NCLEX 形式の優先順位の決定と委任：直前対策パック

An older patient with dementia is restless at night and keeps trying to get out of bed. Which measure should the nurse try first?

1. ARaise all four bed rails so the patient cannot climb out
2. BApply wrist restraints for the rest of the night
3. CGive a sedative from the as-needed list without first assessing the patient
4. DCheck for pain, thirst or a full bladder, and offer toileting

An adult has burns over 40% of the body with no signs of airway injury. Which treatment is the priority during the first hours?

1. ALarge-volume IV fluids with close monitoring of urine output
2. BGiving a high-protein meal to support healing
3. CApplying antibiotic cream to all the burns before anything else
4. DStarting physiotherapy to prevent contractures straight away

Which room lighting is safest at night for a patient at high risk of falls?

1. AComplete darkness so the patient sleeps more deeply
2. BOnly the light from the television screen
3. CBright overhead lights left on all night in the room
4. DA low night light that lights the path to the bathroom

看護師が10 000単位/mLのヘパリンのバイアルを手に取りました。この病棟では通常1000単位/mLのバイアルを備えています。特に注意が必要なのはなぜですか？

1. Aどちらの規格のバイアルも自由に取り替えてよいから
2. B濃度の高いバイアルを間違えて使うと、10倍の過量投与になるから
3. Cヘパリンの濃度は安全性に影響しないから
4. D吸い上げる量が少なくてすむため、濃いバイアルのほうが安全だから

A patient on a heparin infusion has blood in the urine and an aPTT far above the target. The nurse stops the infusion and informs the provider. Which antidote should the nurse anticipate?

1. ANaloxone
2. BProtamine sulfate
3. CVitamin K (phytonadione)
4. DCalcium gluconate

A patient's AST is about twice the ALT, both moderately raised, and the GGT is high. Which cause is most likely?

1. AGallstone blocking the bile duct
2. BAlcohol-related liver disease
3. CAcute myocardial infarction
4. DAcute viral hepatitis A

During a vesicant chemotherapy infusion, the patient reports burning and swelling at the cannula site. What should the nurse do first?

1. AFlush the cannula hard with saline
2. BApply a warm pack and continue the infusion
3. CIncrease the rate so that the infusion finishes as quickly as possible
4. DStop the infusion straight away and follow the extravasation protocol

A patient with known cirrhosis suddenly vomits large amounts of bright red blood and becomes tachycardic. What is the most likely cause?

1. ASwallowed blood from a nosebleed
2. BBleeding from ruptured oesophageal varices
3. CA Mallory-Weiss tear from a small amount of vomiting
4. DA lower GI bleed from diverticular disease

A patient in cardiac rehabilitation asks how hard to exercise. Which simple guide is commonly taught?

1. AExercise only until the heart rate rises even slightly
2. BExercise until chest pain starts, then stop
3. CExercise so they are a little breathless but can still talk
4. DExercise until they are too breathless to speak at all

On day 2 after a surgical tracheostomy, the tube falls out. The patient is breathing but distressed. What should the nurse do first?

1. ACover the stoma completely with a sealed dressing and wait for help
2. BLeave the patient alone while fetching a new tube
3. CForce the tube back through the stoma immediately with firm pressure
4. DCall for expert help and give oxygen to both the face and the stoma

脳灌流圧（CPP）はどのように計算しますか？

1. A収縮期動脈圧に頭蓋内圧を足す
2. B平均動脈圧から頭蓋内圧を引く
3. C拡張期圧から中心静脈圧を引く
4. D平均動脈圧を心拍数で割る

看護師が4人の患者のケアをしています。最初に診るべき患者はどれですか？

1. Aレボチロキシンの時間になっている、安定した甲状腺機能低下症の患者
2. Bリン吸着薬について尋ねている、CKDの患者
3. C排液が透明な、腹膜透析の患者
4. D開頭術の後で、右の瞳孔が新たに散大して対光反応が鈍い患者

全身麻酔の後、患者が回復室に着いたときの最優先事項は何ですか？

1. A気道と呼吸
2. B水を飲ませること
3. C創のドレッシングとドレーン
4. D薬歴

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

1. AApply a tight plastic film directly over the wound
2. BUse a dressing that adds even more moisture
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