NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

활력징후가 정상인 안정된 성인의 손에 봉합이 필요한 상처가 있고 다른 문제는 없습니다. 어느 ESI 단계에 해당하나요?

1. A3단계
2. B2단계
3. C5단계
4. D4단계

신장 병동에서 간호사가 가장 먼저 만나야 할 환자는 누구인가요?

1. A배액된 액이 맑은 복막투석 환자
2. B저인 식이에 대한 조언을 구하는 환자
3. C동정맥루에서 강한 진동(thrill)과 잡음(bruit)이 있는 환자
4. D어제 혈액투석을 거르고 이제 근력 약화와 불규칙한 맥박이 있는 혈액투석 환자

A colleague has drawn up a medication and asks the nurse to give it to her patient. What should the nurse do?

1. ADecline, and give only medications that the nurse prepared or checked personally
2. BGive it, because the colleague is experienced
3. CGive it, as long as the syringe has a label with the drug name on it
4. DGive it, and document that the colleague prepared it

활동성 폐결핵 환자가 방문객이 들어오게 해 달라고 요청합니다. 가장 좋은 대응은?

1. A방문객이 병실에 들어오지 말고 열린 문가에 서 있게 한다
2. B위험을 설명하고, 방문을 제한하고, 방문객이 제공된 보호구를 사용하도록 교육한다
3. C전화 통화를 포함해 모든 접촉을 영구히 금지한다
4. D환자를 지지하도록 아무 방문객이나 주의 없이 들어오게 한다

A stable adult who is not bleeding receives one unit of packed red cells. By about how much is the hemoglobin expected to rise?

1. AAbout 1 g/dL (10 g/L)
2. BAbout 3 g/dL (30 g/L)
3. CAbout 0.1 g/dL (1 g/L)
4. DAbout 5 g/dL (50 g/L)

A patient taking an SGLT2 inhibitor has nausea and fast breathing. Glucose 190 mg/dL (10.5 mmol/L), pH 7.15, bicarbonate 10 mEq/L, blood ketones high. What is the most likely diagnosis?

1. AHyperosmolar hyperglycemic state
2. BSimple fasting ketosis only
3. CEuglycemic diabetic ketoacidosis
4. DRespiratory acidosis from COPD

During a vesicant chemotherapy infusion, the patient reports burning and swelling at the cannula site. What should the nurse do first?

1. AStop the infusion straight away and follow the extravasation protocol
2. BApply a warm pack and continue the infusion
3. CFlush the cannula hard with saline
4. DIncrease the rate so that the infusion finishes as quickly as possible

Which route and site are recommended for the first dose of adrenaline (epinephrine) in anaphylaxis on a ward?

1. AOral tablet dissolved under the tongue
2. BIntramuscular injection into the anterolateral thigh
3. CSubcutaneous injection into the upper arm
4. DIntravenous bolus given by the nurse without monitoring

정맥성 다리 궤양에 압박 요법을 적용하기 전에 꼭 필요한 평가는?

1. A흉부 X선과 심전도
2. B배양 및 감수성 검사를 위한 상처 도말
3. C전혈구 검사와 CRP
4. D발목-상완 혈압지수(ABPI)

A patient has sudden severe chest pain spreading to the back between the shoulder blades. Which finding most supports aortic dissection rather than myocardial infarction?

1. AA heart rate of 104/min and a respiratory rate of 22/min
2. BSweating, nausea and pallor that started with the pain
3. CPain that started at rest
4. DA large difference in blood pressure between the arms

Which nursing care is most important for a patient with diabetes insipidus?

1. AGiving a loop diuretic to clear extra fluid
2. BA strict fluid restriction to reduce the amount of urine passed
3. CWeighing the patient once a month
4. DStrict fluid balance, daily weight and free access to water

A patient has had a high sodium of 160 mmol/L for several days. Why must it be corrected slowly?

1. ARapid correction can cause brain swelling
2. BRapid correction causes kidney stones
3. CRapid correction raises the blood glucose
4. DThe sodium will rise again if corrected quickly

When breaking bad news, what is the first step in frameworks such as SPIKES?

1. AAsk the family to decide what the patient should be told
2. BGive the diagnosis as quickly as possible in the corridor
3. CSet up a private setting with enough time
4. DGive all treatment options before checking understanding

A patient with a sacral pressure ulcer keeps sliding down the bed when the head is raised high. Which advice best reduces shear?

1. ASit the patient upright without any support for the feet
2. BUse a dry sheet and drag the patient up the bed
3. CKeep the head of the bed at or below 30° if possible; use slide sheets
4. DRaise the head of the bed to 90° and pull the patient up the bed by the arms