NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

공식 모음, 모든 주제의 핵심 풀이 단계, 연습 문제 14개가 들어 있으며 전체 풀이는 맨 뒤에 있습니다.

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1공식과 풀이 방법

우선순위 설정과 위임

방법

  1. 아무 조치도 하지 않으면 무엇이 환자를 가장 빨리 해칠지 물으세요.
  2. ABC(심정지에서는 C-A-B)를 적용한 다음 Maslow를 적용하세요: 생리적 욕구가 안전보다, 안전이 심리적 욕구보다 먼저입니다.
  3. 선택지를 비교하세요: 급성이 만성보다, 불안정이 안정보다, 예상치 못한 것이 예상된 것보다, 전신이 국소보다 먼저이며, 각 소견을 환자의 기저 상태와 비교하세요.
  4. 응급이 아니라면 행동하기 전에 사정하세요. 그다음 나머지가 의존하는 단계를 고르세요.
  5. 위임에서는 다섯 가지 권리를 확인하세요: 업무, 상황, 사람, 지시, 감독. 사정, 교육, 평가는 RN의 몫으로 남습니다.

감염 관리와 환자 안전

방법

  1. 모든 환자에게 표준주의부터 시작하세요: 손 위생, 예상되는 노출에 맞는 개인보호구, 안전한 날카로운 기구 관리.
  2. 전파 경로별 주의를 추가하세요: 접촉(가운, 장갑), 비말(수술용 마스크), 공기(N95, 음압실).
  3. 멸균 물품은 멸균 상태로 유지하세요: 의심되면 멸균이 아닙니다. 닦지 말고 교체하세요.
  4. 환경에서 해를 예방하세요: 낙상 예방 조치, 신체 억제는 마지막 수단, 화재에는 RACE와 PASS.
  5. 투약의 권리, 두 가지 환자 확인, 고위험 약물의 추가 안전장치를 확인하고, 오류와 아차사고를 보고하세요.

검사 수치와 전해질

방법

  1. 수치를 검사실 자체의 기준 범위와 비교한 다음, 환자의 기저 상태와 경향에 비교하세요.
  2. 검체를 확인하세요: 용혈, 지연, 또는 정맥로 근처에서 채혈한 혈액은 잘못된 결과를 줄 수 있습니다.
  3. 수치를 그 전형적인 징후와, 그것을 일으키는 약물과 상태에 연결하세요.
  4. 상호작용을 찾으세요: 칼륨이나 마그네슘이 낮으면 디곡신 독성이 커지고, 탈수는 리튬 농도를 높입니다.
  5. 환자에게 조치하세요: 사정하고, 농도가 안전하지 않으면 약물을 보류하고, 위험 수치는 복창하며, 처방자에게 알리세요.

내외과: 심혈관계와 호흡기계

방법

  1. 문제의 이름을 붙이세요: 펌프 기능 부전, 막힌 동맥, 리듬, 혈전, 기도 협착, 감염, 기구 문제.
  2. 위험 징후를 먼저 확인하세요: 저산소증, 저혈압, 흉통, 새로운 혼돈, 차갑고 맥박이 없는 사지.
  3. 산소를 환자에게 맞추세요: 대부분은 94–98%, CO₂ 저류 위험이 있는 환자는 88–92%.
  4. 각 약물을 그 검사와 위험에 연결하세요: 와파린과 INR, 헤파린과 aPTT 및 혈소판, 이뇨제와 칼륨.
  5. 안전한 첫 조치를 선택한 뒤 상급자에게 보고하고 재사정하세요.

내외과: 신경계, 내분비계, 신장

방법

  1. 새로운 혼돈, 쇠약, 경련이 있는 모든 환자에서 혈당을 확인하세요.
  2. 뇌 이상의 가장 이른 경고로 의식 수준을 사용하세요. 동공과 Cushing 삼징후는 늦게 나타납니다.
  3. 당뇨병 응급에서는 DKA(케톤, 산증)와 HHS(매우 높은 삼투압, 탈수)를 구별하고, 수액을 먼저 투여하세요.
  4. 나트륨과 수분에서는 ADH가 과다한지(SIADH) 결핍인지(요붕증)를 판단하고, 만성 변화는 천천히 교정하세요.
  5. 신장 문제에서는 원인을 신전성, 내인성, 신후성으로 분류하고 칼륨과 수분을 관찰하세요.

내외과: 소화기계, 수술 전후, 종양

방법

  1. 무엇이 숨어 있을지 물으세요: 내출혈, 열이 없는 감염, 정상 SpO₂ 뒤에 숨은 저환기.
  2. 수술 후 시간으로 합병증을 좁히세요: 몇 시간 안에는 출혈, 며칠 안에는 흉부 문제, 그 이후에는 상처와 누출 문제.
  3. 통증은 사정하고, 다양식 진통으로 치료하고, 재사정하며, 모든 아편유사제에서 진정을 모니터링하세요.
  4. 암 환자에서는 최저점(nadir) 동안의 모든 질환을 호중구감소성 패혈증으로 취급하고 종양학적 응급을 알아 두세요.
  5. 화상에서는 2도와 3도 부위만 세고, Parkland 시계를 화상 시점부터 시작하며, 소변량에 맞춰 조절하세요.

