공식 모음, 모든 주제의 핵심 풀이 단계, 연습 문제 14개가 들어 있으며 전체 풀이는 맨 뒤에 있습니다.
A parent of a child with influenza talks with the nurse. Which statement shows a need for further teaching?
A victim heavily contaminated with an industrial chemical arrives at the emergency department with stable vital signs. What should happen first?
How does a nurse add a sterile gauze pack to a sterile field that is already set up?
In START triage, a casualty cannot walk and is breathing 36 times a minute. Which category applies?
A patient with hyponatremia from SIADH starts tolvaptan. Why is the serum sodium checked frequently in the first day?
Ten days after chemotherapy, a patient has a platelet count of 9 × 10³/µL and reports a sudden severe headache and blurred vision. What is the priority?
What should a patient starting oral iron tablets be told?
A patient who has had a kidney stone is taught about prevention. Which statement shows a need for further teaching?
최근 뇌졸중이 있고 삼킴곤란이 있는 환자에게 열과 우하엽 수포음이 생겼습니다. 가장 가능성 높은 원인은?
A one-way speaking valve is fitted to a patient's tracheostomy tube while the cuff is still inflated. What is the danger?
만성 신장병 환자가 흔히 식사와 함께 인산염 결합제를 복용하는 이유는?
During haemodialysis, a patient suddenly becomes breathless with chest pain, and air is seen in the line. What should the nurse do first?
Which change suggests that a burn wound is becoming infected?
A 62-year-old with known reflux reports burning central chest pain with sweating and breathlessness that began while walking. What should the nurse do first?
답: B · “I will give my child aspirin to bring the fever down.”
Aspirin in children with viral illnesses such as influenza or chickenpox is linked to Reye syndrome. Fluids, rest at home and reporting breathing trouble are correct.
답: B · Decontamination before the victim enters the treatment area
A stable, contaminated victim is decontaminated before entering the department, to protect staff, other patients and the victim. Life-saving care may come first only if the victim is unstable.
답: A · Open the wrapper away from the field and drop the item on it without reaching over
The nurse opens the package so the sterile item can be dropped onto the field from a short height, without the wrapper or arms crossing over the sterile area. The item must land well inside the non-sterile border.
답: A · Red (immediate)
In START, a non-walking casualty who is breathing more than 30 times a minute is tagged red, immediate. Fast breathing suggests a serious problem that needs urgent treatment.
답: D · The sodium can rise too quickly
Tolvaptan blocks ADH receptors in the kidney, causing free water loss. Sodium can rise too fast, risking osmotic demyelination, so treatment is started in hospital with frequent sodium checks. Fluid restriction is usually avoided at the start.
답: A · Assess neurological status and report it at once as possible brain bleeding
Platelet counts usually reach their lowest point (nadir) about 7–14 days after chemotherapy. With a count below 10 × 10³/µL, a sudden severe headache or visual change may signal intracranial bleeding, which is an emergency. The nurse assesses neurological status and reports it immediately.확인 출처: Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment · National Cancer Institute (NIH) (2022); Pancytopenia · StatPearls (NCBI Bookshelf) (2023)
답: B · Their stools may turn dark or black
Oral iron commonly darkens the stool and can cause constipation or stomach upset. Tea and antacids reduce absorption, while vitamin C may increase it.
답: D · "I will drink less water so I don't need to pass urine as often."
A high fluid intake dilutes urine and is the most important general measure to prevent stones. Dietary advice depends on the stone's composition.
답: A · 흡인성 폐렴
뇌졸중 후 연하곤란은 흡인 위험을 높입니다. 우측 주기관지가 더 넓고 수직에 가까워 흡인된 물질이 흔히 우하엽으로 들어갑니다. 삼킴 선별검사, 똑바로 앉은 자세, 구강 간호가 위험을 줄입니다.
답: C · The patient cannot breathe out and may suffocate
A speaking valve opens on inspiration and closes on expiration, so exhaled air must pass around the tube and up through the larynx. If the cuff is inflated, air cannot escape, causing air trapping and respiratory arrest. The cuff must be fully deflated first.
답: A · 신장이 배설하지 못하는 음식 속 인산염을 결합하기 때문
만성 신장병에서 인산염 저류는 이차성 부갑상선기능항진증, 신성 골질환, 혈관 석회화로 이어집니다. 식사와 함께 복용하는 인산염 결합제는 장에서 식이 인산염을 결합합니다. 식이 인산염도 제한합니다.
답: C · Clamp the lines and lay the patient left side down, head low
In suspected air embolism, the blood lines are clamped at once, the pump stopped, and the patient positioned on the left side with the head down to trap air in the right atrium. Oxygen is given and emergency help called.
답: C · A partial-thickness burn becoming deeper, with new discolouration
Signs of burn wound infection include conversion to a deeper burn, new dark or green discolouration, increasing pain, offensive exudate, spreading redness and systemic signs such as fever or tachycardia.
답: C · Record a 12-lead ECG and escalate as possible cardiac pain
Cardiac pain can feel like heartburn. Exertional pain with sweating and breathlessness must be treated as possible acute coronary syndrome until excluded, so an ECG and urgent review come first.
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