공식 모음, 모든 주제의 핵심 풀이 단계, 연습 문제 14개가 들어 있으며 전체 풀이는 맨 뒤에 있습니다.
A patient with heart failure gained 2 kg (about 4 lb) since yesterday and is more breathless when lying down. What should the nurse do first?
A severely malnourished patient started nutrition two days ago and now has weakness and confusion. Which laboratory result should the nurse check first?
How should a portable oxygen cylinder be kept in a patient’s room?
A patient on an anticoagulant falls and hits their head but says they feel fine. What should the nurse do?
A patient's levothyroxine dose was changed today. When is the TSH usually rechecked?
A patient with diabetes had a glucose of 58 mg/dL (3.2 mmol/L), took 15 g of fast-acting carbohydrate and, 15 minutes later, the glucose is 64 mg/dL (3.6 mmol/L). The patient is alert. What should the nurse do next?
Why is it important to prevent hypothermia during and after surgery?
A nurse teaches a patient with diabetes about foot care. Which statement shows a need for further teaching?
A nurse measures blood pressure on a large upper arm using a cuff that is too small. What effect will this have?
A 74-year-old with atrial fibrillation, hypertension and diabetes asks why she needs an anticoagulant when she feels well. Which reply is best?
A bladder scan straight after voiding shows 450 mL of urine still in the bladder. What does this show?
갑상선 전절제술 후 환자가 불안해하며 협착음과 목의 팽팽한 부기가 생겼습니다. 간호사가 가장 먼저 할 일은?
Which finding means a patient is usually ready to leave recovery for the ward?
간성 뇌병증 환자가 밤에 안절부절못합니다. 수면을 위해 벤조디아제핀이 제안되었습니다. 간호사는 어떻게 해야 합니까?
답: D · Assess the lungs, oxygen saturation and swelling, then inform the provider
A rapid weight gain with orthopnea suggests fluid overload and worsening heart failure. The nurse assesses breathing and fluid status and informs the provider, who may adjust the diuretic.
답: C · Serum phosphate
In refeeding syndrome, a sudden change to carbohydrate metabolism moves phosphate, potassium and magnesium into cells. Low phosphate can cause weakness, confusion, heart failure and breathing problems.
답: D · Secured upright in a stand or holder
Oxygen cylinders are under high pressure and can be damaged or cause injury if they fall. They are kept upright in a holder or cart, away from heat and flames.
답: D · Notify the provider and start neurological observations, because a brain bleed may develop
Head injury in a patient on anticoagulants can cause bleeding inside the skull that shows signs later. The provider is told at once, imaging may be needed and neurological checks are done closely.
답: B · After about 6–8 weeks
Levothyroxine has a half-life of about a week, so a steady state takes about 6 weeks. The TSH is therefore rechecked about 6–8 weeks after a dose change; checking earlier gives a misleading result.확인 출처: Hypothyroidism · MedlinePlus (NIH) (2024)
답: C · Give another 15 g of fast carbohydrate and recheck
The "15-15 rule" is repeated until the glucose is at least 70 mg/dL (3.9 mmol/L); UK guidance uses 4.0 mmol/L and 15–20 g of carbohydrate. Then a snack or meal with complex carbohydrate and protein is given if the next meal is not soon, to prevent recurrence.
답: D · It increases the risk of wound infection, bleeding and cardiac complications
Inadvertent perioperative hypothermia impairs clotting and immune function and increases cardiac events and wound infection. Patients are warmed actively and their temperature monitored.
답: C · "I will walk barefoot at home to toughen my feet."
Diabetic neuropathy and poor circulation mean small injuries can become ulcers. Patients should avoid walking barefoot, inspect their feet daily and get professional foot care.
답: B · The reading will be falsely high
A cuff that is too small needs a higher pressure to compress the brachial artery, giving a falsely high reading. A cuff that is too large can give a falsely low reading. The bladder should encircle most of the arm, so cuff size is chosen by arm circumference.
답: C · Her risk of stroke is high, and an anticoagulant lowers it
In AF, blood stasis in the left atrium causes clots that can travel to the brain. Scores such as CHA₂DS₂-VASc (age, hypertension, diabetes, female sex and others) estimate stroke risk; her score is high. Anticoagulation reduces stroke risk but does not change the rhythm.
답: B · The bladder is not emptying properly
A large post-void residual means incomplete emptying, for example from obstruction or a weak detrusor. It raises the risk of infection and overflow incontinence and may need intermittent catheterisation or treatment of the cause.
답: C · 응급 도움을 요청한다. 혈종이 기도를 압박할 수 있다
협착음을 동반하며 빠르게 커지는 목 혈종은 기도 응급입니다. 긴급 도움을 요청하며, 많은 병동에서는 확정적인 기도 관리와 수술 전에 현지 응급 절차에 따라 침상 옆에서 클립이나 봉합사를 제거해 혈종을 풀어 줍니다.
답: A · Awake, with a clear airway, stable observations and controlled pain
Discharge criteria include a protected airway, adequate breathing and oxygen saturation, stable vital signs, acceptable pain and nausea control, and no active bleeding, as set by local recovery criteria.
답: C · 진정제는 뇌병증을 악화시킬 수 있으므로 처방에 의문을 제기한다
벤조디아제핀과 아편유사제는 간부전에서 축적되어 뇌병증을 유발하거나 악화시킬 수 있습니다. 감염, 변비, 위장관 출혈, 탈수, 전해질 변화 같은 유발 요인을 찾습니다. 알코올 금단에 대한 벤조디아제핀은 주의하여 쓰는 예외입니다.
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