NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

간호사가 간호조무사에게 “환자의 통증을 사정하고 약을 더 줘야 하는지 결정해 주세요”라고 요청합니다. 위임의 어느 권리가 침해되었나요?

1. A올바른 업무
2. B올바른 상황
3. C올바른 사람
4. D올바른 감독과 평가

After the RN taught a patient to inject insulin, an LPN/LVN reports that the patient still cannot draw up the dose correctly. What should happen next?

1. AThe patient is discharged with a leaflet to read at home
2. BThe LPN/LVN writes a new teaching plan and evaluates it at the end of the shift
3. CThe RN reassesses the patient’s learning needs and adjusts the teaching
4. DThe nursing assistant shows the patient again at lunch

환자가 처방된 약을 거부하려 합니다. 간호사는 어떻게 해야 합니까?

1. A이유를 알아보고, 설명하고, 판단 능력이 있는 환자의 선택을 존중하고, 기록한다
2. B반드시 먹게 하려고 환자의 음식이나 음료에 약을 숨긴다
3. C팀의 질문을 피하려고 투약한 것으로 기록한다
4. D처방된 것이므로 어쨌든 투약한다

A nurse has weeping dermatitis on both hands. What is the most appropriate action?

1. AContinue care as usual and wear one pair of gloves
2. BCover the lesions with a waterproof bandage and keep working with patients as usual
3. CUse extra alcohol hand rub on the lesions
4. DAvoid direct patient care and handling of equipment until it heals, and see occupational health

In the US, when is a pregnant woman without known risk factors usually screened for gestational diabetes?

1. AOnly after the baby is born
2. BAt about 24–28 weeks of pregnancy
3. CAt about 38–40 weeks of pregnancy
4. DAt about 6–8 weeks of pregnancy

The nurse teaches a patient who is starting warfarin. Which statement shows a need for further teaching?

1. A"If I miss a dose, I will take two tablets the next day"
2. B"I will have my INR checked as often as I am told to"
3. C"I will tell my dentist and pharmacist that I take warfarin"
4. D"I will keep my intake of green leafy vegetables about the same"

새로 만든 결장루 장루가 수술 후 2일째 짙은 자주색에서 검은색으로 보입니다. 이것이 나타내는 것은?

1. A긴급한 평가가 필요한 장루의 허혈 가능성
2. B조치가 필요 없는 장루의 정상적인 수술 후 멍
3. C변비
4. D정상적인 건강한 장루

A patient with known cirrhosis suddenly vomits large amounts of bright red blood and becomes tachycardic. What is the most likely cause?

1. ASwallowed blood from a nosebleed
2. BA Mallory-Weiss tear from a small amount of vomiting
3. CA lower GI bleed from diverticular disease
4. DBleeding from ruptured oesophageal varices

영구 심박조율기를 삽입한 후 처음 몇 주 동안 흔히 하는 지시는?

1. A그쪽 팔을 어깨 높이 위로 올리지 않는다
2. B6주 동안 샤워나 세안을 전혀 하지 않는다
3. C6개월 이상 팔걸이로 팔을 완전히 고정한다
4. D하루에 두 번 상처를 세게 마사지한다

Which instruction from the registered nurse to a healthcare assistant (unlicensed assistive personnel) caring for a patient with COPD is most appropriate?

1. A"Turn his oxygen up to whatever he needs if he looks short of breath."
2. B"Teach him how to use his new inhaler this afternoon after his rest."
3. C"Listen to his chest after lunch and let me know what you can hear."
4. D"Tell me straight away if his SpO₂ is under 88% or he is more breathless."

A patient has confirmed meningococcal meningitis. What is usually offered to their close household contacts?

1. ANo action unless they develop symptoms
2. BA full course of IV antibiotics in hospital
3. CA lumbar puncture to check for infection
4. DPreventive antibiotics

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

1. ANo concern, because more drainage always lowers the ICP safely
2. BOverdrainage of CSF, so act per protocol and inform the team
3. CAn infected drain, so the dressing should be removed
4. DUnderdrainage, so the drain should be lowered further

Which initial treatment is usual for symptomatic hypercalcaemia of malignancy?

1. AOral calcium tablets and vitamin D
2. BFluid restriction and a thiazide diuretic
3. CA high-calcium diet with extra milk
4. DIV fluids followed by an IV bisphosphonate

A patient with a platelet count of 8 × 10⁹/L (8,000/µL) develops a sudden severe headache and confusion. What should the nurse suspect?

1. AIntracranial bleeding
2. BDehydration from poor intake
3. CA tension headache from stress
4. DNormal effects of chemotherapy