NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

A patient with diabetes is unresponsive and has a blood glucose of 40 mg/dL (2.2 mmol/L). What should the nurse do first?

1. AGive the scheduled dose of insulin
2. BGive IV dextrose or glucagon as prescribed
3. CWait 15 minutes and recheck the glucose
4. DPour orange juice into the patient’s mouth

A patient with septic shock remains hypotensive, with a mean arterial pressure of 58 mmHg, after adequate IV fluids. What should the nurse anticipate?

1. AAn oral fluid challenge with a sports drink
2. BA loop diuretic to remove the extra fluid that has been given
3. CA vasopressor, such as norepinephrine, to raise the pressure
4. DA beta-blocker to slow the heart rate

How does a nurse add a sterile gauze pack to a sterile field that is already set up?

1. AOpen the wrapper away from the field and drop the item on it without reaching over
2. BPlace the whole wrapped pack on the field and open it there with sterile gloves
3. CTip the item onto the field and push it into place with the wrapper
4. DReach across the field with clean gloves to place the item

밀봉 방사성 삽입물이 있는 환자가 삽입물이 빠져 침대 위에 떨어졌다고 알립니다. 간호사는 어떻게 해야 합니까?

1. A도움이 올 때까지 환자에게 들고 있게 한다
2. B내일 방사선팀이 올 때까지 침대 위에 그대로 둔다
3. C장갑 낀 손으로 집어 임상 폐기물에 넣는다
4. D긴 손잡이 집게로 집어 납 용기에 넣는다

Which finding during a transfusion suggests transfusion-associated circulatory overload (TACO)?

1. AA low temperature and slow heart rate
2. BCrackles, hypertension and a raised BNP
3. CBack pain with dark red urine output
4. DHives and itching without other signs

A patient with acute pancreatitis has a rising BUN, a falling calcium and a glucose of 250 mg/dL (13.9 mmol/L) over the first 48 hours. What do these results suggest?

1. AAn unrelated new kidney stone
2. BA lab error from lipemic samples
3. CA resolving, mild pancreatitis
4. DIncreasingly severe pancreatitis

What happens in third-degree (complete) heart block?

1. AEvery impulse reaches the ventricles, but each one is slightly delayed
2. BThe atria beat chaotically with no P waves, and the ventricular rate is irregular
3. CNo impulses from the atria reach the ventricles, so they beat independently
4. DThe ventricles beat very fast and regularly

수막염이 의심되는 환자가 발열, 목 경직, 눌러도 사라지지 않는 발진을 보입니다. 우선순위는?

1. A검사를 기다리지 않고 긴급 평가와 즉각적인 항생제 투여
2. B조명을 어둡게 하고 휴식을 권하며 4시간 후 활력징후를 다시 확인함
3. C열에 아세트아미노펜을 주고 내일 환자를 평가함
4. D치료를 시작하기 전에 요추천자 결과를 기다림

흉관 배액통의 수봉실에서 환자가 기침을 하지 않는데도 계속 기포가 올라옵니다. 이는 무엇을 시사합니까?

1. A흡인 장치가 꺼짐
2. B폐가 완전히 다시 펴졌고 배액관을 제거할 준비가 됨
3. C폐 또는 배액 시스템에서의 공기 누출
4. D관 속 혈전으로 배액관이 막힘

A patient being treated for pulmonary TB repeatedly misses doses and stops when they feel better. Which strategy is most effective?

1. AStopping treatment, as it is clearly not working for this patient
2. BSwitching to a single drug to make it easier
3. CDirectly observed therapy with support for barriers to adherence
4. DDoubling the dose on the days the patient remembers to take it

갑상선 수술 일주일 후에도 환자의 목소리가 여전히 쉬고 약합니다. 가장 가능성 높은 합병증은?

1. A반회후두신경 손상
2. B접착 드레싱 테이프에 대한 알레르기 반응
3. C부갑상선 손상으로 인한 낮은 칼슘
4. D수술로 인한 갑상선 위기

A patient with Guillain–Barré syndrome has a blood pressure that swings between 80/50 and 190/100 mmHg and a heart rate that changes suddenly. What does this suggest?

1. AAutonomic dysfunction, which needs continuous cardiac monitoring
2. BA drug reaction that means all medicines must stop
3. CA faulty blood pressure cuff that should be replaced and the readings ignored
4. DAnxiety that will settle with reassurance alone

Why do patients usually have a dental review before radiotherapy to the head and neck?

1. AThe dentist gives the radiotherapy
2. BIt causes dry mouth and raises the risk of decay and jaw damage
3. CRadiotherapy can only be given once all the teeth have been removed
4. DTeeth block the radiation beam completely

Which medicine commonly needs enteral feeds paused before and after each dose because the feed reduces its absorption?

1. APhenytoin
2. BOmeprazole liquid
3. CLactulose
4. DParacetamol