NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

A patient receiving IV magnesium sulfate for pre-eclampsia has absent knee reflexes and a respiratory rate of 10/min. What does the nurse do first?

1. AStop the magnesium infusion and call for help
2. BGive oral fluids to help clear the drug faster
3. CTurn the patient onto her back and recheck later
4. DIncrease the infusion to prevent a seizure

A visitor on the ward becomes threatening and shows a knife. What is the nurse’s priority?

1. AMove away to safety, keep others away and call security or the police
2. BTry to take the knife away from the visitor straight away before anyone is hurt
3. CIgnore the visitor and carry on with patient care
4. DArgue with the visitor to persuade them to leave

면역이 정상인 환자의 가슴 한 부위에 대상포진(herpes zoster)이 있고 병변을 완전히 가릴 수 있습니다. 보통 필요한 주의는?

1. A병변을 가린 표준주의
2. B양압의 보호 환경
3. C비말주의만
4. D음압실의 공기주의

Which patient should the nurse assess first?

1. AA patient with an MRSA wound due for a routine dressing change
2. BA patient on chemotherapy with a new temperature of 38.4 °C (101.1 °F)
3. CA patient who wants more alcohol hand rub in the room
4. DA patient with tuberculosis who is asking to have visitors

A patient starts high-dose prednisone. Which laboratory change should the nurse expect?

1. AA fall in the white cell count
2. BA rise in blood glucose
3. CA rise in serum potassium
4. DA fall in serum sodium

An RN cares for a patient on a 24-hour urine collection. Which task can be delegated to unlicensed assistive personnel (UAP), such as a nursing or healthcare assistant?

1. ADeciding whether to restart the collection after a missed sample
2. BTeaching the patient why the 24-hour collection is needed
3. CSaving all urine in the collection container as instructed
4. DInterpreting the creatinine clearance result when it comes back

의식이 없는 당뇨병 환자의 혈당이 2.1 mmol/L이고 정맥로가 없습니다. 무엇을 줄 수 있나요?

1. A피하 인슐린
2. B근육주사 글루카곤
3. C입으로 과일 주스
4. D입으로 포도당 정제

A healthcare assistant reports four observations. Which one needs the nurse's immediate action?

1. A"Ms Ali has walked to the bathroom on her own."
2. B"Mr Patel's breathing rate is 8 a minute and he's hard to wake."
3. C"Mr Chen's blood pressure is 128/80 as usual."
4. D"Mrs Jones would like a cup of tea and her glasses cleaned."

환자가 심부정맥혈전증으로 와파린을 시작합니다. 처음 며칠 동안 헤파린이나 저분자량 헤파린도 함께 투여하는 이유는?

1. A헤파린이 와파린으로 인한 출혈을 막아 주기 때문
2. B두 약을 평생 항상 함께 유지해야 하기 때문
3. C와파린이 완전한 효과에 이르기까지 며칠이 걸리기 때문
4. D헤파린이 와파린의 흡수를 개선하기 때문

A patient on spironolactone and an ACE inhibitor has a potassium of 6.8 mmol/L (6.8 mEq/L) with peaked T waves. What is usually given first to protect the heart?

1. AIntravenous calcium gluconate or chloride
2. BAn IV furosemide bolus as the only treatment
3. CA dose of digoxin
4. DOral potassium supplements

After pressing the plunger of an insulin pen, what should the patient do?

1. APull the needle out at once and rub the site firmly
2. BInject a second dose straight away to be sure
3. CLeave the needle on the pen for the next injection
4. DKeep the needle in the skin for about 10 seconds

A patient's glucose is 6.2 mmol/L (112 mg/dL) at 03:00 and 12 mmol/L (216 mg/dL) before breakfast. No hypoglycaemia occurred overnight. What is the most likely explanation?

1. AThe meter is faulty and should be replaced
2. BA large snack eaten in the night by mistake
3. CThe Somogyi effect from a night-time hypo
4. DThe dawn phenomenon from early-morning hormones

마비성 장폐쇄(paralytic ileus)란?

1. A혈액 공급을 차단하는 대장의 꼬임
2. B종양에 의한 장관 내강의 폐색
3. C발열을 동반한 장벽의 감염
4. D물리적 폐색 없이 장운동이 소실된 상태

A nurse teaches a patient after a laparoscopic fundoplication for reflux. Which statement shows a need for further teaching?

1. A"Some difficulty swallowing can happen in the early weeks."
2. B"I should eat smaller meals for a while after the operation."
3. C"Fizzy drinks will help me bring up wind after meals."
4. D"I'll eat soft, moist food at first and chew it well."