公式集、全トピックの解法の要点、14 問の演習問題。完全な解答は巻末にあります。
A nurse teaches foot care to a patient with diabetes. Which statement shows a need for further teaching?
A patient with diabetes is sweaty and confused, and no glucose meter is available. The patient can swallow. What should the nurse do?
患者の胸部の一部に帯状疱疹があり、免疫は正常で、病変は完全に覆うことができます。通常、どの予防策が必要ですか？
While preparing a chemotherapy infusion, the drug splashes onto a nurse’s forearm. What should the nurse do first?
A patient with HIV on antiretroviral therapy has an undetectable viral load. What does this mean?
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?
A pressure ulcer shows full-thickness tissue loss with exposed bone. Which category (stage) is this?
After a head injury, a patient has clear fluid leaking from the nose. What does this most likely suggest?
After a bronchoscopy with throat anaesthesia, when can the patient eat and drink?
A patient with pneumonia has a temperature of 39 °C, pain and a sinus tachycardia of 122/min. BP is normal. What is the best way to manage the heart rate?
Why are patients with an acute spinal cord injury at high risk of deep vein thrombosis?
頭蓋内圧が亢進している患者に、気管内吸引が必要です。最も適切な方法はどれですか？
創傷治癒のうち、肉芽組織と新しい血管の形成が起こる段階はどれですか？
Which medicine commonly needs enteral feeds paused before and after each dose because the feed reduces its absorption?
答え: B · “I will soak my feet in hot water every evening.”
Neuropathy can stop the patient feeling heat, so hot soaks can cause burns, and long soaking dries the skin. Daily checks, careful drying and well-fitting shoes are correct.
答え: C · Treat for hypoglycemia with fast-acting oral carbohydrate
When in doubt, treat as hypoglycemia. A little sugar will not harm a patient with high glucose, but untreated hypoglycemia can cause brain injury within minutes, and insulin could be fatal.
答え: D · 病変を覆った標準予防策
免疫が正常な患者の限局した帯状疱疹で、病変を覆える場合は、標準予防策で管理します。播種性帯状疱疹では、すべての病変が乾燥して痂皮化するまで空気予防策と接触予防策が必要で、免疫不全患者の限局した帯状疱疹では、播種が否定されるまでこれらの予防策が必要です。水痘に対する免疫のない職員は対応してはいけません。
答え: B · Remove contaminated PPE and wash the skin with soap and water at once
Skin exposure to hazardous drugs is washed immediately with soap and water after removing contaminated gloves or gown. The exposure is then reported and treated according to policy.
答え: C · The treatment is suppressing the virus very well
An undetectable viral load shows that antiretroviral therapy is suppressing viral replication. The virus remains in the body, so treatment must continue. People with a sustained undetectable viral load do not transmit HIV sexually.
答え: B · Gradual replacement of free water over many hours
Older adults have a reduced sense of thirst and easily develop hypernatremia from water loss. Free water is replaced gradually, because lowering sodium too quickly can cause cerebral edema. Hypertonic saline and fluid restriction would make it worse.
答え: D · Category 4
Category 4 involves full-thickness tissue loss with exposed bone, tendon or muscle. Category 3 is full-thickness skin loss without exposed bone or tendon. US (NPIAP) terminology calls these stages rather than categories.
答え: C · A base-of-skull fracture with a cerebrospinal fluid leak
Clear fluid from the nose or ear after head injury suggests a CSF leak from a skull base fracture, with a risk of meningitis. Nasal tubes and nose-blowing should be avoided and the patient reviewed urgently.
答え: B · When the gag and cough reflexes have returned
Local anaesthetic sprayed on the throat abolishes the gag and cough reflexes for a time, so food or fluid could be aspirated. The nurse checks that the reflexes have returned (often after about one to two hours) before giving sips of water and then food.
答え: D · Treat the fever, pain and possible dehydration, then reassess
Sinus tachycardia is usually a physiological response to fever, pain, hypovolaemia, anxiety, hypoxia or sepsis. Treating the cause (antipyretics, analgesia, fluids, oxygen if needed) is appropriate, while watching for sepsis. Rate-slowing drugs can be harmful by masking compensation.
答え: D · Paralysed leg muscles no longer pump blood back to the heart
Paralysis removes the calf muscle pump, and immobility causes venous stasis. Trauma also makes the blood more likely to clot. Prophylaxis usually combines anticoagulation and mechanical methods when safe.
答え: D · 事前に酸素化し、1回ごとを短くして、回数を制限する
吸引は、咳、低酸素、高二酸化炭素血症を通じてICPを上げます。必要なときにだけ、事前の酸素化、約10～15秒以内の短い吸引、少ない回数、頭部の挙上と正中位の保持のもとで行います。施設によっては、鎮静やリドカインを用いることがあります。
答え: D · 増殖期
治癒には、重なり合う4つの段階があります。止血、炎症、増殖（肉芽組織、血管新生、上皮化）、成熟（コラーゲンの再構築で、1年以上続くこともあります）です。
答え: C · Phenytoin
Enteral feeds bind phenytoin and lower its levels, risking seizures. Feeds are usually paused around doses, as advised by the pharmacist, and drug levels are monitored.
ExamProblems · examproblems.com/courses/nclex-style-prioritization-and-delegation