공식 모음, 모든 주제의 핵심 풀이 단계, 연습 문제 14개가 들어 있으며 전체 풀이는 맨 뒤에 있습니다.
A young adult has just started an SSRI antidepressant for major depression. What should the nurse monitor most closely in the first weeks?
Which nursing approach may raise intracranial pressure in a patient with a head injury?
A patient cannot bear weight and cannot help with transfers. Which method is safest to move the patient from bed to chair?
According to the “Swiss cheese” model of error, why do errors reach patients?
Which technique is recommended for a capillary blood glucose test on an adult's finger?
At the start of a shift, the nurse reviews four new results. Which patient needs attention first?
Which measure helps reduce the risk of surgical site infection?
An older man has sudden severe abdominal and back pain, is hypotensive and has a pulsating mass in the abdomen. What should be suspected?
고혈압 환자가 암로디핀을 복용 중입니다. 간호사가 가장 흔히 관찰하게 될 부작용은?
A fit 24-year-old marathon runner has a resting heart rate of 46/min on admission for minor surgery. He has no dizziness, chest pain or breathlessness, and his BP is 118/70 mmHg. What is the appropriate response?
A patient has radioactive iodine treatment for hyperthyroidism. Which advice is correct?
Which patient with a spinal cord injury is at risk of autonomic dysreflexia?
장루 기구의 구멍은 얼마나 크게 잘라야 합니까?
Four hours after surgery, a catheterised patient's urine output has been 10 mL/h for two hours. Vital signs are stable. What should the nurse check first?
답: C · Thoughts of suicide or self-harm
In the early weeks of antidepressant treatment, especially in young people, suicidal thoughts may increase. Patients and families are taught to report them at once.
답: C · Doing suctioning, turning and bathing all at the same time
Clustering several stimulating activities can cause a sustained rise in intracranial pressure. Spacing care, keeping the neck straight and a calm environment help keep it down.
답: C · A mechanical lift used by enough trained staff
For a patient who cannot bear weight or help, a mechanical lift prevents injury to both patient and staff. Lifting under the arms can injure the shoulders, and pivot transfers need weight bearing.
답: B · Weaknesses in several layers of defense line up at the same time
Reason’s Swiss cheese model shows that each safety layer, such as prescribing, dispensing, checking and scanning, has weaknesses. Harm happens when the holes in several layers line up, so safety improvement focuses on strengthening the system.
답: D · Prick the side of the fingertip
The sides of the fingertips are less sensitive than the pads, so they are used for capillary sampling. Rotating sites reduces soreness, and hard squeezing can add tissue fluid that gives inaccurate results.
답: A · Sodium 119 mEq/L in a patient with new confusion and vomiting
Severe hyponatremia with confusion and vomiting suggests cerebral edema and can progress to seizures and coma. The other results are mildly abnormal and expected for those conditions, so they are less urgent.확인 출처: Low blood sodium - Medical Encyclopedia · MedlinePlus (NIH) (2025); Sodium Blood Test · MedlinePlus (NIH) (2024)
답: C · Removing hair, if needed, with clippers rather than a razor
Razors cause micro-abrasions that increase infection risk, so hair is removed only if necessary with clippers just before surgery. Keeping patients warm and good skin preparation also help.
답: B · A ruptured abdominal aortic aneurysm
A ruptured AAA classically presents with pain, shock and a pulsatile mass. It is a surgical emergency needing immediate senior help and transfer to theatre.
답: B · 발목 부종
암로디핀 같은 디히드로피리딘 칼슘 채널 차단제는 세동맥을 확장시켜 모세혈관압을 높이고 말초 부종, 안면 홍조, 두통을 일으킵니다. 마른기침은 ACE 억제제의 전형적인 부작용이고, 천명음은 천식에서 비선택적 베타차단제의 부작용입니다.
답: C · Document and report it, as this is often normal in an athlete
Endurance training increases vagal tone and stroke volume, so resting rates in the 40s can be normal. Without symptoms or haemodynamic compromise, no treatment is needed, though it is recorded and the team informed. Symptomatic bradycardia is treated.
답: B · Limit close contact with children and pregnant women for a time
After radioiodine, patients are advised to limit close and prolonged contact, especially with young children and pregnant women, for a period set by the department. It is contraindicated in pregnancy and breastfeeding.
답: C · A patient with an injury at T4
Autonomic dysreflexia usually occurs with injuries at T6 or above. Below this level, the body can still control the sympathetic response to stimuli such as a full bladder. Lumbar and sacral injuries do not usually cause it.
답: C · 스토마보다 둘레로 약 2~3 mm 더 크게
구멍은 스토마 주위에 약 2~3 mm(약 1/8인치)의 작은 여유를 두고 가깝게 맞도록 자릅니다. 너무 크면 피부가 배출물에 노출되고, 너무 작으면 스토마를 파고들 수 있습니다. 스토마는 처음 몇 주 동안 줄어들므로 측정을 반복합니다.
답: C · That the catheter and tubing are not kinked or blocked
A sudden low output may be due to a kinked tube or blocked catheter. If drainage is normal, hypovolaemia or kidney injury is considered and the team is informed, with a fluid assessment.
이 자료는 독립적인 연습 자료입니다. ExamProblems는 이 시험을 주관하는 기관과 제휴하거나 그 기관의 승인을 받지 않았으며, 시험 이름은 내용을 설명하는 데에만 사용됩니다. NCLEX®, NCLEX-RN® and NCLEX-PN®은(는) the National Council of State Boards of Nursing, Inc. (NCSBN)의 상표이며, 이 기관은 ExamProblems와 제휴하지 않았고 이를 보증하거나 정확성을 책임지지 않습니다.
ExamProblems · examproblems.com/courses/nclex-style-prioritization-and-delegation