NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

Five days after starting heparin, a patient’s platelet count has fallen by more than half. What should the nurse suspect?

1. AHeparin-induced thrombocytopenia
2. BVitamin K deficiency
3. CIron deficiency anemia
4. DAn expected effect that needs no action

A nurse has a needlestick injury from a used needle. What should the nurse do first?

1. AFinish the shift and report it tomorrow
2. BWash the area with soap and water
3. CScrub the area with bleach
4. DSqueeze the wound hard and suck it

같은 균에 감염된 두 환자가 입원했는데 사용할 수 있는 1인실이 없습니다. 인정되는 선택은?

1. A복도에 둔다
2. B감염관리 자문에 따라 같은 병실에 코호트 격리한다
3. C접촉주의를 중단한다
4. D각각을 면역이 저하된 환자와 같은 병실에 둔다

A nurse has just started a unit of red blood cells when a colleague asks for urgent help with another patient. What is the best action?

1. ASpeed up the transfusion so it finishes sooner
2. BStay with the transfusing patient for the first 15 minutes and ask another nurse to help
3. CPause the transfusion until the nurse is free again
4. DLeave to help the other patient, and check the transfusion again in about an hour

A blood sample drawn just after a patient ate a fatty meal is reported as "lipemic." What does this mean for the results?

1. AThe results are more accurate than in a fasting sample
2. BHigh fat in the sample may interfere with some test results
3. CThe sample shows the patient has diabetic ketoacidosis
4. DThe sample was contaminated by an IV fluid with dextrose

심부전 환자의 BNP가 입원 때 매우 높았다가 이뇨제 치료 후 떨어지고 있습니다. 이는 가장 가능성이 높게 무엇을 보여 주나요?

1. A심장에 가해지는 늘어남이 줄었으며 호전에 부합한다
2. B이뇨제를 즉시 중단해야 한다는 것
3. C이뇨제로 인한 새로운 신부전
4. D수액이 더 필요한 심부전의 악화

심부전 환자가 분홍색 거품 섞인 가래를 보이고 양쪽 폐 전체에서 수포음이 들립니다. 무슨 일이 일어나고 있나요?

1. A급성 폐부종
2. B기흉
3. C천식 발작
4. D상부 위장관 출혈

A patient taking dapagliflozin is vomiting and unwell, with high blood ketones and a blood glucose of only 11 mmol/L (198 mg/dL). What should be suspected?

1. AHypoglycaemia
2. BSimple gastroenteritis with no further concern
3. CHyperosmolar hyperglycaemic state
4. DEuglycaemic diabetic ketoacidosis

A 34-year-old has hypertension that is hard to control and a low serum potassium without taking diuretics. Which cause should be considered?

1. APrimary hyperaldosteronism
2. BIron-deficiency anaemia
3. CEssential hypertension of ageing
4. DHypothyroidism

Thirty minutes after extubation, a patient develops a high-pitched noise on breathing in and is anxious. SpO₂ is falling. What should the nurse do?

1. AEncourage the patient to sleep it off and recheck them in an hour
2. BGive a large drink of cold water to soothe the throat and settle it
3. CLay the patient flat and reassure them
4. DSit the patient up, give oxygen and call for urgent airway help

A patient with Addison's disease takes fludrocortisone as well as hydrocortisone. Why?

1. ATo replace the missing aldosterone
2. BTo lower the blood pressure
3. CTo treat a low thyroid hormone level
4. DTo replace the missing adrenaline

중추성 요붕증 환자가 데스모프레신을 시작합니다. 간호사가 감시해야 하는 합병증은?

1. A고칼륨혈증
2. B저나트륨혈증
3. C고혈당
4. D심한 설사

Which description fits a category (stage) 4 pressure ulcer?

1. AA shallow wound into the dermis only
2. BIntact skin with redness that does not blanch
3. CA blister filled with clear fluid over the heel or sacrum
4. DFull-thickness loss with exposed bone, tendon or muscle

A nurse teaches a patient to self-inject low molecular weight heparin at home. Which statement shows a need for further teaching?

1. A"I'll report any unusual bruising or bleeding."
2. B"I'll put the used syringe in the sharps bin."
3. C"I'll change the injection site each day."
4. D"I'll rub the area afterwards to spread the medicine."