NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

A patient’s chest tube becomes disconnected from the drainage system. What should the nurse do first?

1. AClamp the tube for the rest of the shift
2. BPlace the end of the tube in a bottle of sterile water
3. CRemove the tube and cover the site
4. DWait for the provider to arrive before doing anything else

바쁜 근무 중에 네 가지 업무가 예정되어 있습니다. 간호사가 가장 먼저 해야 할 것은 무엇인가요?

1. A안정된 환자가 내일 메뉴 카드를 작성하도록 돕기
2. B패혈증이 의심되는 환자에게 정맥 항생제 첫 용량 주기
3. C관리자 감사 전에 간호 계획 갱신하기
4. D같은 시간에 해야 하는 일상적인 하루 한 번 비타민 정제 주기

During routine handwashing with soap and water (medical asepsis), how are the hands held?

1. ATouching the inside of the sink for support
2. BHigher than the elbows, so water runs down the arms
3. CLevel with the shoulders, away from the sink
4. DLower than the elbows, so water runs off the fingertips

According to the “Swiss cheese” model of error, why do errors reach patients?

1. ATechnology fails more often than people do
2. BPatients often do not follow their care instructions
3. COne careless person makes a mistake that no system could stop
4. DWeaknesses in several layers of defense line up at the same time

A patient has a calcium of 7.0 mg/dL (1.75 mmol/L) and tingling around the mouth. Which nursing measure is most appropriate?

1. AEncourage 3 L of fluid per day to dilute the calcium
2. BPut seizure precautions in place and report the result
3. CPromote walking to move calcium back into the bone
4. DLimit dairy products until the level falls again

An 82-year-old woman without a catheter has a urine culture growing bacteria, but no fever, urinary symptoms or change in mental state. What is the best interpretation?

1. AAsymptomatic bacteriuria, usually not treated with antibiotics
2. BPyelonephritis, which needs admission and IV fluids today
3. CContamination, so the culture must be repeated every week
4. DA urinary tract infection that needs urgent IV antibiotics

A patient with renal colic is asked to pass urine through a strainer. Why?

1. ATo make passing urine less painful
2. BTo catch any stone so that it can be analysed
3. CTo remove bacteria from the urine
4. DTo measure the urine's pH and specific gravity

오랜 기아 후 경관 영양을 받는 환자에게 저인산혈증, 저칼륨혈증, 부정맥이 생깁니다. 가장 가능성 높은 것은?

1. A덤핑 증후군
2. B갑상샘기능항진증
3. C재급식 증후군
4. D당뇨병성 케톤산증

A patient's blood pressure is high in clinic but normal on home readings. Which step best confirms the diagnosis?

1. AStarting two antihypertensive drugs at once at full dose
2. BAmbulatory or structured home blood pressure monitoring
3. CA single repeat reading in the same clinic visit
4. DA chest X-ray

A nurse teaches a patient how to measure blood pressure at home. Which statement shows a need for further teaching?

1. A"I will sit with my back supported and my arm at heart level."
2. B"I will rest quietly for five minutes before measuring."
3. C"I will take two readings and write them both down."
4. D"I will measure it straight after my morning jog."

A patient taking warfarin is diagnosed with an intracerebral haemorrhage. What is the priority treatment?

1. ADoubling the warfarin dose to stabilise the INR
2. BUrgent reversal of the anticoagulant effect
3. CIV thrombolysis within 4.5 hours
4. DStarting aspirin to prevent further clots

A patient with myasthenia gravis took extra pyridostigmine doses. They now have more weakness, heavy salivation, sweating, diarrhoea, small pupils and a slow pulse. What is most likely?

1. AA cholinergic crisis from too much medication
2. BA myasthenic crisis from too little medication
3. CAn allergic reaction to the drug
4. DA normal response to a higher dose

많은 항암제 투여 후 체액에 대한 특별 주의는 보통 얼마나 오래 취합니까?

1. A필요하지 않다
2. B주입 중에만
3. C1년 내내
4. D흔히 약 48시간

고관절 수술 3일째에 고령 환자가 급성으로 혼란스러워하고 주의력이 변동하며 초조해합니다. 간호사가 가장 먼저 할 일은?

1. A저산소증, 감염, 통증, 약물 같은 원인을 찾고 상급자에게 보고한다
2. B환자가 안정되도록 가족에게 집으로 데려가라고 요청한다
3. C환자를 억제하고 즉시 많은 용량의 진정제를 준다
4. D치매라고 가정하고 간호 계획을 그대로 계속한다