NCLEX 形式の優先順位の決定と委任：直前対策パック

When making patient assignments, what should the charge nurse consider first?

1. AGiving each nurse patients in rooms next to each other
2. BMatching each patient’s needs to staff competence
3. CGiving the newest staff the most complex patients
4. DLetting staff choose the patients they prefer

A patient with major depression has been withdrawn for weeks but is suddenly calm and cheerful and gives away her belongings. What should the nurse suspect?

1. AThat she is getting ready for discharge as planned
2. BA full recovery, so observation can be reduced
3. CA side effect of her antidepressant medicine that needs no special action
4. DA raised risk of suicide, because she may have made a decision

Which practice reduces back strain when a nurse moves a patient or heavy object?

1. ABend at the waist and keep both knees straight
2. BKeep the load close to the body and avoid twisting
3. CHold the load at arm’s length to keep it steady
4. DStand with the feet close together for balance

Minutes after the first IV dose of an antibiotic starts, the patient develops wheezing, hives and low blood pressure. What should the nurse do first?

1. AStop the infusion
2. BSlow the infusion rate
3. CGive an oral antihistamine
4. DRecord the new allergy in the chart

A patient on a heparin infusion has an aPTT below the target range on the protocol. What should the nurse do?

1. ASwitch the infusion to oral warfarin without a prescription
2. BAdjust the rate as the protocol directs and recheck as scheduled
3. CStop the infusion and give protamine sulfate as quickly as possible
4. DContinue the same rate and recheck the aPTT in a few days

糖尿病性ケトアシドーシスの患者の、インスリン点滴を開始する前のカリウムが 3.0 mEq/L です。看護師は何を予想すべきですか？

1. Aカリウムが正常になるまで、輸液を止める
2. Bただちに、より高い速度でインスリンを開始する
3. Cカリウムを先に補充し、インスリンは、プロトコルに従って濃度が安全になるまで待つ
4. Dインスリンがカリウムを上げるので、カリウムは補充しない

心臓のリズムにとって最も危険な電解質異常は？

1. Aカリウムの高すぎや低すぎ
2. Bリン酸の低下
3. Cナトリウムの低下
4. Dクロールの上昇

A patient who used sildenafil the day before develops chest pain. Why is glyceryl trinitrate (GTN, nitroglycerin) normally avoided?

1. ASildenafil stops GTN from being absorbed under the tongue at all
2. BGTN makes sildenafil toxic to the liver
3. CThe combination causes severe hyperkalaemia
4. DThe combination can cause a severe, dangerous fall in blood pressure

After coronary artery bypass surgery through a median sternotomy, which instruction is usually given for the first several weeks?

1. ASleep only on the stomach to protect the wound
2. BAvoid heavy lifting and pushing up with the arms
3. CAvoid walking until the stitches are removed
4. DLift the arms above the head often to stretch the chest

A nurse teaches a patient who is starting warfarin. Which statement shows a need for further teaching?

1. A"I will have regular INR blood tests."
2. B"I will tell my dentist that I take warfarin."
3. C"If I miss a dose, I will take two the next day."
4. D"I will check before taking any new medicines or herbal remedies."

急性腎障害のとき、またはリスクのある患者のヨード造影剤の前後に、メトホルミンが通常保留されるのはなぜですか？

1. A蓄積して乳酸アシドーシスのリスクが高まりうるから
2. B造影剤と併用すると重度の低血糖を起こすから
3. C腎臓が障害されると高カリウム血症を起こすから
4. D造影剤を遮断して、画像が読めなくなるから

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

1. AA patient with Parkinson's disease whose next dose is due in two hours
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 stable CKD waiting for a renal diet review

肝硬変の患者で出血のリスクが高いのはなぜですか？

1. A肝硬変の高い動脈圧が血管を破裂させるから
2. B凝固因子の減少、低い血小板、門脈圧亢進による静脈瘤
3. C肝硬変は血小板数を増やし、血小板を弱くするから
4. D瘢痕化した肝臓が、ヘパリンなどの抗凝固物質を血液中に放出するから

A patient with haematemesis becomes drowsy and starts to vomit blood again. What is the immediate priority?

1. ATurn the patient onto their side to protect the airway
2. BSend a stool sample for faecal occult blood testing
3. CGive a large glass of iced water to slow the bleeding
4. DComplete the admission paperwork and medication history