NCLEX 形式の優先順位の決定と委任：直前対策パック

病棟での心停止で、患者に反応がなく正常な呼吸がないことを確認したあと、最初に行う行動はどれですか？

1. A応援を呼ぶ前に、蘇生の方針を確認するために患者の記録を探す
2. B応援を呼び、胸骨圧迫を開始する
3. C人工呼吸を 2 回行い、その後 1 分間脈拍を確認する
4. D血圧を測定する

看護師が 4 人の患者のケアをしています。定型的なケアとして、看護助手に安全に割り当てられるのは誰ですか？

1. A血糖が 52 mg/dL（2.9 mmol/L）で、汗をかいている患者
2. B脳卒中の 5 日後で、入浴の介助が必要で、バイタルサインが安定している患者
3. C手術から戻ってきて、最初の術後アセスメントが必要な患者
4. D1 時間前に新たに胸腔ドレーンを挿入した患者

A patient walking with a gait belt suddenly starts to fall. What should the nurse do?

1. AHold the belt, widen the stance and ease the patient gently to the floor
2. BGrab the patient under both arms and try hard to keep them standing up
3. CPull the patient backwards quickly toward the bed
4. DLet go of the belt and run to call for help

A nurse has raised a safety concern about an order with the prescriber, who dismissed it without addressing it. What should the nurse do next?

1. ADiscuss the concern with the patient and let them decide
2. BState the concern clearly a second time and, if still unresolved, use the chain of command
3. CRefuse to care for the patient for the rest of the shift until the prescriber apologizes
4. DCarry out the order as written, because the prescriber has heard the concern

A pregnant woman's blood type is O Rh-negative, and her antibody screen (indirect Coombs test) is negative. What is usually offered at about 28 weeks?

1. ADaily oral iron and folic acid supplements only
2. BA transfusion of group O Rh-positive red cells
3. CAn IV dose of vitamin K given for the fetus
4. DAnti-D immunoglobulin (Rho(D) immune globulin)

A nursing student has a positive interferon-gamma release assay (IGRA) for tuberculosis, no symptoms and a normal chest X-ray. What does this most likely mean?

1. AActive pulmonary TB, which is contagious
2. BPast BCG vaccination only, with no infection
3. CA false result, as the test does not detect TB
4. DLatent TB infection, which is not contagious

交通事故後の患者に強い息切れ、片側の呼吸音の消失、低血圧があり、気管が反対側に偏位しています。考えられる診断は？

1. A肺炎
2. B肺水腫
3. C緊張性気胸
4. D喘息

A healthcare assistant reports four observations. Which one needs the nurse's immediate action?

1. A"Mr Chen's blood pressure is 128/80 as usual."
2. B"Ms Ali has walked to the bathroom on her own."
3. C"Mr Patel's breathing rate is 8 a minute and he's hard to wake."
4. D"Mrs Jones would like a cup of tea and her glasses cleaned."

A patient taking isosorbide mononitrate asks about sildenafil for erectile dysfunction. What is the main danger?

1. AA very high potassium level
2. BSevere hypertension
3. CBleeding from the gums
4. DSevere hypotension

Twelve hours after a coronary stent, a patient has sudden severe chest pain again with new ST elevation in the same leads. What is the most likely cause?

1. AAcute stent thrombosis
2. BNormal pain from the procedure site
3. CPericarditis from the catheter
4. DIndigestion from the hospital meal

A patient with a new ileal conduit has threads of mucus in their urine. What should the nurse explain?

1. AThe kidneys have stopped working properly after surgery
2. BThis proves a serious kidney infection
3. CThis is a sign that the stoma is dying
4. DThis is normal, because the conduit is made from bowel

Which task for a patient with a urinary catheter can the nurse delegate to a healthcare assistant (nursing assistant)?

1. ADeciding whether the catheter can be removed
2. BTeaching self-catheterisation for the first time
3. CAssessing a patient whose irrigation is not draining
4. DEmptying the drainage bag and recording the volume

湿潤が必要な、乾燥したスラフのある創に、一般に適したドレッシングはどれですか？

1. Aフォーム
2. Bハイドロジェル
3. C乾いたガーゼ
4. Dアルギン酸塩

A patient is booked for a urea breath test for H. pylori. Which medicine should usually be stopped 2 weeks before the test?

1. AParacetamol (acetaminophen)
2. BOmeprazole
3. CAmlodipine
4. DLevothyroxine