NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

A patient taking lithium has vomiting, diarrhea and a new coarse tremor. What should the nurse do?

1. AGive the dose with food to reduce the stomach upset
2. BReassure the patient that a coarse tremor is expected at first
3. CEncourage the patient to cut down on salt and fluids
4. DHold the next dose and report for an urgent lithium level

Four laboratory results come back at once. Which one should the nurse report first?

1. AGlucose 180 mg/dL after a meal in a patient with diabetes
2. BPotassium 3.4 mEq/L in a patient on a diuretic
3. CCreatinine 1.3 mg/dL in an older adult, unchanged from last week
4. DHemoglobin 6.5 g/dL (65 g/L) in a patient with a GI bleed

Which IV fluid can be given with packed red blood cells in the same line?

1. ALactated Ringer’s (Hartmann’s) solution
2. B5% dextrose in 0.45% sodium chloride
3. C0.9% sodium chloride
4. D5% dextrose in water

Victims of a chemical spill arrive at the emergency department with liquid on their skin and clothing. What is the priority before they enter the building?

1. ADecontaminate them outside, with staff wearing appropriate PPE
2. BTake them straight into the resuscitation room so treatment is not delayed
3. CTake a full history in the waiting room
4. DGive them hospital gowns and seat them in triage

Which finding during a transfusion suggests transfusion-associated circulatory overload (TACO)?

1. ABack pain with dark red urine output
2. BA low temperature and slow heart rate
3. CHives and itching without other signs
4. DCrackles, hypertension and a raised BNP

Two days after bowel surgery, a patient with nasogastric suction has a distended abdomen, absent bowel sounds and muscle weakness. The potassium is 2.8 mEq/L. Which interpretation is best?

1. AThe potassium is normal for the second day after surgery
2. BHypokalemia from gastric losses is contributing to paralytic ileus
3. CThe low potassium is due to the patient drinking too much water
4. DHyperkalemia from tissue damage is causing the bowel to stop

Which blood results are typical of Addison's disease (primary adrenal insufficiency)?

1. ALow sodium and high potassium
2. BHigh glucose and high calcium
3. CHigh sodium and low potassium
4. DLow haemoglobin and high platelets

A patient is taught to self-inject low-molecular-weight heparin. Which statement shows a need for further teaching?

1. A"I will inject into the fatty tissue of my abdomen."
2. B"I will change the injection site each time."
3. C"I will report any unusual bleeding or bruising."
4. D"I will rub the area firmly after the injection."

항고혈압제를 막 시작한 환자가 침대에서 일어날 때 어지럽다고 합니다. 올바른 조언은?

1. A다음 날 아침 두 배 용량을 복용한다
2. B혈액이 계속 흐르도록 빨리 일어선다
3. C의사나 간호사에게 알리지 않고 약을 중단한다
4. D일어서기 전에 침대 가장자리에 잠시 앉아 있는다

A nurse finds a patient collapsed in bed and unresponsive. What should the nurse do first?

1. AGive two rescue breaths, then check the blood glucose before calling anyone
2. BLeave the patient to fetch a defibrillator before calling anyone
3. CShout for help, open the airway and check breathing for up to 10 seconds
4. DTake a full set of observations, including temperature and blood glucose

Why is pyridostigmine often taken about 30–60 minutes before meals by patients with myasthenia gravis?

1. ATo stop the drug from irritating an empty stomach later on
2. BTo lower the blood glucose rise after eating a meal
3. CTo improve the strength of chewing and swallowing at mealtimes
4. DTo reduce stomach acid so the food is digested better

A patient with suspected meningitis has a GCS of 9 and pupils that have become unequal. A doctor plans an immediate lumbar puncture. What is the main concern?

1. AThere is no concern, because the lumbar puncture lowers pressure safely
2. BA lumbar puncture would spread the infection to the blood
3. CThe patient is too confused to stay still, so it is not needed
4. DRaised pressure in the skull, so the procedure could cause herniation

Which diet is usually recommended for a patient with cirrhosis and hepatic encephalopathy?

1. AA very low-protein diet for the rest of their life to lower ammonia
2. BNormal protein and enough calories, with a late-evening snack
3. COnly clear fluids for several weeks
4. DNo food at all until the confusion settles

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

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