NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

낙상 예방 주의가 필요한 환자에 대해 간호사가 간호조무사에게 위임해야 할 업무는 무엇인가요?

1. A계획대로 2시간마다 환자의 화장실 이용을 돕기
2. B매일 아침 환자의 낙상 위험 점수를 사정하고 기록하기
3. C침대 알람이 아직 필요한지 결정하기
4. D가족에게 집에서 낙상을 예방하는 방법을 가르치기

중심정맥관을 제거하는 도중 환자가 갑자기 숨이 차고 흉통이 생기며 SpO₂가 떨어집니다. 간호사가 가장 먼저 해야 할 일은 무엇인가요?

1. A환자에게 천천히 깊게 숨 쉬게 하고 계속한다
2. B환자를 똑바로 앉히고 관을 빨리 마저 제거한다
3. C막힘을 뚫기 위해 카테터를 생리식염수로 세척한다
4. D부위를 덮고, 머리를 낮춘 왼쪽 옆으로 눕히며, 산소를 주고, 도움을 요청한다

After teaching a patient about a new medication, how does the nurse best check understanding?

1. AAsk “Do you understand?” and accept a yes
2. BAsk the family whether they understood the teaching
3. CGive a printed leaflet about the drug and assume the patient will read it at home
4. DAsk the patient to explain in their own words how and when to take it

Which action by assistive personnel requires the nurse to step in?

1. AWashing hands with soap and water after leaving a C. difficile room
2. BPutting soiled linen straight into a laundry bag at the bedside
3. CRemoving gloves and then cleaning the hands with alcohol rub
4. DGoing from one patient’s bed to the next while wearing the same gloves

A patient with a potassium of 2.8 mEq/L has potassium chloride prescribed IV. Which statement about giving it is correct?

1. AIt may be given as a slow IV push over one minute if the level is very low
2. BIt is added to the IV bag without mixing, so it stays at the bottom
3. CIt is given as an undiluted bolus into a large vein to avoid irritation
4. DIt is always diluted and given by infusion pump, never as an IV push

간호사가 가장 먼저 보고해야 할 환자의 결과는 무엇인가요?

1. A땀을 흘리며 혼돈이 있는 환자의 혈당 42 mg/dL (2.3 mmol/L)
2. B제2형 당뇨병 환자의 HbA1c 7.4% (57 mmol/mol)
3. C목표를 약간 넘는 총 콜레스테롤
4. D안정적인 만성 콩팥병이 알려진 환자의 크레아티닌 1.6 mg/dL (141 µmol/L)

미분획 헤파린을 역전시키는 데 쓰는 약은?

1. A날록손
2. B비타민 K(피토메나디온)
3. C프로타민 황산염
4. D플루마제닐

A patient is admitted with suspected meningococcal disease. Which infection control measure is usually needed?

1. ANo precautions, because it is not contagious
2. BIsolation only after the patient has gone home
3. CDroplet precautions until 24 hours of effective antibiotics have been given
4. DAirborne precautions with a negative-pressure room for the whole hospital stay

A patient has just started an ACE inhibitor. Which blood tests are usually checked within the first one to two weeks?

1. ALiver enzymes and amylase
2. BPotassium and creatinine
3. CINR and platelet count
4. DTroponin and creatine kinase

지역사회획득 폐렴이 있는 82세 환자가 새로 혼돈을 보이며 호흡수 32회/분, 혈압 88/52 mmHg, 요소 9 mmol/L입니다. 이는 무엇을 나타냅니까?

1. A고령자의 감염에 대한 정상 반응
2. BCURB-65 점수 3점. 일반 병동 일상 입원만 필요함
3. CCURB-65 점수 5점. 상급자의 긴급 검토가 필요한 고위험
4. DCURB-65 점수 1점. 집에서 경구 항생제가 적합함

Why might a patient bleed more from the needle sites straight after haemodialysis?

1. ADialysis raises the blood pressure sharply for several hours
2. BHeparin is often used to stop the circuit from clotting
3. CDialysis removes all the platelets from the blood
4. DThe fistula has been damaged and must be tied off

A patient with Parkinson's disease becomes agitated and confused at night. Which newly prescribed drug should the nurse question?

1. AParacetamol (acetaminophen)
2. BHaloperidol
3. CLactulose
4. DMelatonin

How should pancreatic enzyme replacement capsules usually be taken?

1. AOnce a day at bedtime
2. BOne hour after meals, on an empty stomach
3. CWith every meal and snack
4. DOnly on days with abdominal pain

An incontinent patient has diffuse, shiny, red and broken skin in the natal cleft and buttocks with irregular edges, not over a bony prominence. What is most likely?

1. AA category 4 pressure ulcer over the sacrum
2. BA full-thickness burn
3. CIncontinence-associated dermatitis
4. DAn arterial ulcer caused by poor circulation