NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

The day after a total thyroidectomy, a patient reports tingling around the mouth and in the fingers. What should the nurse do first?

1. AReassure the patient that this is normal after neck surgery
2. BGive the patient’s routine oral iron supplement early
3. CEncourage deep breaths into a paper bag until it passes
4. DCheck for signs of low calcium and inform the provider

A 2-month-old infant has a spiral fracture of the femur. The parents say the baby rolled off the sofa. What should the nurse recognize?

1. ANo further action is needed once the fracture is treated
2. BThe injury does not fit the infant’s development, so possible abuse must be reported
3. CInfants of this age often roll off furniture and break bones in this way
4. DA spiral fracture in an infant is always caused by birth trauma

How should a newborn be moved through hospital corridors?

1. ACarried in the nurse’s arms for comfort
2. BIn the arms of any visitor who offers to help
3. CIn a bassinet, not carried in the arms
4. DOn the mother’s lap in a wheelchair, without staff

A patient takes medicines prescribed by several providers. Which advice best reduces the risk of medication errors at home?

1. AKeep one up-to-date list of all medicines and use one pharmacy where possible
2. BKeep each provider’s medicines in separate bags
3. COnly tell each provider about the drugs they prescribed
4. DStop taking any medicine that seems to repeat another one, without asking anyone

A patient with diabetes also takes propranolol. Why is regular glucose monitoring especially important?

1. AThe drug stops the meter from reading correctly
2. BThe drug blocks the insulin injection site
3. CThe drug causes very high glucose in all patients
4. DThe drug can mask warning signs of hypoglycemia

Two sets of blood cultures were taken from separate sites. Only one bottle in one set grows coagulase-negative staphylococci, and the patient has no line or implant. What is the most likely interpretation?

1. AProbable skin contamination of the sample
2. BProof that the patient has infective endocarditis
3. CCertain bloodstream infection needing treatment
4. DInfection with a resistant organism such as MRSA

Which lifestyle advice helps a patient with gastro-oesophageal reflux disease?

1. AEat one very large meal a day rather than several small ones
2. BAvoid large meals late in the evening and raise the head of the bed
3. CWear tight belts to support the stomach
4. DLie down straight after each meal to let the food settle

A nurse phones a doctor about a deteriorating patient using SBAR. Which statement belongs in the "R" section?

1. A"I am calling about Mr Smith, who is breathless."
2. B"His blood pressure is 85/50 and he is confused."
3. C"He was admitted three days ago with pneumonia."
4. D"Please review him within the next 15 minutes."

A patient with an implantable cardioverter-defibrillator asks what to do if it fires. Which teaching is correct?

1. ARemove the device battery at home if it fires more than once
2. BDrive straight to hospital alone after any shock so the device can be checked by the team
3. CIgnore any shock at all, because the device is designed to fire every day and needs no follow-up
4. DOne shock and well: contact the device clinic; repeated shocks or unwell: call emergency services

A nurse teaches a patient with heart failure who takes ramipril and spironolactone. Which statement shows a need for further teaching?

1. A"I will avoid ibuprofen for my joint pain."
2. B"I will call if I gain weight quickly or get more breathless."
3. C"I will use a salt substitute instead of ordinary salt."
4. D"I will weigh myself every morning after I go to the toilet."

Which headache feature most suggests raised intracranial pressure from a brain tumour?

1. AOnly present after reading for a long time
2. BA tight band across the forehead that eases with rest
3. CBetter in the morning and worse with stress
4. DWorse on waking and on coughing, with vomiting

A patient with a new arm fistula says their hand on that side is cold, pale and painful, especially during dialysis. What is the concern?

1. AAn allergic reaction to the dressing on the arm
2. BFluid overload in the arm
3. CSteal syndrome, which needs urgent review
4. DNormal healing that needs no action

Which nursing intervention best reduces preoperative anxiety?

1. ATelling the patient that there is nothing to worry about
2. BExplaining what will happen and answering questions
3. CKeeping family members away until after surgery
4. DAvoiding talking about the operation at all

환자가 음압 상처 치료(NPWT)를 받고 있습니다. 펌프 알람이 울리고 드레싱의 밀폐가 풀렸습니다. 가장 적절한 행동은?

1. A검토 때까지 며칠 동안 흡인 없이 폼을 상처에 그대로 둔다
2. B밀폐를 되돌리려고 흡인을 최대 설정으로 올린다
3. C폼 위에 마른 거즈를 채우고 테이프로 단단히 붙인다
4. D밀폐를 복구하고, 제때 안 되면 습윤 드레싱으로 바꾼다