NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

응급 중증도 지수(ESI)를 사용할 때 가장 높은 중증도 단계를 받는 환자는 누구인가요?

1. A3일간 인후통이 있고 활력징후가 정상인 환자
2. B의식이 없고 헐떡이는 불규칙한 호흡을 하는 환자
3. C발목 골절이 의심되는 환자
4. D활력징후가 정상인 흉통 환자

A provider asks a nurse to perform a procedure that is outside the nurse’s scope of practice. What should the nurse do?

1. ADo it, because the provider gave the instruction
2. BAsk a nursing assistant to do it instead
3. CDo it just this once and promise the provider not to do it again
4. DDecline, explain why and suggest who can safely do it

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 water
3. C5% dextrose in 0.45% sodium chloride
4. D0.9% sodium chloride

혼란스러워하는 환자가 손목 억제대를 하고 있는데 한쪽 손가락이 차갑고 창백하며 같은 쪽의 요골 맥박이 약합니다. 간호사가 가장 먼저 할 일은?

1. A그쪽 억제대를 풀고 손의 순환을 사정한다
2. B환자가 당기지 못하도록 다른 쪽 억제대를 더 조인다
3. C소견을 꼼꼼히 기록하고 두 시간 뒤에 다시 확인한다
4. D억제대는 그대로 두고 베개 위에 손을 올린다

A healthy patient has a mildly raised CK after running a marathon yesterday, without dark urine or symptoms. What is the most likely explanation?

1. AThe patient has developed acute pancreatitis
2. BAn acute myocardial infarction has occurred
3. CThe patient has developed acute hepatitis
4. DStrenuous exercise raised CK from skeletal muscle

A patient on hemodialysis receives epoetin, but the hemoglobin has not risen in 2 months. Which results should be checked first?

1. ATroponin and creatine kinase
2. BAmylase and lipase levels
3. CTSH and the free T₃ level
4. DFerritin and transferrin saturation

교통사고 후 환자가 심한 호흡곤란, 한쪽 호흡음 소실, 저혈압, 반대쪽으로 밀린 기관을 보입니다. 가능성 높은 진단은?

1. A폐부종
2. B천식
3. C긴장성 기흉
4. D폐렴

Which statement about oxygen in a patient with suspected acute coronary syndrome is correct?

1. AOxygen replaces the need for an ECG
2. BHigh-flow oxygen should always be given, whatever the SpO₂
3. COxygen must never be given in chest pain
4. DOxygen is given if the SpO₂ is below the target range

Which foot care advice is correct for a patient with peripheral arterial disease?

1. ACut corns with a razor blade to prevent pressure
2. BWalk barefoot at home to strengthen the feet
3. CCheck the feet daily and wear well-fitting shoes
4. DUse a hot water bottle on the feet at night

A patient who injects drugs has a fever, a new heart murmur and splinter haemorrhages. Before antibiotics are started, what is most important?

1. AArrange an exercise ECG test
2. BTake a single blood culture from the cannula
3. CTake several sets of blood cultures from separate sites
4. DWait for an echocardiogram before taking any samples

DKA 치료 중 혈당이 약 14 mmol/L(약 250 mg/dL) 아래로 떨어졌지만 케톤은 여전히 높습니다. 보통 어떻게 합니까?

1. A인슐린 주입을 즉시 중단한다
2. B환자가 식사를 하고 정맥 치료를 중단한다
3. C수액에 포도당을 추가하고 인슐린은 계속한다
4. D수분 과다를 피하려고 모든 정맥 수액을 중단한다

A patient who has taken prednisolone daily for years is vomiting and cannot keep tablets down. What should the nurse do?

1. AOmit the steroid until the vomiting stops
2. BEscalate urgently for steroid by injection
3. CGive the tablets again after every vomit
4. DGive the next dose with a glass of milk

Which nerve is at risk if the arm is poorly padded at the elbow during surgery?

1. AUlnar nerve
2. BFacial nerve
3. CSciatic nerve
4. DFemoral nerve

A patient finds daily wound dressing changes very painful. What is the most effective nursing approach?

1. AChange the dressing less often than the plan says
2. BGive analgesia timed so it works during the dressing change
3. CDo the dressing quickly and give analgesia afterwards
4. DAvoid analgesia so the patient can report any problems during the change