NCLEX 形式の優先順位の決定と委任：直前対策パック

Several patients on a gastroenterology unit need care. Which patient should the nurse see first?

1. AUlcerative colitis, asking about diet changes for home
2. BLong-standing back pain, asking for the usual analgesic
3. CTwo hours after a colonoscopy: rigid abdomen and severe new pain
4. DCrohn disease, waiting to be taken down for a scheduled CT scan

A patient with suspected sepsis has four prescribed orders. Which should usually be done first?

1. ATake blood cultures
2. BRepeat the lactate in six hours
3. CArrange a chest X-ray for later today
4. DGive the IV antibiotic

A woman who is pregnant asks for the MMR vaccine because she is not immune to rubella. What is correct?

1. AMMR is only given to pregnant women who work in hospitals
2. BMMR is a live vaccine and is not given during pregnancy, but can be given after delivery
3. CMMR should be given as soon as possible in the first trimester to protect the baby
4. DMMR is safe at any stage of pregnancy

While preparing a chemotherapy infusion, the drug splashes onto a nurse’s forearm. What should the nurse do first?

1. AFinish hanging the infusion and then wash the skin
2. BCover the area with a dressing and report later
3. CWipe the skin with an alcohol swab and continue preparing the infusion
4. DRemove contaminated PPE and wash the skin with soap and water at once

A patient with pneumonia had a CRP of 180 mg/L on admission and 40 mg/L after 4 days of antibiotics. What does this most likely show?

1. AThe patient has developed a new infection
2. BThe infection has spread to another organ
3. CThe antibiotic is causing liver damage
4. DThe inflammation is settling with treatment

A patient with long-standing rheumatoid arthritis has a hemoglobin of 10.5 g/dL (105 g/L), a low serum iron, a low total iron-binding capacity (TIBC) and a high-normal ferritin. Which condition fits best?

1. AAcute blood loss anemia
2. BVitamin B₁₂ deficiency anemia
3. CAnemia of chronic disease (inflammation)
4. DIron-deficiency anemia

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

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

術後の患者で肺塞栓症を最も強く示唆する所見は？

1. A高血圧を伴う遅い脈
2. Bサルブタモールで良くなる喘鳴
3. C1 週間かけてゆっくり始まる、黄色い痰を伴う咳と軽い発熱
4. D頻脈を伴う突然の息切れと胸膜痛

Why is a higher level of HDL cholesterol considered protective?

1. AHDL is converted into vitamin D in the walls of the arteries
2. BHDL carries cholesterol from the tissues back to the liver
3. CHDL lowers the blood pressure directly
4. DHDL thins the blood in the same way as an anticoagulant

患者の胸腔ドレーンが、誤って引き抜かれました。直ちにすべきことは何ですか？

1. A滅菌の閉鎖性ドレッシングで部位を密閉し、応援を呼ぶ
2. B閉じ込められた空気が逃げるよう、穴を覆わないでおく
3. Cドレーンを胸部に押し戻し、テープで固定する
4. D肺を広げるため、患者に強く咳をするよう頼む

Several hours after a carotid endarterectomy, which finding needs the most urgent action?

1. AA small amount of dried blood on the dressing
2. BA blood pressure slightly above the baseline
3. CAn expanding neck swelling with noisy breathing
4. DMild pain at the incision site

A patient with hypopituitarism needs both hydrocortisone and levothyroxine. Which is usually started first?

1. ALevothyroxine
2. BBoth on the same day, in any order
3. CNeither, until symptoms appear
4. DHydrocortisone

Which change suggests that a burn wound is becoming infected?

1. ADry, healing skin with mild itching
2. BThe wound becoming pink and a little smaller at each dressing change
3. CA partial-thickness burn becoming deeper, with new discolouration
4. DLess exudate on each dressing change

A patient with haematemesis becomes drowsy and starts to vomit blood again. What is the immediate priority?

1. ATurn the patient onto their side to protect the airway
2. BComplete the admission paperwork and medication history
3. CSend a stool sample for faecal occult blood testing
4. DGive a large glass of iced water to slow the bleeding