NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

인수인계 후 간호사가 가장 먼저 만나야 할 환자는 누구인가요?

1. A이뇨제를 복용 중이며 08:00 이후 소변을 400 mL 본 환자
2. B골관절염이 있고 매일 아침 뻣뻣함을 호소하는 환자
3. C새 깁스를 했고 발이 저리며 발가락이 차갑다고 말하는 환자
4. D방문객이 오기 전에 샤워를 도와 달라는 환자

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. C같은 시간에 해야 하는 일상적인 하루 한 번 비타민 정제 주기
4. D관리자 감사 전에 간호 계획 갱신하기

A nurse wants to set up a sterile field in the morning for a procedure that will take place after lunch. What is correct?

1. ASet it up in the morning and leave it uncovered in an empty room
2. BSet it up in the morning and cover it with a clean towel until the procedure starts
3. CSet it up in the morning and ask a colleague to check it once
4. DSet it up just before the procedure, because a waiting field may become contaminated

A handwritten order is hard to read, and the nurse is not sure of the drug name. What should the nurse do?

1. AHold the drug until the next day without telling anyone
2. BContact the prescriber to clarify before giving anything
3. CChoose the drug that seems most likely from the diagnosis
4. DAsk a colleague to guess what it says

A patient on peritoneal dialysis notices that the drained fluid is cloudy and has abdominal pain. What should the nurse do?

1. ARecord it as normal and continue the usual exchanges
2. BSend the fluid for cell count and culture and report it
3. CAdd more glucose to the next bag to clear the fluid
4. DStop dialysis for a week and recheck the fluid later

A patient has macrocytic anemia with low vitamin B₁₂ and antibodies to intrinsic factor. What does this suggest, and how is it usually treated?

1. AIron deficiency, treated with oral iron tablets
2. BFolate deficiency, treated with folic acid only
3. CPernicious anemia, treated with B₁₂ injections
4. DHemolytic anemia, treated with blood transfusion

미분획 헤파린을 역전시키는 데 쓰는 약은?

1. A날록손
2. B프로타민 황산염
3. C플루마제닐
4. D비타민 K(피토메나디온)

An older patient with delirium is trying to leave the ward at night, saying he must go home. What is the best initial approach?

1. APhysically restrain him in bed until the morning so that he cannot fall
2. BLet him leave, because adults can always do as they wish whatever their state
3. CCalmly reassure and redirect him while the team assesses his capacity and safety
4. DGive a sedative straight away without a prescription

박출률(ejection fraction)이란?

1. A매 심장 박동마다 내보내는 혈액량
2. B이완기 충만이 끝날 때의 좌심실 압력
3. C심장이 매분 내보내는 혈액량
4. D매 박동마다 박출되는 심실 혈액의 백분율

Two adults with cystic fibrosis are admitted to the same ward. What is the correct infection-control plan?

1. ANurse them in separate single rooms and keep them apart
2. BPut them in the same bay so they can support each other
3. CLet them share physiotherapy sessions and equipment
4. DUse standard precautions only, as CF is not infectious

척수 손상 후 간헐적 자가 도뇨를 흔히 교육하는 이유는?

1. A주로 소변량을 정확히 측정하는 데 쓰이기 때문
2. B방광이 시간이 지나며 점차 커지도록 훈련하기 때문
3. C방광이 비워지지 않을 수 있으며 정기적으로 비우면 신장을 보호하기 때문
4. D요로감염 위험을 완전히 없애 주기 때문

A patient with a new arm fistula says their hand on that side is cold, pale and painful, especially during dialysis. What is the concern?

1. ANormal healing that needs no action
2. BAn allergic reaction to the dressing on the arm
3. CSteal syndrome, which needs urgent review
4. DFluid overload in the arm

Why is the time a surgical limb tourniquet is inflated carefully recorded?

1. AIt shows how long the anaesthetic gas was used
2. BLong inflation can cause nerve and muscle damage
3. CThe tourniquet slowly loses all its air after one minute
4. DThe surgeon is paid per minute of use

A patient's long-standing groin hernia has become tender, red and irreducible, and they are vomiting. What should the nurse do?

1. APush the hernia firmly back in, then discharge home
2. BAdvise the patient to wear a tight truss and rest
3. CApply a hot water bottle and give a laxative
4. DKeep them nil by mouth and arrange urgent surgical review