공식 모음, 모든 주제의 핵심 풀이 단계, 연습 문제 14개가 들어 있으며 전체 풀이는 맨 뒤에 있습니다.
Which postoperative patient should the nurse see first?
A patient with known abdominal aortic aneurysm suddenly has severe back pain, a pulsing mass in the abdomen and a falling blood pressure. What should the nurse do?
A newly hired nurse had BCG vaccine as a child. Which TB screening test is usually preferred?
A patient with fever and a spreading rash is suspected of having smallpox. Which precautions are needed?
A patient takes valproate (valproic acid) for epilepsy. Which tests are monitored regularly?
새로운 심부정맥혈전증 환자가 헤파린을 주입 중이고 와파린이 막 시작되었습니다. 헤파린을 며칠간 계속하는 이유는 무엇인가요?
Why are patients asked to fast before a general anaesthetic?
노인 환자가 밤사이 갑자기 혼란스러워지고 주의력이 오락가락합니다. 먼저 찾아야 할 원인은?
A patient's blood pressure is 120/60 mmHg. What is the approximate mean arterial pressure?
Why is the cuff pressure of an endotracheal or tracheostomy tube checked regularly?
When the nurse squeezes the trapezius muscle, the patient brings a hand up above the collarbone towards the stimulus. Which GCS motor score is this?
심한 두부 손상 환자가 눈을 뜨지 않고, 통증에 팔이 펴지며 안쪽으로 회전하고 다리가 펴집니다. 이는 무엇을 나타냅니까?
A patient had an upper GI endoscopy with a local anaesthetic throat spray. What must the nurse check before giving a drink?
An 80-year-old has a fluid balance 3 L positive two days after surgery. They are now breathless, with crackles at both lung bases and swollen ankles. What should the nurse do?
답: C · Dressing soaked with bright red blood and a heart rate rising to 118/min
Heavy fresh bleeding with a rising heart rate suggests hemorrhage and early shock. The other patients have routine needs that can wait.
답: A · Call for emergency help at once and prepare for urgent surgery
Sudden severe back or abdominal pain with hypotension in a patient with an aneurysm suggests rupture, which is fatal without urgent surgery. The mass should not be palpated firmly.
답: C · An interferon-gamma release assay (IGRA) blood test
BCG vaccine can cause a false-positive tuberculin skin test. IGRA blood tests are not affected by BCG, so they are preferred for people who have had the vaccine.
답: C · Airborne and contact precautions
Smallpox spreads by respiratory particles and by contact with lesions or contaminated items, so airborne and contact precautions are used. Only immunized staff should provide care where possible.
답: D · Liver function tests and platelet count
Valproate can cause liver toxicity and thrombocytopenia, so liver tests and the platelet count are monitored. It can also raise ammonia; confusion or vomiting should prompt an ammonia level.확인 출처: Valproic Acid · StatPearls (NCBI Bookshelf) (2024)
답: B · 와파린이 완전한 항응고 효과에 이르기까지 며칠이 걸린다
와파린은 새로운 비타민 K 의존성 응고 인자의 생성을 막지만, 이미 있는 인자는 며칠간 남아 있습니다. 따라서 INR이 목표 범위에 도달해 보통 24시간 이상 유지되고 최소 약 5일이 지날 때까지 헤파린을 겹쳐 사용합니다.
답: B · To reduce the risk of aspirating stomach contents
Under general anaesthesia the airway reflexes are lost, so food or fluid in the stomach could be regurgitated and inhaled. Fasting reduces the risk of aspiration pneumonitis.
답: B · 감염이나 약물 같은 기저 문제로 인한 섬망
섬망은 몇 시간에서 며칠에 걸쳐 생기고 변동합니다. 흔한 원인은 감염, 약물, 탈수, 통증, 변비, 요정체입니다. 치매는 천천히 진행합니다.
답: B · 80 mmHg
MAP ≈ diastolic + (systolic − diastolic) ÷ 3 = 60 + 60 ÷ 3 = 80 mmHg. The heart spends longer in diastole, so MAP is closer to the diastolic value. A MAP of at least about 65 mmHg is a common target for organ perfusion.
답: B · Too high a pressure damages the trachea; too low allows aspiration
Cuff pressure is usually kept at about 20–30 cmH₂O. Higher pressures reduce blood flow to the tracheal mucosa, risking ulceration and stenosis; lower pressures allow secretions to leak past and cause aspiration and VAP. A cuff manometer is used.
답: C · 5, localises to pain
Localising to pain (5) means a purposeful movement towards the source of pain. Withdrawal (4) is pulling away, abnormal flexion (3) is decorticate posturing, and obeying commands (6) needs no pain at all. A central stimulus, such as a trapezius squeeze, is used to test for localising.
답: A · 신전(제뇌) 자세: 심한 뇌간 손상
통증에 대한 비정상적인 신전(GCS 운동 점수 2)은 뇌간이나 그 근처의 심한 손상을 나타내며 비정상적인 굴곡(제피질 자세, 운동 점수 3)보다 예후가 나쁩니다. 새로 생긴 비정상적인 자세는 즉시 상급자에게 보고해야 합니다.
답: B · That swallowing and the gag reflex have returned
Throat spray numbs the pharynx, so drinking too early risks aspiration. Fluids are given once the gag reflex and swallowing have returned, usually after about an hour, starting with sips of water.
답: D · Stop the IV fluids, sit the patient up and escalate
Older patients and those with heart or kidney disease can develop fluid overload. The nurse stops fluids, sits the patient up, gives oxygen if needed and asks for medical review, often for diuretics.
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