NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

A patient on hemodialysis has an arteriovenous fistula in the left arm. Which instruction should the nurse give the nursing assistant?

1. AMeasure blood pressure on the left arm only, every 4 hours
2. BDo not measure blood pressure on the left arm
3. CHelp the patient carry shopping bags on the left arm
4. DKeep the left arm wrapped tightly in a bandage at night

A patient with COPD on 2 L/min oxygen becomes drowsy and hard to wake. The SpO₂ is 93%. What is the priority?

1. AAssess breathing and escalate for a blood gas, as carbon dioxide may be rising
2. BGive the as-needed sedative so the patient rests comfortably
3. CLet the patient sleep, because the saturation is above target
4. DIncrease the oxygen to 6 L/min so that the saturation goes even higher than now

A newly hired nurse had BCG vaccine as a child. Which TB screening test is usually preferred?

1. AA chest x-ray every month for the first year
2. BNo screening, because BCG prevents all TB
3. CAn interferon-gamma release assay (IGRA) blood test
4. DA tuberculin skin test, which is read 24 hours after it is placed

간호사가 정맥 모르핀을 투여하려 합니다. 환자의 호흡수는 9회/분이고 매우 졸려 합니다. 간호사는 어떻게 해야 합니까?

1. A앞서 통증을 호소했으므로 투약한다
2. B투약을 보류하고 환자를 사정하며 처방자에게 알린다
3. C용량의 절반을 투약한다
4. D투약하고 내일 호흡수를 다시 확인한다

A nurse has a needlestick injury from a patient with unknown HIV status. Which test is usually done for the nurse as soon as possible?

1. AA baseline HIV test
2. BA serum lipase test
3. CA sweat chloride test
4. DA thyroid panel test

Weeks after neck surgery, a patient has muscle cramps and tingling. Calcium is low, phosphate is high and parathyroid hormone (PTH) is low. Which condition fits best?

1. AHypoparathyroidism
2. BChronic kidney disease
3. CPrimary hyperparathyroidism
4. DVitamin D toxicity

A patient with DKA has an arterial blood gas showing a low pH and a low bicarbonate. Which disturbance is this?

1. ARespiratory acidosis
2. BMetabolic alkalosis
3. CMetabolic acidosis
4. DRespiratory alkalosis

고유량 산소를 받는 COPD 환자가 졸리고 맥박이 강하며 피부가 붉습니다. 혈액가스에서 PaCO₂가 상승하고 pH가 낮습니다. 가장 가능성 높은 원인은?

1. A아편유사제 알레르기
2. B저혈당
3. C구토로 인한 대사성 알칼리증
4. D부분적으로 과도한 산소로 인한 고탄산성 호흡부전

A patient choosing between a mechanical and a biological heart valve asks about the main difference. Which answer is accurate?

1. ABoth types need no medicines after surgery
2. BBiological valves last longer but need lifelong warfarin
3. CMechanical valves last longer but need lifelong anticoagulation
4. DMechanical valves wear out within one year

아침 디곡신 투약 전에 환자의 심첨 맥박이 54회/분이고 구역감을 느낍니다. 간호사는 어떻게 해야 합니까?

1. A투약을 보류하고 중독 가능성을 보고한다
2. B절반 용량을 주고 한 시간 뒤 맥박을 다시 확인한다
3. C요골 맥박만 의미가 있으므로 투약한다
4. D투약하고 구토억제제를 주며 내일 맥박을 다시 확인한다

Why might a patient bleed more from the needle sites straight after haemodialysis?

1. AHeparin is often used to stop the circuit from clotting
2. BThe fistula has been damaged and must be tied off
3. CDialysis raises the blood pressure sharply for several hours
4. DDialysis removes all the platelets from the blood

밤새 지속 경관영양을 받는 환자가 영양 주입 시간에 맞춘 인슐린을 맞습니다. 02:00에 튜브가 막혀 영양 주입이 멈췄습니다. 주된 위험은 무엇이며 간호사는 어떻게 해야 합니까?

1. A케톤산증. 아침까지 모든 인슐린을 중단한다
2. B저혈당. 혈당을 자주 확인하고 혈당 보충 계획을 따른다
3. C고혈당. 즉시 추가 인슐린을 준다
4. D위험 없음. 인슐린은 영양 주입이 재개될 때까지 저장된다

How are skin staples usually removed from a healed incision?

1. AThe staples are left in permanently under the skin
2. BOnly the staples at each end, leaving the others for good
3. CAlternate staples first, then the rest if the wound holds
4. DAll staples at once by pulling each one straight up from the skin

A patient on warfarin has a major upper GI bleed with an INR of 5. Which treatment should the nurse anticipate to reverse the warfarin?

1. AMore warfarin to stabilise the INR
2. BOral aspirin to balance the clotting system quickly
3. CProthrombin complex concentrate with IV vitamin K
4. DProtamine sulfate on its own