공식 모음, 모든 주제의 핵심 풀이 단계, 연습 문제 14개가 들어 있으며 전체 풀이는 맨 뒤에 있습니다.
Which infant with gastroenteritis should the nurse see first?
A patient at 34 weeks of pregnancy has painless, bright red vaginal bleeding. Which action should the nurse avoid?
A nurse pours sterile saline into a bowl on a sterile field. Which technique is correct?
질식 위험이 있는 의식이 있는 환자에게 경구 약을 주고 있습니다. 가장 안전한 방법은?
혈당이 54 mg/dL(3.0 mmol/L)인 의식 있는 환자가 속효성 탄수화물 15 g을 섭취했습니다. 혈당은 언제 다시 확인해야 하나요?
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?
A patient has lost more than 10% of their body weight without trying over the last few months and has a low BMI. What is the most appropriate action?
A patient has a single hot, swollen, very painful knee and a fever. Why is urgent joint aspiration important?
A patient's blood pressure is 120/60 mmHg. What is the approximate mean arterial pressure?
A patient with lung cancer develops swelling of the face and arms, distended neck and chest veins and breathlessness that is worse when bending forward. What is the most likely cause?
After a lumbar discectomy, which finding should the nurse report promptly?
A patient with long-standing diabetes suddenly has many new floaters and painless loss of vision in one eye. What is most likely, and what is needed?
Which is a recognised cause of anaphylaxis during surgery?
A patient has had a large terminal ileum resection for Crohn's disease. Which long-term problems should the nurse anticipate?
답: D · Lethargic, sunken fontanel, no wet diaper for 8 hours
Lethargy, a sunken fontanel and no urine for hours suggest severe dehydration, which can lead to shock in infants. The other infants are well hydrated.
답: A · A vaginal examination
Painless, bright red bleeding suggests placenta previa. A vaginal examination could cause severe hemorrhage, so it is avoided until the placenta position is known.
답: C · Hold the bottle with the label in the palm and pour without touching the bowl
The nurse pours from a little height without touching the sterile bowl, avoiding splashes that would wet the field. Holding the label in the palm keeps it readable and free of drips.
답: D · 환자를 똑바로 앉히고 한 번에 한 알씩 준다
똑바로 앉히고 한 번에 하나씩 주면 질식 위험이 줄어듭니다. 분쇄는 약제부가 안전하다고 확인한 경우에만 하는데, 일부 서방형이나 장용성 제품은 분쇄하면 위험하기 때문입니다.
답: B · 약 15분 뒤
15의 법칙은 속효성 탄수화물 15 g을 먹고 15분 뒤 재확인하며, 혈당이 아직 70 mg/dL(3.9 mmol/L) 미만이면 반복하는 것입니다. 그 뒤 간식이나 식사로 재발을 막습니다.확인 출처: Low blood sugar - self-care · MedlinePlus (NIH) (2026)
답: C · 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: C · Refer to the dietitian and start a nutrition care plan with food charts
Large unplanned weight loss with a low BMI means high malnutrition risk. Management includes dietitian referral, food and fluid charts, support with eating and regular weighing.
답: C · To rule out septic arthritis, which can rapidly destroy the joint
Septic arthritis can destroy cartilage within days. Aspiration allows microscopy and culture, and helps distinguish infection from crystal arthritis such as gout.
답: B · 80 mmHg
MAP ≈ diastolic + (systolic − diastolic) ÷ 3 = 60 + 60 ÷ 3 = 80 mmHg. The heart spends longer in diastole, so MAP is closer to the diastolic value. A MAP of at least about 65 mmHg is a common target for organ perfusion.
답: A · Superior vena cava obstruction
A tumour in the mediastinum can compress the superior vena cava, causing swelling of the face, neck and arms, dilated veins on the chest and breathlessness. It is an oncological emergency. The patient is sat upright and given oxygen if hypoxic, and treatment may include a stent, steroids or radiotherapy.
답: B · New weakness or numbness in the legs
New or worsening leg weakness, numbness or problems passing urine may indicate a haematoma or nerve root compression and need urgent review. Mild wound pain and stiffness are expected.
답: D · A bleed into the eye from retinopathy, needing urgent review
Proliferative diabetic retinopathy causes fragile new blood vessels that can bleed into the vitreous, causing sudden floaters or vision loss. It needs same-day or urgent ophthalmology review. Retinal detachment is also possible.
답: A · Chlorhexidine skin preparation
Common causes of perioperative anaphylaxis include neuromuscular blockers, antibiotics, chlorhexidine and latex. Allergies are documented, and suspected reactions are investigated afterwards.
답: B · Vitamin B12 deficiency and bile-acid diarrhoea
The terminal ileum absorbs vitamin B12 and bile acids. After resection, B12 replacement may be needed, and unabsorbed bile acids reaching the colon cause diarrhoea.
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