NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

A patient with a head injury is being monitored. Which set of findings suggests rising intracranial pressure?

1. ARising systolic pressure, slow pulse and irregular breathing
2. BLow temperature, fast breathing and a strong appetite
3. CNormal blood pressure, normal pulse and clear speech
4. DFalling blood pressure, a fast pulse and warm, flushed dry skin

START 트리아지에서 성인이 호흡하지 않습니다. 기도를 재배치했는데도 여전히 호흡하지 않습니다. 올바른 범주는 무엇인가요?

1. A검정(사망 또는 기대 불가)
2. B빨강, 그리고 즉시 심폐소생술 시작
3. C노랑, 나중에 다시 오기
4. D빨강. 호흡이 없는 것이 가장 긴급한 소견이기 때문

A visitor with a cold wants to see a patient who has severe neutropenia. What should the nurse advise?

1. AVisit as usual after washing the hands
2. BVisit but avoid touching the patient’s bed
3. CVisit only if the cold started more than a day ago
4. DPostpone the visit until the visitor is well

An audit shows poor hand hygiene compliance on a ward. Which plan is most likely to improve it?

1. AA single poster about hand hygiene placed in the staff room
2. BDisciplining staff who are seen not cleaning their hands, with no other change
3. CRemoving all sinks so staff must use hand rub
4. DA combined approach with education, hand rub at every bedside, regular audits and feedback

A breathless patient in the emergency department has a BNP below 100 pg/mL. What does this suggest?

1. ASevere heart failure is certainly the cause of the problem
2. BThe patient has had a myocardial infarction in the past day
3. CHeart failure is an unlikely cause of the breathlessness
4. DThe kidneys are failing and the patient needs dialysis

A patient on digoxin has a calcium of 12.1 mg/dL (3.0 mmol/L) and new nausea and a slow pulse. Why is the calcium result important?

1. AHigh calcium blocks digoxin, so the drug stops working
2. BHigh calcium increases the risk of digoxin toxicity
3. CHigh calcium makes the kidneys clear digoxin faster
4. DHigh calcium only matters if the potassium is also high

Why is blood pressure monitored closely in a patient with an epidural infusion?

1. ABlood pressure readings show whether the catheter is infected
2. BThe epidural pump uses the blood pressure to set the rate
3. CThe local anaesthetic can block sympathetic nerves and cause hypotension
4. DEpidurals always cause severe hypertension that needs regular treatment

내과 병동의 환자가 3일 동안 설사를 했습니다. 가장 적절한 감염 관리 조치는?

1. A자원을 아끼기 위해 알코올 손 소독제만 쓰고 장갑은 피한다
2. B신속히 격리하고, 접촉 주의를 적용하며, 대변 검체를 보낸다
3. C설사가 일주일 지속될 때까지 아무 조치도 하지 않는다
4. D1인실을 비워 두도록 환자를 다인실로 옮긴다

Which investigation is most often used to confirm a pulmonary embolism?

1. AAbdominal ultrasound
2. BCT pulmonary angiography
3. CPeak flow measurement
4. DSputum culture

A nurse is reviewing four telemetry patients. Which rhythm needs attention first?

1. AFirst-degree heart block with a stable blood pressure and no symptoms
2. BSinus bradycardia of 54/min in a patient who is asleep and comfortable
3. CRate-controlled atrial fibrillation at 82/min
4. DRepeated runs of ventricular tachycardia in a patient who feels dizzy

A patient with a suspected basal skull fracture needs a gastric tube. Which route is preferred?

1. AThrough a fine-bore nasal tube
2. BThrough the nose with a guidewire
3. CThrough the nose (nasogastric)
4. DThrough the mouth (orogastric)

During a TURP, a patient becomes confused and nauseated, with a slow pulse and a raised BP. The sodium is 121 mmol/L. What is most likely?

1. AAn allergic reaction to the catheter
2. BA normal reaction to the spinal anaesthetic
3. CHypoglycaemia from fasting for many hours before surgery
4. DTURP syndrome from absorbed irrigation fluid

In the UK National Early Warning Score (NEWS2), what does an aggregate score of 5 or more usually trigger?

1. ADischarge planning for the next day
2. BNo change unless the patient complains
3. CAn urgent review by a clinician skilled in acute illness
4. DRoutine observations once every 12 hours, with no other change in care

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