공식 모음, 모든 주제의 핵심 풀이 단계, 연습 문제 14개가 들어 있으며 전체 풀이는 맨 뒤에 있습니다.
A patient has a serum potassium of 2.9 mEq/L. Which finding should the nurse expect?
간호사가 예정된 퇴원에 이의를 제기해야 하는 환자는 누구인가요?
When should the transparent dressing over a peripheral IV site be changed?
혼란스러워하는 환자가 계속 비위관을 잡아당깁니다. 가장 먼저 시도할 방법은?
A patient receives repeated nebulized albuterol (salbutamol) for severe asthma. Which laboratory change should the nurse watch for?
A patient without symptoms has a finger-stick glucose of 340 mg/dL (18.9 mmol/L). The previous values were normal, and the patient has just peeled an orange. What should the nurse do first?
Which blood result often rises in an upper GI bleed because blood is digested in the gut?
A day after surgery, a patient's haemoglobin has fallen from 125 g/L to 85 g/L (12.5 to 8.5 g/dL) and their heart rate has risen to 118/min. What is the priority?
COPD에서 폐 재활이란?
A patient has been on continuous NIV via a full-face mask for two days. Which nursing measure helps prevent the most common complication?
Why might a patient bleed more from the needle sites straight after haemodialysis?
After a TURP, a patient on bladder irrigation has bladder spasms. The drainage has slowed and contains clots, and the bag holds less than the irrigant given. What should the nurse do first?
Patients on immune checkpoint inhibitors may develop immune-related side effects. Which symptom should they report promptly?
On day 5 after bowel resection, a patient has a fever, tachycardia and worsening abdominal pain, and the drain contains brown, faeculent fluid. What is most likely?
답: A · Muscle weakness and U waves on the ECG
Hypokalemia causes muscle weakness, cramps and arrhythmias, with flattened T waves and U waves on the ECG. Peaked T waves are a sign of hyperkalemia.
답: B · 수술 2일 후 새롭게 심박수가 분당 112회이고 체온이 38.4 °C인 환자
수술 후의 새로운 발열과 빈맥은 감염이나 다른 합병증의 신호일 수 있으므로, 간호사는 퇴원 전에 사정하고 우려를 제기해야 합니다. 다른 환자들은 안정적이고 기대되는 목표를 달성하고 있습니다.
답: D · When it is damp, loose or visibly soiled
A dressing that is wet, loose or dirty no longer protects the insertion site and is changed using aseptic technique. Otherwise, it is changed according to policy.
답: D · 현실 감각 일깨우기와 보조 관찰자 같은 덜 제한적인 방법
덜 제한적인 방법을 먼저 시도합니다. 현실 감각 일깨우기, 통증 같은 원인 확인, 관을 보이지 않게 고정하기, 누군가 환자 곁에 머무르기입니다. 억제대나 진정제는 이것들이 실패하고 환자가 위험할 때에만 처방에 따라 사용합니다.
답: A · A fall in serum potassium
Beta-2 agonists push potassium into cells and can cause hypokalemia, especially at high doses; they also raise blood glucose. For this reason nebulized albuterol is sometimes used as an extra treatment for hyperkalemia.
답: C · Have the patient wash and dry their hands, then repeat the test
Sugar residue on the fingers can give a falsely high finger-stick result. The hands are washed with soap and water and dried, and the test repeated. If the value is still high, it is confirmed and reported. Treating a false result could cause hypoglycemia.
답: A · Urea (blood urea nitrogen)
Blood proteins digested in the upper GI tract are absorbed and converted to urea, so urea rises out of proportion to creatinine. Urea is part of the Glasgow-Blatchford bleeding score.
답: A · Escalate urgently, as the patient may be bleeding
A large fall in haemoglobin with tachycardia suggests ongoing blood loss. The nurse assesses the patient with ABCDE, checks wounds and drains and escalates for urgent review.
답: B · 호흡곤란을 덜어 주는 감독 하의 운동과 교육
폐 재활은 개인에 맞춘 운동 훈련, 교육, 호흡법을 결합합니다. 운동 능력, 호흡곤란, 삶의 질을 개선하고 입원을 줄입니다. 호흡곤란으로 활동이 제한되는 COPD 환자와 악화 후에 권장됩니다.
답: A · Check mask fit and protect the bridge of the nose
Pressure injury over the bridge of the nose is common with NIV masks. Correctly sized masks, avoiding overtightening (allowing a small gap under the straps), protective dressings and regular skin checks reduce it. Other problems include eye irritation, dryness and gastric distension.
답: D · Heparin is often used to stop the circuit from clotting
Heparin is commonly used during haemodialysis to prevent clotting in the circuit. Its effect can cause prolonged bleeding from puncture sites, so procedures such as IM injections may be timed with care.
답: B · Suspect a clot in the catheter and follow the protocol
Clots blocking the catheter make the bladder distend, causing pain and spasms. The nurse checks for kinks, adjusts the irrigation rate per protocol, performs a bladder washout if trained and escalates if not cleared.
답: B · New diarrhoea or abdominal pain
Checkpoint inhibitors can cause immune-mediated colitis, pneumonitis, hepatitis, skin reactions and endocrine problems. Early reporting allows grading and treatment, often with corticosteroids.
답: C · An anastomotic leak
Leakage at the join in the bowel causes peritonitis and sepsis, usually a few days after surgery. Faeculent drain fluid makes it very likely. It needs urgent surgical review, sepsis care and often return to theatre.
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