공식 모음, 모든 주제의 핵심 풀이 단계, 연습 문제 14개가 들어 있으며 전체 풀이는 맨 뒤에 있습니다.
During an IV vancomycin infusion, a patient develops flushing and itching of the face and neck. What should the nurse do first?
A visitor on the ward becomes threatening and shows a knife. What is the nurse’s priority?
새 바늘을 쓰더라도 인슐린 펜을 두 명 이상의 환자에게 사용하면 안 되는 이유는?
In START triage at a mass-casualty incident, a casualty cannot walk, breathes 20 times a minute, has a radial pulse and follows simple commands. Which category applies?
Apart from the lithium level, which tests are monitored regularly in long-term lithium therapy?
A patient in DKA is receiving IV fluids and insulin. The glucose has fallen to about 220 mg/dL (12.2 mmol/L), but the anion gap is still high. What change would the nurse expect?
A patient taking a statin reports unexplained muscle pain and weakness. What should the nurse do?
Why is a patient kept under observation for several hours after successful treatment of anaphylaxis?
장거리 비행 중이나 수술 후에 심부정맥혈전증을 예방하는 데 도움이 되는 조언은?
고혈압이 있는 환자의 혈압이 186/112 mmHg이지만 증상이 없고 장기 손상 징후도 없습니다. 가장 적절한 대응은?
소변량과 관련된 급성 신손상(KDIGO) 기준은?
A patient with a long-term catheter has fever and rigors, and a catheter UTI is suspected. Which action is recommended before starting antibiotics?
Which advice helps a patient with haemorrhoids?
A patient with a severe flare of ulcerative colitis develops abdominal distension, fever and tachycardia, and the stool frequency has dropped. What should the nurse suspect?
답: D · Stop or slow the infusion and inform the provider
Flushing of the upper body during vancomycin is usually an infusion reaction related to the rate. The nurse stops or slows the infusion, assesses for anaphylaxis and informs the provider.
답: A · Move away to safety, keep others away and call security or the police
In a threat involving a weapon, staff keep a safe distance, protect patients where possible and call security or the police. Trying to disarm the person puts staff at serious risk.
답: C · 혈액이 카트리지로 역류하여 감염을 퍼뜨릴 수 있다
혈액과 피부 세포가 카트리지로 되빨려 들어갈 수 있으므로 펜을 공유하면 혈액매개 감염이 전파될 수 있습니다. 각 펜에는 한 환자 전용임을 표시합니다.
답: B · Yellow (delayed)
The casualty cannot walk, so is not green. Breathing is under 30 a minute, perfusion is adequate and they obey commands, so none of the red criteria apply. This makes them yellow, delayed.
답: C · Kidney function and thyroid function
Long-term lithium can cause hypothyroidism and impair kidney function, including nephrogenic diabetes insipidus. Creatinine/eGFR and TSH are therefore checked regularly, together with sodium and the lithium level.확인 출처: Hypothyroidism · MedlinePlus (NIH) (2024)
답: C · Add dextrose to the IV fluids and continue the insulin
The glucose usually falls before the ketoacidosis resolves. Dextrose is added so insulin can continue, clearing ketones without causing hypoglycemia, until the anion gap closes. Stopping insulin too early lets ketoacidosis return.
답: A · Report it, as statins can cause muscle damage
Statins can cause myopathy and, rarely, rhabdomyolysis. Unexplained muscle symptoms should be reported so creatine kinase can be checked and the drug reviewed.
답: D · Symptoms can return later in a biphasic reaction
Some patients have a second wave of symptoms hours after the first, called a biphasic reaction. Observation, an adrenaline auto-injector where indicated and allergy referral are part of safe discharge.
답: C · 규칙적으로 발목 운동을 하고 수분을 충분히 마신다
종아리 근육 활동, 수분 섭취, 그리고 적응이 되면 알맞게 맞춘 압박 스타킹이나 약물 예방은 정맥 울혈과 혈전 형성을 줄입니다. 다리를 꼬거나 꽉 끼는 밴드는 정맥 환류를 방해하고, 탈수는 혈액 점도를 높입니다.
답: C · 다시 측정하고 보고하며 몇 시간에서 며칠에 걸친 경구 치료를 예상한다
급성 장기 손상이 없는 중증 고혈압(때로 고혈압 긴급증이라 함)은 측정값을 확인하고, 통증이나 빠뜨린 투약 같은 원인을 찾고, 몇 시간에서 며칠에 걸쳐 혈압이 내려가도록 경구 치료를 조정하여 관리합니다. 빠르게 낮추면 뇌, 심장, 신장의 허혈 위험이 있지만, 무시하는 것도 안전하지 않습니다.
답: B · 6시간 이상 0.5 mL/kg/h 미만
KDIGO는 AKI를 48시간 내 크레아티닌 ≥26.5 µmol/L(0.3 mg/dL) 상승, 7일 내 기저치의 ≥1.5배로의 상승, 또는 6시간 동안 소변량 0.5 mL/kg/h 미만으로 정의합니다. 따라서 정확한 수분 균형 기록이 필수입니다.
답: C · Replace the catheter and take a sample from the new one
Long-term catheters develop a biofilm that contaminates samples. Guidance usually advises replacing the catheter, collecting a sample from the new one and then starting antibiotics. Bag samples are not used.
답: C · Eat more fibre, drink enough fluid and avoid straining
Soft stools reduce straining and pressure on the anal cushions. Long sitting on the toilet and constipating drugs such as codeine should be avoided.
답: A · Toxic megacolon
Toxic megacolon is dilatation of the inflamed colon with systemic toxicity and a high risk of perforation. Antimotility drugs and opioids are avoided, an abdominal X-ray is done and the surgical team is involved.
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