NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

A nurse cannot read part of a medication order. What should the nurse do?

1. AAsk another nurse to guess what the order most likely says, then give it
2. BContact the prescriber to clarify the order before giving the drug
3. CSkip the drug and not tell anyone until the next ward round
4. DGive the usual dose of the drug the nurse thinks was meant

A patient is admitted with inhalational anthrax. Which precautions are needed?

1. AAirborne precautions in a negative-pressure room for the whole of the hospital stay
2. BFull contact and droplet precautions for all staff and visitors on the unit
3. CDroplet precautions with a surgical mask for everyone who enters
4. DStandard precautions, because it does not usually spread from person to person

A family member tells the nurse, “My father is not himself. Something is wrong.” The hospital has a family-activated rapid response system. What is correct?

1. AThe family must wait for the next scheduled ward round to raise the concern with a doctor
2. BThe family can call the rapid response team if they are worried and staff have not responded
3. CThe family should call emergency services from outside the hospital
4. DOnly doctors may call the rapid response team

입원 시 집에서 복용하던 약 목록에 새 병원 처방에 없는 항응고제가 있습니다. 간호사는 어떻게 해야 합니까?

1. A병원 처방이 집에서 먹던 약을 대체하므로 무시한다
2. B환자에게 몰래 가져온 약을 먹으라고 말한다
3. C처방자에게 불일치를 확인한다
4. D처방 없이 집에서 먹던 용량을 투약한다

푸로세미드를 복용하는 환자의 칼륨이 2.9 mEq/L입니다. 간호사가 예상하는 소견은 무엇인가요?

1. A장 운동 항진으로 인한 설사와 복부 경련
2. B심전도의 높고 뾰족한 T파
3. C근력 약화와 다리 경련
4. D입 주위의 저림과 양성 크보스텍 징후

당뇨병성 케톤산증 환자의 칼륨이 인슐린 주입을 시작하기 전에 3.0 mEq/L입니다. 간호사는 무엇을 예상해야 하나요?

1. A칼륨이 정상이 될 때까지 수액을 중단한다
2. B칼륨을 먼저 보충하고, 프로토콜에 따라 농도가 안전해질 때까지 인슐린을 미룬다
3. C인슐린이 칼륨을 올릴 것이므로 칼륨은 보충하지 않는다
4. D인슐린을 더 높은 속도로 즉시 시작한다

After removing a peripheral IV cannula, what should the nurse check?

1. AThat the cannula is intact, and apply pressure until bleeding stops
2. BThat the cannula is put back in its sterile packet for the next patient
3. CThat the patient's blood glucose is normal before removal
4. DThat the site is left uncovered and bleeding freely

Why should chronic hypernatraemia be corrected gradually?

1. AFast correction causes severe hyperkalaemia
2. BFast correction causes osmotic demyelination from swelling of the kidneys
3. CSlow correction is only needed in children
4. DLowering the sodium too fast can cause cerebral oedema

COPD 환자에게 보통 권장되는 예방접종은?

1. A악화를 유발한다고 알려져 있으므로 어떤 백신도 접종하지 않음
2. B매년 파상풍 추가 접종만
3. C5년마다 BCG 백신
4. D매년 인플루엔자 접종과 폐렴구균 접종

종아리 심부정맥혈전증이 확진되어 치료 용량의 항응고를 시작한 환자가 침상 안정을 해야 하는지 묻습니다. 가장 정확한 답은?

1. A걷기 전마다 다리를 마사지해야 한다
2. B혈전이 완전히 녹을 때까지 걷는 것이 허용되지 않는다
3. C최소 2주간 엄격한 침상 안정이 필요하다
4. D치료가 시작되면 보통 견딜 수 있는 만큼 걷기를 권장한다

A patient has acute low back pain with no red flags. Which advice is most appropriate?

1. AStay as active as possible and use simple pain relief
2. BWear a rigid back brace all day and night for at least three months
3. CAvoid all movement until an MRI scan has been done
4. DStay in bed for two weeks until the pain is gone

A patient on warfarin starts levothyroxine for hypothyroidism. What should the nurse expect to monitor more closely?

1. AThe INR, because it may rise
2. BThe urine output, because it may stop
3. CThe blood glucose, because it may fall
4. DThe potassium, because it may rise

A nasogastric feeding tube appears blocked. What is usually the first step?

1. AUse a small 5 mL syringe with firm pressure
2. BCut the end of the tube to release the blockage inside it
3. CFlush gently with warm water in a 50 mL enteral syringe
4. DPush the guidewire back in to clear it

A nurse teaches a patient with a new ileostomy. Which statement shows a need for further teaching?

1. A"I'll drink less so my bag fills more slowly."
2. B"I'll chew my food well to avoid blockages."
3. C"I'll report if my output becomes very watery and high."
4. D"I'll watch for dizziness and dark urine."