NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

An Rh-negative mother has just given birth to an Rh-positive baby. What does the nurse expect to give the mother?

1. AA dose of the hepatitis B vaccine instead
2. BRh immunoglobulin within 72 hours
3. CVitamin K to the mother
4. DNo treatment is needed

A child is admitted with a suspected Wilms tumor (nephroblastoma). Which instruction is most important for all staff?

1. ADo not palpate the abdomen
2. BGive a warm bath with abdominal massage
3. CMeasure abdominal girth by pressing firmly
4. DEncourage the child to play contact sports

경구 액제 약물을 표준 정맥 주사기가 아니라 경구용 또는 경장용 주사기로 주는 이유는?

1. A안전상 이유는 없고 단지 관행일 뿐이다
2. B경구용 주사기는 정맥 라인에 맞지 않아 잘못된 경로의 오류를 막는다
3. C정맥 주사기는 경구 액제의 소량을 정확하게 잴 수 없다
4. D경구용 주사기는 정맥 용량을 더 정확하게 잰다

Several patients on a ward develop vomiting and diarrhea within two days, and a norovirus outbreak is suspected. What should the nurse do first?

1. AMove the affected patients to different wards so that fewer people are exposed
2. BWait for all the stool results to come back before taking any action
3. CNotify the infection prevention team and place affected patients on contact precautions
4. DAsk visitors to bring in bottled water for all patients

A patient on warfarin has an INR of 7.8 and a nosebleed. Which medication would the nurse expect the provider to prescribe?

1. ANaloxone hydrochloride
2. BProtamine sulfate
3. CAcetylcysteine
4. DVitamin K (phytonadione)

The nurse teaches a patient with chronic kidney disease about a potassium-restricted diet. Which statement shows a need for further teaching?

1. A"I can leach potatoes by soaking them before cooking them"
2. B"Dried apricots and raisins will be a good snack for me now"
3. C"I'll limit bananas, oranges and potatoes in my meals"
4. D"I'll check food labels and ask my dietitian about portion sizes"

A confused patient keeps trying to climb out of bed. Why are bed rails not automatically the answer?

1. APatients can be seriously injured climbing over or becoming trapped in rails
2. BBed rails stop staff from taking observations
3. CBed rails are illegal in all hospitals and must never be used at all
4. DBed rails always make patients more confused, but only during the day

항응고제를 복용하는 환자가 넘어져 머리를 부딪혔지만 괜찮아 보입니다. 올바른 조치는?

1. A관찰 없이 환자에게 자도록 권한다
2. B의학적 평가와 CT 촬영 가능성을 준비하고 신경학적 관찰을 한다
3. C항응고제를 추가로 투여한다
4. D환자가 괜찮아 보이므로 아무 조치도 하지 않는다

A patient is going home with a 24-hour Holter monitor. Which instruction is most important?

1. AShower as normal with the monitor on
2. BRemove the monitor whenever symptoms occur and restart it
3. CStay in bed for the full 24 hours so the trace is clear
4. DKeep a diary of symptoms and activities with the times

흉관 제거에서 흔히 가르치는 방법은?

1. A환자가 길고 깊게 들이쉬는 동안 천천히 제거한다
2. B제거한 뒤 하루 동안 부위를 열어 두어 배액되게 한다
3. C숨을 참거나 날숨 동안 제거한 뒤 부위를 밀봉한다
4. D흡인을 최대 출력으로 켠 채 제거한다

A stroke patient speaks fluently, but the words make little sense, and they do not follow simple instructions. Which type of aphasia is this?

1. AGlobal aphasia with no speech at all
2. BDysarthria from facial weakness
3. CExpressive (Broca's) aphasia
4. DReceptive (Wernicke's) aphasia

급성 세뇨관 괴사에서 회복 중인 환자가 다뇨기에 접어들어 하루 4 L 넘게 소변을 봅니다. 주된 간호 우려는?

1. A팽창된 방광에 소변이 고이는 것
2. B과도한 인슐린으로 인한 저혈당
3. C높은 칼륨 수치를 동반한 수분 과다
4. D낮은 칼륨과 나트륨을 동반한 탈수

아편유사제를 투여받는 환자가 더 진정되는 것이 중요한 이유는?

1. A진정이 심해지는 것은 보통 호흡 억제에 앞서 나타나기 때문
2. B진정은 이제 더 높은 용량이 필요하다는 뜻이기 때문
3. C진정은 모든 아편유사제의 무해하고 예상되는 효과이기 때문
4. D진정은 통증이 이제 완전하고 안전하게 조절되었다는 뜻이기 때문

A patient on modified-release morphine for cancer pain has needed four breakthrough doses every day for several days. What should the nurse do?

1. AGive all breakthrough doses at the same time
2. BStop the breakthrough doses to reduce opioid use
3. CReport it, as the regular background dose may need review
4. DTell the patient to put up with the pain between doses