NCLEX 形式の優先順位の決定と委任：直前対策パック

Which patient should the RN see first after receiving a report from the night nurse?

1. ADay 1 after bowel surgery, new chest pain and heart rate 110/min
2. BDay 4 after bowel surgery, waiting for discharge teaching
3. CDay 3 after bowel surgery, wants a shower and hair wash before breakfast
4. DDay 2 after bowel surgery, asking to start a soft diet

A nursing assistant has twice not reported abnormal vital signs to the RN. What is the RN’s best action?

1. AComplain about the assistant to the patients during care
2. BTalk to the assistant privately, restate what must be reported and follow up closely
3. CStop delegating any tasks to the assistant for the rest of the year
4. DSay nothing to the assistant and quietly recheck all of the assistant’s vital signs in secret

Which information must be documented when a patient is restrained?

1. AOnly the name of the nurse who applied it and the unit where it happened
2. BOnly the time the restraint was put on and the time it was taken off
3. CThe reason, alternatives tried, type of restraint, times and regular assessments
4. DOnly whether the family agreed to the restraint

A nurse caring for a patient with influenza on droplet precautions will assist with an aerosol-generating procedure, such as bronchoscopy. What change in PPE is needed?

1. AWear a fit-tested respirator (N95 or FFP3) and eye protection instead of a surgical mask
2. BWear two surgical masks, one on top of the other, for the length of the procedure
3. CNo change, because influenza only needs droplet precautions
4. DWear gloves only, because the procedure is short

A patient with hyperkalemia is prescribed an oral potassium binder such as patiromer or sodium zirconium cyclosilicate. How does this drug lower potassium?

1. AIt binds potassium in the gut so it leaves in the stool
2. BIt stops the kidneys from absorbing water in the tubules
3. CIt moves potassium into cells in the next few minutes
4. DIt protects the heart muscle against high potassium levels

An 82-year-old woman without a catheter has a urine culture growing bacteria, but no fever, urinary symptoms or change in mental state. What is the best interpretation?

1. APyelonephritis, which needs admission and IV fluids today
2. BContamination, so the culture must be repeated every week
3. CAsymptomatic bacteriuria, usually not treated with antibiotics
4. DA urinary tract infection that needs urgent IV antibiotics

Which measure helps prevent delirium in older inpatients?

1. AReorientation, glasses and hearing aids in use, and good sleep and hydration
2. BMoving the patient to a different bed each night to give them a change of scene
3. CKeeping the lights on all night
4. DRestricting fluids to avoid incontinence

A few hours after cardiac surgery, a patient has low blood pressure, a raised jugular venous pressure and quiet, muffled heart sounds. What should be suspected?

1. APneumonia
2. BHyperkalaemia
3. CCardiac tamponade
4. DHypovolaemia from dehydration

Suspected pulmonary TB is being investigated. How are sputum samples usually collected?

1. AA swab from the nose only
2. BOne sample of saliva collected at any time of the day
3. CA single sample after the first week of treatment
4. DSeveral samples, ideally including early-morning sputum

A patient who has had a total laryngectomy becomes breathless and needs oxygen. How should it be given?

1. AVia a standard face mask over the nose and mouth
2. BVia a mask or humidified device over the neck stoma
3. CVia a non-rebreather mask over the mouth only
4. DVia nasal cannula at 2 L/min

Which picture fits anterior cord syndrome?

1. ALoss of movement and pain sense, with position sense kept
2. BArms much weaker than legs after a neck injury
3. CWeakness on one side and loss of pain sensation on the other side
4. DNormal movement but complete loss of position sense

A nurse teaches a patient with CKD and a high potassium about diet. Which statement shows a need for further teaching?

1. A"I will boil my potatoes and throw away the water."
2. B"I will use a salt substitute instead of ordinary salt."
3. C"I will check food labels for added salt when I go shopping."
4. D"I will keep bananas and dried fruit to a minimum."

小腸閉塞と大腸閉塞の主な臨床的な違いは何ですか？

1. A小腸：早期の嘔吐で膨満は軽い。大腸：遅れて嘔吐し、著明な膨満
2. B小腸：嘔吐がまったくない。大腸：膨満のない、早期の大量嘔吐
3. C小腸：著明な膨満のみ。大腸：痛みも嘔吐も膨満も全くない
4. D臨床的な違いはなく、CTでしか区別できない

An immobile patient on opioids drinks very little. Which laxative choice is least appropriate?

1. AA stimulant laxative taken regularly
2. BAn osmotic laxative such as a macrogol
3. CA bulk-forming laxative used on its own
4. DA stool softener with a stimulant laxative