NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

Which action by a nursing assistant needs the nurse to step in?

1. ATaking an oral temperature just after the patient drank cold water
2. BLowering the bed to its lowest position and locking the wheels after care
3. CCleaning hands before entering the room
4. DPutting the call light within the patient’s reach

After cardiac surgery, a patient becomes hypotensive with distended neck veins and muffled heart sounds, and chest drain output has suddenly stopped. What should the nurse suspect?

1. AA blocked urinary catheter
2. BLeft-sided heart failure
3. CHypovolemic shock from dehydration
4. DCardiac tamponade

A patient has severe neutropenia after chemotherapy. Which route for measuring temperature should be avoided?

1. ARectal
2. BTemporal artery
3. CTympanic
4. DOral

A patient who speaks little English is being discharged with new medications. The patient’s 12-year-old child offers to interpret. What should the nurse do?

1. AUse a professional medical interpreter
2. BLet the child interpret, because the family prefers it
3. CUse simple English and many hand gestures
4. DGive written instructions in English only

In countries that screen all pregnant women (such as the US), a vaginal-rectal swab is taken at about 36–37 weeks. Which organism is it screening for?

1. AHepatitis B virus
2. BGroup B Streptococcus
3. CCandida albicans
4. DStaphylococcus aureus

A patient with a serum albumin of 1.9 g/dL (19 g/L) has signs of phenytoin toxicity, although the total phenytoin level is in the usual range. What is the most likely explanation?

1. ALow albumin makes the total level falsely high in all cases
2. BLow albumin raises the free (active) fraction of phenytoin
3. CLow albumin makes the liver clear phenytoin much faster
4. DLow albumin stops phenytoin from crossing into the brain

심장 리듬에 가장 위험한 전해질 이상은?

1. A낮은 인산
2. B낮은 나트륨
3. C칼륨이 너무 높거나 낮은 것
4. D높은 염소

A nurse teaches a patient with hypertension about their medicines. Which statement shows a need for further teaching?

1. A"I'll keep taking my tablets even if I feel well."
2. B"I'll have my blood pressure checked regularly."
3. C"I'll get up slowly from sitting."
4. D"I'll stop my tablets once my readings are normal."

How is orthostatic (postural) hypotension usually assessed?

1. ABP once sitting, then once lying down straight after a large meal
2. BBP only standing, after a brisk walk along the corridor
3. CBP lying after rest, then again after 1 and 3 minutes standing
4. DBP in both arms at the same moment while sitting

After a fall onto the chest, part of a patient's chest wall moves inward when they breathe in and outward when they breathe out. What does this indicate?

1. AA single simple rib fracture with no lung injury
2. BNormal chest movement caused by pain on breathing
3. CA flail chest from ribs broken in more than one place
4. DA large pleural effusion pressing on the chest wall

요붕증과 SIADH를 가장 잘 구별하는 소변 소견은?

1. A요붕증은 묽은 소변, SIADH는 농축된 소변
2. B요붕증은 농축된 소변, SIADH는 묽은 소변
3. C두 질환 모두 매우 농축된 소변
4. D요붕증은 소변 내 포도당, SIADH는 단백질

수 주 동안 약을 걸렀던 갑상선기능저하증 환자가 저체온, 졸림, 맥박 46회/분, 낮은 나트륨, 상승한 PaCO₂로 입원했습니다. 가장 가능성 높은 질환은?

1. A점액부종 혼수
2. B열사병
3. C부신 위기
4. D갑상선 위기

Why should metoclopramide not be used for nausea in mechanical bowel obstruction?

1. AIt always causes severe diarrhoea
2. BIt makes the bowel stop moving completely
3. CIt blocks the effect of all opioids
4. DIt increases gut movement against the blockage

During bowel preparation, an older patient becomes dizzy and confused. Blood tests show sodium 127 mmol/L. What should the nurse do?

1. ARecord it and continue as planned, as this is expected
2. BStop the preparation and escalate to the medical team
3. CEncourage plain water only, as much as possible
4. DGive the rest of the preparation more quickly