2연습 문제

1.우선순위 설정과 위임보통

A nurse teaches foot care to a patient with diabetes. Which statement shows a need for further teaching?

  1. A“I will wear shoes that fit well, even at home.”
  2. B“I will check the soles of my feet every day with a mirror.”
  3. C“I will soak my feet in hot water every evening.”
  4. D“I will dry well between my toes after washing.”
2.우선순위 설정과 위임어려움

A patient with known abdominal aortic aneurysm suddenly has severe back pain, a pulsing mass in the abdomen and a falling blood pressure. What should the nurse do?

  1. AEncourage the patient to walk to ease the back pain
  2. BCall for emergency help at once and prepare for urgent surgery
  3. CGive an oral analgesic and reassess the patient in about one hour
  4. DPalpate the mass firmly to check its size and spread
3.감염 관리와 환자 안전보통

In the US (EPA/OSHA) hazmat system, which level of PPE gives the highest level of protection?

  1. ALevel C
  2. BLevel B
  3. CLevel A
  4. DLevel D
4.감염 관리와 환자 안전어려움

A nurse calculates a child’s prescribed dose and finds it is ten times higher than the usual dose for the child’s weight. What should the nurse do?

  1. AHold the dose and verify it with the prescriber and pharmacist
  2. BGive half the dose and watch the child closely
  3. CGive it, because the prescriber must have a reason
  4. DGive one-tenth of the dose without telling anyone about it
5.검사 수치와 전해질보통

The heparin infusion rate was changed according to protocol. When is the aPTT usually rechecked?

  1. AOnly after the infusion is stopped
  2. BAbout 6 hours after the change
  3. CAbout 30 minutes after the change
  4. DAbout 3 days after the change
6.검사 수치와 전해질어려움

The nurse teaches a patient with iron-deficiency anemia who is starting oral iron. Which statement shows a need for further teaching?

  1. A"I'll take my iron tablet with a big glass of milk"
  2. B"I'll keep the tablets out of reach of the children"
  3. C"I can take it with orange juice to help absorption"
  4. D"My stools may look darker while I take the tablets"
7.임상간호학보통

An arterial blood gas shows a low pH, a high PaCO2 and a normal bicarbonate. What does this show?

  1. ARespiratory alkalosis
  2. BRespiratory acidosis
  3. CMetabolic alkalosis
  4. DMetabolic acidosis
8.임상간호학어려움

A nurse teaches a patient with diabetes about foot care. Which statement shows a need for further teaching?

  1. A"I will wear well-fitting shoes."
  2. B"I will check my feet every day for cuts or blisters."
  3. C"I will walk barefoot at home to toughen my feet."
  4. D"I will see the podiatrist about hard skin."
9.내외과: 심혈관계와 호흡기계보통

A patient on theophylline develops nausea, vomiting, a fast heart rate and restlessness. What should the nurse suspect?

  1. AA theophylline allergy causing a rash
  2. BTheophylline toxicity
  3. CHypoglycaemia caused by the drug
  4. DAn expected sign that the drug is working
10.내외과: 심혈관계와 호흡기계어려움

A patient with COPD who is known to retain CO₂ arrives on 15 L/min oxygen. They are now drowsy with SpO₂ 99%. What is the most appropriate action?

  1. AGive a sedative to help the patient rest
  2. BKeep the oxygen at 15 L/min because the saturation is excellent
  3. CRemove the oxygen completely and observe
  4. DReduce the oxygen to aim for 88–92% and get a blood gas
11.내외과: 신경계, 내분비계, 신장보통

Which measure best prevents catheter-associated urinary tract infection?

  1. AKeep the drainage bag above bladder level
  2. BRemove the catheter as soon as it is no longer needed
  3. CDisconnect the bag regularly to empty it
  4. DChange the catheter for a new one every day
12.내외과: 신경계, 내분비계, 신장어려움

After a stroke, a patient suddenly cries or laughs at odd moments. They say they do not feel sad. Which response is most appropriate?

  1. AAsk the doctor for a sedative to stop the outbursts
  2. BExplain that this is emotional lability after stroke and help the family understand
  3. CIgnore it, because it shows that the patient is seeking attention from the staff
  4. DTell the patient that crying will slow their recovery
13.내외과: 소화기계, 수술 전후, 종양보통

Patients on immune checkpoint inhibitors may develop immune-related side effects. Which symptom should they report promptly?

  1. ANew diarrhoea or abdominal pain
  2. BA small bruise after a knock
  3. CMild tiredness after a busy day
  4. DSlight hair thinning over months
14.내외과: 소화기계, 수술 전후, 종양어려움

After surgery, a patient keeps asking for analgesia before it is due, watches the clock and rates pain 8/10. What is the most appropriate interpretation?

  1. APain may be undertreated; reassess and ask for a review of the plan
  2. BThe patient is addicted and should have analgesia withheld
  3. CThe patient needs only distraction and no change in drugs
  4. DThe patient is exaggerating, so the pain scores should be ignored for now

3용액

1.우선순위 설정과 위임

답: C · “I will soak my feet in hot water every evening.”

