공식 모음, 모든 주제의 핵심 풀이 단계, 연습 문제 14개가 들어 있으며 전체 풀이는 맨 뒤에 있습니다.
After a hip replacement using a posterior approach, which statement shows a need for further teaching?
A patient has central chest pain that started 30 minutes ago at rest and has not eased with rest or nitroglycerin. What does this suggest?
How should the urethral meatus be cared for in a patient with an indwelling urinary catheter?
A nurse teaches parents about using an infant car seat. Which statement shows a need for further teaching?
A patient on a heparin infusion has blood in the urine and an aPTT far above the target. The nurse stops the infusion and informs the provider. Which antidote should the nurse anticipate?
A patient has fever, chills, flank pain and costovertebral angle tenderness. Urinalysis shows many white cells and white cell casts. Which condition is most likely?
Which technique is correct when suctioning through a tracheostomy?
A patient two days after abdominal surgery coughs and says something "gave way". The wound has opened and bowel is visible. What should the nurse do first?
A patient on home oxygen has dry, sore lips. Which product is safest to use?
A patient with a stab wound to the chest has a hole that sucks air with each breath. What is the immediate management?
A patient has Cushing's syndrome. Which nursing assessment is especially important?
Six weeks after a kidney transplant, a patient has a fever, tenderness over the graft, less urine and a rising creatinine. What is most likely?
Why are antibody levels checked after a healthcare worker receives the hepatitis B vaccine?
A patient on immunotherapy for melanoma has six watery stools a day and abdominal cramps. What should the nurse do?
답: D · “I will cross my legs when I sit, so I am more comfortable.”
After a posterior hip replacement, crossing the legs, bending the hip beyond 90 degrees and turning the leg inwards can cause dislocation. Raised seats and a pillow between the knees help prevent it.
답: D · A possible myocardial infarction that needs urgent action
Chest pain that lasts and is not relieved by rest or nitroglycerin suggests acute coronary syndrome, possibly a heart attack. The nurse acts at once: ECG, escalation and prescribed treatment.
답: C · With routine hygiene, using soap and water during daily washing
Routine perineal hygiene with soap and water is recommended. Antiseptic creams and routine irrigation do not reduce infection, and moving the catheter in and out carries organisms into the bladder.
답: C · “We will put the rear-facing seat in the front so we can see the baby.”
A rear-facing car seat must never be placed in front of an active airbag, which can strike the seat with great force. Infants ride rear-facing in the back seat, with a snug harness, on every trip.
답: A · Protamine sulfate
Protamine sulfate binds heparin and reverses its effect quickly. Unfractionated heparin has a short half-life, so stopping the infusion is the first step. Vitamin K reverses warfarin, not heparin.확인 출처: Heparin Sodium Injection (Carpuject) prescribing information - Overdosage · Pfizer (FDA-approved labeling); Partial Thromboplastin Time (PTT) Test · MedlinePlus (NIH) (2026)
답: B · Acute pyelonephritis
White cell casts show that the inflammation is in the kidney itself, not just the bladder. With fever and flank pain this indicates pyelonephritis. Glomerulonephritis typically causes red cell casts, and nephrotic syndrome causes heavy protein loss.확인 출처: Urinary casts · MedlinePlus (NIH) (2025); Glomerulonephritis · MedlinePlus (NIH) (2025)
답: C · Apply suction only while withdrawing the catheter, for no more than about 10–15 seconds
Suctioning only on withdrawal and keeping it brief reduces hypoxia and mucosal damage. Suction is performed when needed, not routinely, and the patient is pre-oxygenated if required.
답: D · Cover the wound with sterile, saline-moistened dressings and get urgent surgical help
Evisceration is a surgical emergency. The exposed bowel is covered with sterile moist dressings, the patient is positioned to reduce tension on the abdomen (for example knees bent), kept nil by mouth and reviewed urgently.
답: A · A water-based lubricant
Oil-based products such as petroleum jelly can ignite or burn intensely in high oxygen concentrations and have caused facial burns. Water-based products are recommended. Oxygen cylinders are kept upright and secured, away from heat and flames.
답: D · Cover it with a vented chest seal or a dressing taped on three sides
An open (sucking) chest wound lets air enter the pleural space. A vented chest seal or a dressing taped on three sides acts as a flap valve, letting air out but not in. A fully sealed dressing can cause a tension pneumothorax. A chest drain is placed away from the wound.
답: B · Regular blood glucose checks
Cortisol raises blood glucose, so hyperglycaemia and diabetes are common. Hypertension, hypokalaemia, infection and fragile skin are other problems to watch for.
답: D · Acute rejection, needing urgent transplant team review
Fever, graft tenderness, falling urine output and rising creatinine suggest acute rejection, although infection must also be ruled out. Early treatment, often with high-dose steroids, can save the graft, so the transplant team is contacted urgently.
답: D · To confirm that the vaccine produced immunity
Some people do not develop protective anti-HBs antibodies after vaccination. Testing identifies non-responders, who may need further doses and advice after exposures.
답: A · Escalate urgently, as immune-related colitis is likely
Severe diarrhoea on checkpoint inhibitors suggests immune-mediated colitis, which can perforate. It needs urgent assessment, infection testing and often high-dose steroids, not only antidiarrhoeals.
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