NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

Which patient with diabetes should the nurse see first?

1. ANeeds foot care teaching before discharge tomorrow
2. BHbA1c result of 8.2%, asking about diet
3. CGlucose 48 mg/dL (2.7 mmol/L), sweating and confused
4. DGlucose 210 mg/dL (11.7 mmol/L) after a large lunch, feels well

A patient in labor is receiving oxytocin, and the fetal monitor shows repeated late decelerations. What should the nurse do first?

1. APlace the patient flat on her back
2. BIncrease the oxytocin rate
3. CStop the oxytocin infusion
4. DEncourage the patient to start pushing

Before a blood transfusion is started, which check is required?

1. AThe patient signs the blood bag label to confirm their name before it is hung
2. BThe nurse checks only that the bag number matches the order
3. CThe patient’s identity is checked against the blood product and its paperwork at the bedside
4. DOne nurse checks the blood product against the order at the nurses’ station

한 간호사가 동료가 손 위생 없이 한 환자에서 다음 환자로 가는 것을 봅니다. 가장 좋은 행동은?

1. A즉시 동료에게 정중하게 일깨워 준다
2. B동료가 다음에도 그러는지 지켜본다
3. C팀 내 갈등을 피하려고 아무 말도 하지 않는다
4. D한 달 뒤에 관리자에게 익명으로 보고한다

디곡신을 투여할 시간이 된 환자의 칼륨이 3.1 mEq/L입니다. 이 결과가 왜 중요한가요?

1. A낮은 칼륨은 디곡신을 무효로 만들므로 용량을 두 배로 해야 한다
2. B낮은 칼륨은 디곡신의 부작용으로부터 심장을 보호한다
3. C칼륨과 디곡신은 상호작용하지 않는다
4. D낮은 칼륨은 디곡신 독성의 위험을 높인다

A 5-year-old has new bruising and petechiae two weeks after a viral illness. Platelets are 12 × 10³/µL; hemoglobin, white cell count and clotting times are normal. Which condition is most likely?

1. AImmune thrombocytopenia (ITP)
2. BHemophilia A
3. CAcute leukemia
4. DDisseminated intravascular coagulation

A pressure ulcer shows full-thickness tissue loss with exposed bone. Which category (stage) is this?

1. ACategory 4
2. BCategory 3
3. CCategory 2
4. DCategory 1

In a patient with a head injury, which is usually the earliest sign of rising intracranial pressure?

1. AIrregular breathing pauses
2. BA change in level of consciousness
3. CA fixed, dilated pupil on both sides
4. DA slow pulse with high blood pressure

Why is a beta-blocker started at a low dose and increased slowly in heart failure?

1. AIt can briefly worsen symptoms before long-term benefit appears
2. BIt works only if the dose is never changed after the first day
3. CIt is safe only at the highest possible dose from the very start
4. DIt must be stopped as soon as symptoms improve

After a pneumonectomy, how is the patient usually positioned?

1. AHead down with the legs raised, to drain secretions from the lung
2. BFlat and prone for the whole of the first day after surgery
3. COn the back or the operated side, not fully on the remaining lung
4. DFully on the non-operated side, to help drain the empty space

Why is IV calcium gluconate given in severe hyperkalaemia?

1. AIt removes potassium through the kidneys
2. BIt moves potassium into the cells
3. CIt binds potassium in the gut
4. DIt protects the heart from arrhythmias

A patient with a brain injury has a mean arterial pressure of 80 mmHg and an ICP of 25 mmHg. How should the nurse interpret this?

1. AThe ICP cannot affect brain perfusion if the blood pressure is normal
2. BThe cerebral perfusion pressure is 105 mmHg, which is too high
3. CThe cerebral perfusion pressure is 80 mmHg, which is normal
4. DThe cerebral perfusion pressure is 55 mmHg, below the usual target

Why is the "whoosh" test no longer used to check nasogastric tube position?

1. AIt needs an X-ray machine at the bedside
2. BThe test is far too painful for most patients to tolerate
3. CThe air always makes the tube block
4. DAir can be heard even when the tube is in the lung

항암 화학요법 후 필그라스팀(G-CSF)을 투여받는 환자가 어떤 부작용을 예상해야 하는지 묻습니다. 가장 흔한 부작용은?

1. A첫 주사 후 며칠 안에 생기는 완전한 탈모
2. B영구적인 청력 소실
3. C골수가 자극되어 생기는 쑤시는 뼈 통증
4. D백혈구 수의 빠른 감소