NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

Which patient is most suitable for the nurse to assign to a nurse who has just finished orientation?

1. AA patient with sepsis whose blood pressure is falling
2. BA patient with a new tracheostomy who needs frequent suctioning
3. CA patient on a continuous heparin infusion with rising aPTT values
4. DA patient with stable cellulitis on scheduled IV antibiotics

A patient is bleeding internally after a fall. Which finding is usually an early sign of hypovolemic shock?

1. AA very low blood pressure with fixed, dilated pupils
2. BA slow heart rate with warm, dry, flushed skin and a normal blood pressure throughout
3. CRestlessness and a rising heart rate while the blood pressure is still normal
4. DLoss of consciousness with gasping breaths

An order reads “Give potassium chloride by IV push.” What should the nurse do?

1. AGive half by IV push and the rest later
2. BGive it slowly by IV push over two minutes while watching the cardiac monitor
3. CDilute it in a small syringe and push it
4. DNot give it, and contact the prescriber, because it is never given by IV push

A nurse teaches a patient who has had a splenectomy. Which statement shows a need for further teaching?

1. A“Now that my spleen is out, a fever is nothing to worry about.”
2. B“I will keep my vaccinations up to date.”
3. C“I will get medical help quickly if I get a high temperature.”
4. D“I will tell all of my health care providers that I have no spleen.”

For most hospitalized adults with diabetes who are critically ill, which glucose target range is commonly recommended?

1. AAbout 300–350 mg/dL (16.7–19.4 mmol/L)
2. BAbout 60–80 mg/dL (3.3–4.4 mmol/L)
3. CAbout 250–300 mg/dL (13.9–16.7 mmol/L)
4. DAbout 140–180 mg/dL (7.8–10 mmol/L)

오래된 폐 질환이 있는 환자의 혈청 중탄산염이 32 mEq/L, 동맥 PaCO₂가 늘 높고 pH는 7.36입니다. 어떤 상태가 가장 잘 맞나요?

1. A심한 탈수와 구토를 동반한 급성 당뇨병성 케톤산증
2. B빠른 호흡을 동반한 급성 아스피린 과다 복용
3. C만성 CO₂ 저류와 대사성 보상을 동반한 COPD
4. D많은 중탄산염 손실을 동반한 급성 중증 설사

저나트륨혈증 환자에게 특히 관찰해야 할 것은?

1. A청력 손실
2. B선홍색 발진
3. C털 증가
4. D혼돈, 두통, 경련

Why must a unit of red cells be transfused within the set time limit (commonly four hours) after it leaves controlled cold storage?

1. AThe red cells break down and turn into plasma
2. BBacteria can grow in the blood at room temperature
3. CThe blood group of the cells changes after a few hours
4. DThe bag stops dripping after four hours

A patient's ankle–brachial pressure index (ABPI) is 0.6. What does this suggest?

1. AA deep vein thrombosis
2. BStiff, calcified arteries that read falsely high
3. CNormal leg circulation
4. DSignificant peripheral arterial disease

A patient receiving noradrenaline (norepinephrine) through a peripheral cannula has pale, cold skin around the site. What should the nurse do?

1. AMassage the area firmly to spread the drug out into the surrounding tissue
2. BIncrease the rate so the drug enters the vein faster and leaks less
3. CContinue the infusion, as this is expected
4. DStop it at that site, inform the team and follow the extravasation policy

환자가 스스로 기도를 보호하지 못할 수 있음을 보통 시사하는 글래스고 혼수 척도(GCS) 점수는?

1. A8 이하
2. B15
3. C11 이상
4. D13 이하

급성 세뇨관 괴사에서 회복 중인 환자가 다뇨기에 접어들어 하루 4 L 넘게 소변을 봅니다. 주된 간호 우려는?

1. A낮은 칼륨과 나트륨을 동반한 탈수
2. B과도한 인슐린으로 인한 저혈당
3. C팽창된 방광에 소변이 고이는 것
4. D높은 칼륨 수치를 동반한 수분 과다

Which advice is appropriate for a patient with a very low platelet count?

1. AFloss hard every day to prevent gum disease
2. BUse a razor blade for shaving every day
3. CUse a soft toothbrush and an electric razor
4. DTake aspirin regularly for headaches

An hour after a line flush, a patient receiving parenteral nutrition has rigors and a temperature of 39.1 °C. What should the nurse suspect and do?

1. AFluid overload; reduce the infusion rate only
2. BA normal reaction; give paracetamol and continue the infusion
3. CLine infection; escalate and take blood cultures
4. DLow blood glucose; give a sugary drink