NCLEX 形式の優先順位の決定と委任：直前対策パック

Two hours after birth, the nurse finds the uterus firm but above the umbilicus and pushed to the right. What should the nurse do first?

1. AGive a dose of oxytocin straight away
2. BMassage the uterus firmly for ten minutes
3. CHelp the patient empty her bladder
4. DAsk the patient to lie still for another hour

A patient’s serum potassium is 6.1 mEq/L. Which of the patient’s medications should the nurse question first?

1. AHydrochlorothiazide
2. BOmeprazole
3. CSpironolactone
4. DFurosemide

A cup of water is spilled over an infusion pump plugged into the wall. What should the nurse do?

1. ASwitch it off and unplug it safely, then have it checked before reuse
2. BWipe it dry quickly with a towel and keep using it for the infusion
3. CLeave it running and place a towel over it until it dries
4. DTurn the pump upside down to drain it while running

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

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

肝硬変の患者のアルブミンが 2.2 g/dL（22 g/L）です。最も関連しそうな所見はどれですか？

1. A尿量の増加
2. B高血圧
3. C浮腫と腹水
4. D高カリウム血症

手術後、大量の低張性輸液を受けている患者に、頭痛、悪心、錯乱が現れました。これを最もよく説明する結果はどれですか？

1. Aカリウム 4.2 mEq/L
2. Bカルシウム 9.4 mg/dL（2.35 mmol/L）
3. C血糖 110 mg/dL（6.1 mmol/L）
4. Dナトリウム 126 mEq/L

An older adult has left lower abdominal pain, fever and a raised CRP. Which condition is most likely?

1. ADiverticulitis
2. BGastric ulcer
3. CBiliary colic
4. DAppendicitis

After a head injury, a patient has clear fluid leaking from the nose. What does this most likely suggest?

1. AAcute sinusitis
2. BA normal and harmless response to head trauma
3. CAllergic rhinitis triggered by the hospital environment
4. DA base-of-skull fracture with a cerebrospinal fluid leak

A patient taking simvastatin drinks a large glass of grapefruit juice every morning. Why is this a concern?

1. AIt raises statin levels and the risk of muscle damage
2. BIt stops the statin from being absorbed from the gut at all
3. CIt causes the cholesterol level to rise sharply
4. DIt turns the statin into a blood thinner

A patient with rheumatoid arthritis is due to start an anti-TNF biologic drug. Which screening is essential beforehand?

1. AAn exercise ECG test on a treadmill
2. BScreening for latent tuberculosis
3. CA peak flow diary for a month
4. DA sweat chloride test

A patient taking a GLP-1 receptor agonist has severe, constant upper abdominal pain spreading to the back, with vomiting. What should the nurse suspect?

1. ANormal nausea from the drug
2. BLow blood glucose
3. CAcute pancreatitis
4. DA simple urinary tract infection

A patient on carbamazepine is admitted confused, with a sodium of 121 mmol/L. Which explanation is most likely?

1. AThe low sodium proves the patient has stopped taking the drug
2. BCarbamazepine can cause hyponatraemia through an SIADH-like effect
3. CConfusion is a normal, expected effect of carbamazepine and is unrelated to sodium
4. DCarbamazepine causes salt loss through severe diarrhoea

Which is correct when caring for a patient with a PICC line?

1. ALeave the external length unchecked once it is placed
2. BFlush the line only when it blocks
3. CAvoid taking blood pressure on the arm with the line
4. DUse the PICC arm for heavy lifting to keep it flexible

On the morning of elective hip surgery, a patient says she took her usual warfarin last night despite being told to stop. What should the nurse do?

1. AProceed with the usual checklist and say nothing
2. BInform the surgical and anaesthetic teams, who will check the INR
3. CTell her the surgery must be cancelled for a month
4. DGive a double dose of vitamin K by mouth without waiting for a prescription