもしれないことを、通常示唆するグラスゴー・コーマ・スケール（GCS）のスコアはどれですか？

1. A11以上
2. B8以下
3. C13以下
4. D15

長期間、高用量のプレドニゾロンを服用している患者が、腸の手術の3日後です。腹痛は軽いと訴えるだけですが、心拍数が115/分に上がり、体温は37.4 °Cです。看護師が特に懸念すべきなのはなぜですか？

1. Aステロイドは発熱、痛み、腹膜刺激症状を隠し、合併症を見えなくしうるから
2. B軽い痛みは、腸が予想どおり治っていることを示すから
3. Cステロイドは感染から守るので、敗血症の可能性は非常に低いから
4. Dステロイドはすべての患者で頻脈を起こすので、対応は不要だから

In the SBAR communication tool, what belongs under "A"?

1. AThe patient's admission date only
2. BThe address and phone number of the patient's next of kin
3. CA list of the patient's allergies only
4. DThe nurse's assessment of what the problem is

A patient with diabetes on continuous enteral feeding and an insulin regimen has the feed stopped for a procedure. What is the main concern?

1. AHyperglycaemia because the stomach is empty
2. BDiarrhoea from stopping the feed suddenly
3. CRefeeding syndrome from too much glucose
4. DHypoglycaemia if insulin continues without the feed