NCLEX 形式の優先順位の決定と委任：直前対策パック

Which postoperative patient should the nurse see first?

1. AWants help with washing her hair before her visitors arrive this afternoon
2. BAsking when the urinary catheter will be removed
3. CDressing soaked with bright red blood and a heart rate rising to 118/min
4. DPain of 4/10 one hour after an oral analgesic

During JumpSTART triage, a child who cannot walk is breathing 50 times a minute. Which category is the child given?

1. AGreen (minor)
2. BBlack (expectant)
3. CRed (immediate)
4. DYellow (delayed)

A patient has orthostatic hypotension. Which teaching helps to prevent falls?

1. AAvoid drinking fluids in the morning to reduce trips to the toilet
2. BSit on the edge of the bed for a short time before standing up slowly
3. CGet out of bed quickly so the dizziness passes sooner
4. DStand up straight after a hot shower to increase blood flow

A nurse teaches new parents about safe infant sleep. Which statement shows a need for further teaching?

1. A“We will lay the baby on the back for every sleep, including naps.”
2. B“We will not smoke near the baby.”
3. C“We will keep the crib in our room, next to our bed, for the first months.”
4. D“We will put a soft bumper pad and a blanket in the crib so the baby is cozy.”

A healthy patient has a mildly raised CK after running a marathon yesterday, without dark urine or symptoms. What is the most likely explanation?

1. AThe patient has developed acute pancreatitis
2. BAn acute myocardial infarction has occurred
3. CThe patient has developed acute hepatitis
4. DStrenuous exercise raised CK from skeletal muscle

A frail older adult in a nursing home has been drinking very little during a heat wave. She is confused, and her sodium is 158 mEq/L. Which treatment would the nurse expect?

1. ARapid infusion of 3% saline to raise the volume
2. BA loop diuretic to remove the extra sodium quickly
3. CGradual replacement of free water over many hours
4. DStrict fluid restriction to below 800 mL a day

A confused patient keeps trying to climb out of bed. Why are bed rails not automatically the answer?

1. ABed rails stop staff from taking observations
2. BPatients can be seriously injured climbing over or becoming trapped in rails
3. CBed rails always make patients more confused, but only during the day
4. DBed rails are illegal in all hospitals and must never be used at all

A patient with suspected appendicitis says the pain suddenly eased, but an hour later has pain all over the abdomen, a rigid abdomen and a fever. What is most likely?

1. AThe appendicitis has resolved without treatment
2. BThe patient has developed gastroenteritis
3. CThe analgesia has started working
4. DThe appendix has perforated, causing peritonitis

患者のB型ナトリウム利尿ペプチド（BNPまたはNT-proBNP）が上昇しています。これは主に何を反映していますか？

1. A心筋の虚血性障害
2. Bうっ血による肝臓の炎症
3. C心室の伸展と圧負荷
4. D転倒後の骨格筋の損傷

心臓手術の1時間後、縦隔ドレーンから鮮紅色の血液が350 mL排液され、心拍数が上昇しています。看護師はどうすべきですか？

1. A直ちに外科チームに報告する
2. B5分ごとにチューブを強くしごく
3. C量を記録し、1時間ごとの確認を続ける
4. Dさらなる出血を止めるため、ドレーンをクランプする

Why is pyridostigmine often taken about 30–60 minutes before meals by patients with myasthenia gravis?

1. ATo lower the blood glucose rise after eating a meal
2. BTo reduce stomach acid so the food is digested better
3. CTo stop the drug from irritating an empty stomach later on
4. DTo improve the strength of chewing and swallowing at mealtimes

C5の脊髄損傷の2日後、患者が不安を訴え、呼吸数が30/分、肺活量が低下しています。看護師はどうすべきですか？

1. A呼吸を遅くして不安を和らげるため、鎮静薬を投与する
2. B約12時間後に、もう一度肺活量を再確認する
3. C気道を開くため、頭を後ろに倒して水平に寝かせる
4. D緊急に上申する。脊髄の浮腫が呼吸不全を起こしているかもしれない

消化管出血のある安定した患者への赤血球輸血で、現在のエビデンスに合う方針はどれですか？

1. Aすべての内視鏡検査の前に、日常的に2単位輸血する
2. B多くの安定した患者で、しばしば約70 g/Lの制限的な閾値
3. Cヘモグロビンを常に150 g/L超に保つよう、全員に輸血する
4. Dヘモグロビンや症状にかかわらず、決して輸血しない

A nurse teaches a patient with chronic pancreatitis. Which statement shows a need for further teaching?

1. A"I'll report increased thirst or passing urine more often."
2. B"Oily, floating stools may mean my dose needs changing."
3. C"I should not drink any alcohol."
4. D"I'll take my enzyme capsules at bedtime."