이것이 답인 이유

Neuropathy can stop the patient feeling heat, so hot soaks can cause burns, and long soaking dries the skin. Daily checks, careful drying and well-fitting shoes are correct.

답

C · “I will soak my feet in hot water every evening.”
2.우선순위 설정과 위임

답: B · Call for emergency help at once and prepare for urgent surgery

이것이 답인 이유

Sudden severe back or abdominal pain with hypotension in a patient with an aneurysm suggests rupture, which is fatal without urgent surgery. The mass should not be palpated firmly.

답

B · Call for emergency help at once and prepare for urgent surgery
3.감염 관리와 환자 안전

답: C · Level A

이것이 답인 이유

Level A is a fully encapsulating, vapor-tight suit with self-contained breathing apparatus, used for unknown or highly toxic agents. Level D is ordinary work clothing with minimal protection.

답

C · Level A
4.감염 관리와 환자 안전

답: A · Hold the dose and verify it with the prescriber and pharmacist

이것이 답인 이유

Tenfold errors are common in pediatrics, usually from decimal or unit mistakes. The nurse holds the dose and clarifies it, and never changes the dose on their own.

답

A · Hold the dose and verify it with the prescriber and pharmacist
5.검사 수치와 전해질

답: B · About 6 hours after the change

이것이 답인 이유

Most weight-based heparin protocols check the aPTT (or anti-Xa level) about 6 hours after starting or changing the rate, because it takes this long to reach a new steady state. Checking too early can lead to wrong adjustments.

답

B · About 6 hours after the change
6.검사 수치와 전해질

답: A · "I'll take my iron tablet with a big glass of milk"

이것이 답인 이유

Calcium in milk, as well as antacids and tea, reduces iron absorption, so iron should not be taken with them. Vitamin C improves absorption, dark stools are expected, and iron overdose is a serious poisoning risk in young children.확인 출처: Iron deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2025); Iron in diet - Medical Encyclopedia · MedlinePlus (NIH) (2025)

답

A · "I'll take my iron tablet with a big glass of milk"
7.임상간호학

답: B · Respiratory acidosis

이것이 답인 이유

A raised PaCO2 with a low pH means the lungs are not removing enough CO2, for example from hypoventilation. A normal bicarbonate suggests it is acute.

답

B · Respiratory acidosis
8.임상간호학

답: C · "I will walk barefoot at home to toughen my feet."

이것이 답인 이유

Diabetic neuropathy and poor circulation mean small injuries can become ulcers. Patients should avoid walking barefoot, inspect their feet daily and get professional foot care.

답

C · "I will walk barefoot at home to toughen my feet."
9.내외과: 심혈관계와 호흡기계

답: B · Theophylline toxicity

이것이 답인 이유

Theophylline has a narrow therapeutic window. Toxicity causes nausea, vomiting, tachycardia, arrhythmias, agitation and seizures. Levels are monitored, and many drugs and smoking status change its clearance. The nurse should hold the dose and report.

답

B · Theophylline toxicity
10.내외과: 심혈관계와 호흡기계

답: D · Reduce the oxygen to aim for 88–92% and get a blood gas

이것이 답인 이유

In patients at risk of hypercapnic respiratory failure, excess oxygen can raise PaCO₂ and cause drowsiness and acidosis. Oxygen is stepped down to a target of 88–92% (for example via a Venturi mask), not stopped abruptly, which could cause dangerous hypoxaemia. An arterial blood gas guides further treatment, which may include NIV.

답

D · Reduce the oxygen to aim for 88–92% and get a blood gas
11.내외과: 신경계, 내분비계, 신장

답: B · Remove the catheter as soon as it is no longer needed

이것이 답인 이유

The risk of CAUTI rises with each day a catheter is in place. Avoiding unnecessary catheters and removing them early are the most effective measures. A closed system and keeping the bag below bladder level also help.

답

B · Remove the catheter as soon as it is no longer needed
12.내외과: 신경계, 내분비계, 신장

답: B · Explain that this is emotional lability after stroke and help the family understand

이것이 답인 이유

Emotional lability (pseudobulbar affect) is common after stroke: crying or laughter does not match the person's mood. Explaining it, staying calm and gently distracting the patient helps. True depression is also common and should be screened for separately.

답

B · Explain that this is emotional lability after stroke and help the family understand
13.내외과: 소화기계, 수술 전후, 종양

답: A · New diarrhoea or abdominal pain

이것이 답인 이유

Checkpoint inhibitors can cause immune-mediated colitis, pneumonitis, hepatitis, skin reactions and endocrine problems. Early reporting allows grading and treatment, often with corticosteroids.

답

A · New diarrhoea or abdominal pain
14.내외과: 소화기계, 수술 전후, 종양

답: A · Pain may be undertreated; reassess and ask for a review of the plan

이것이 답인 이유

Clock-watching often reflects inadequate analgesia. The nurse reassesses pain and function, considers multimodal options, and asks the prescriber to review the plan rather than labelling the patient.

답

A · Pain may be undertreated; reassess and ask for a review of the plan

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