NCLEX 形式の優先順位の決定と委任：直前対策パック

A patient arrives in the recovery room after general anesthesia. What does the nurse assess first?

1. AUrine output
2. BThe surgical dressing and the drains
3. CThe pain score
4. DAirway patency and breathing

A patient has central chest pain that started 30 minutes ago at rest and has not eased with rest or nitroglycerin. What does this suggest?

1. AStable angina that will pass without treatment
2. BA possible myocardial infarction that needs urgent action
3. CIndigestion that is best treated with an antacid and a glass of milk
4. DMuscle strain that needs a warm compress

患者が手首の抑制を受けている間、最も重要なアセスメントはどれですか？

1. Aその日の飲食の好み
2. B時計を使った両耳の聴力
3. C抑制具より末梢の循環、感覚、皮膚
4. D身長と体重

無菌的な中心静脈カテーテルのドレッシング交換中に、同僚が開いた滅菌野の上に腕を伸ばしてテープを手渡しました。看護師はどうすべきですか？

1. A滅菌野は汚染されたとみなし、新しく準備し直す
2. B滅菌タオルで滅菌野を覆い、その上で続ける
3. C同僚は滅菌物に触れていないので、続ける
4. D腕が上を通った場所に最も近い物だけを取り除く

患者が皮下注射のエノキサパリン（低分子量ヘパリン）を投与されています。モニタリングについて、正しい記述はどれですか？

1. A用量を調整するために、aPTT を 6 時間ごとに確認しなければならない
2. Bワルファリンと同様に、各用量を調整するために INR を用いる
3. C通常の aPTT は不要で、代わりに血小板と腎機能を確認する
4. Dいかなる血液検査も決して必要ない

A patient in hyperosmolar hyperglycemic state has a glucose of 1,050 mg/dL (58 mmol/L), very dry mucous membranes and a fast pulse. Which treatment is usually the first priority?

1. AStrict fluid restriction
2. BOral glucose-lowering tablets
3. CLarge-volume IV fluid replacement
4. DAn IV bolus of sodium bicarbonate

Which blood result often rises in an upper GI bleed because blood is digested in the gut?

1. AGlucose
2. BCalcium
3. CSodium
4. DUrea (blood urea nitrogen)

Which feature best distinguishes delirium from dementia?

1. ADementia always causes visual hallucinations
2. BDelirium starts suddenly and fluctuates, while dementia develops gradually
3. CDelirium is permanent, while dementia is reversible
4. DDelirium only affects people under 50, while dementia affects older people

A patient stops ramipril because of a troublesome dry cough. Which drug class is a common alternative?

1. AA non-selective beta-blocker such as propranolol
2. BA nitrate such as isosorbide mononitrate
3. CA loop diuretic such as furosemide
4. DAn angiotensin II receptor blocker such as losartan

A nurse has four cardiac patients. Which one should be seen first?

1. AA patient after a radial angiogram asking when they can eat
2. BA patient with angina whose chest pain has not eased with rest and who is sweating
3. CA patient with heart failure whose weight is 0.3 kg up on yesterday's morning weight
4. DA patient with AF and a heart rate of 86/min who is due an apixaban dose this morning

Which statement about the PSA blood test is correct?

1. AA normal result always rules out any prostate cancer
2. BIt can be raised by benign problems as well as by cancer
3. CA raised result always means prostate cancer
4. DIt is only raised in women with bladder cancer

The nurse has four patients. Which one needs to be seen first?

1. AA patient with stable CKD waiting for a renal diet review
2. BA patient with hypothyroidism asking when to take levothyroxine
3. CA patient on insulin for DKA whose potassium is now 2.9 mmol/L
4. DA patient with Parkinson's disease whose next dose is due in two hours

Which advice helps prevent dumping syndrome after gastrectomy?

1. AThree large meals a day with plenty of sweet drinks with each meal
2. BSit upright and walk briskly straight after every meal
3. CSmall, frequent meals low in simple sugars, with fluids between meals
4. DA high-sugar diet with fruit juice to keep energy levels up

On the ward after surgery, a patient has a red, blistered area of skin under where the diathermy plate was. What should the nurse do?

1. AWash it with alcohol and leave it uncovered
2. BApply a hot water bottle to improve the circulation
3. CIgnore it because skin changes after surgery are normal and expected to fade
4. DTreat it as a possible burn, report it and complete an incident form