NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

Several patients on a gastroenterology unit need care. Which patient should the nurse see first?

1. AUlcerative colitis, asking about diet changes for home
2. BCrohn disease, waiting to be taken down for a scheduled CT scan
3. CLong-standing back pain, asking for the usual analgesic
4. DTwo hours after a colonoscopy: rigid abdomen and severe new pain

At the end of a shift, the nurse’s relief has not arrived and the patients are acutely ill. What should the nurse do?

1. AStay and tell the charge nurse, and hand over before leaving
2. BAsk a nursing assistant to watch the patients until someone comes
3. CLeave a written note at the station and go home
4. DLeave on time, because the shift has officially ended

A child has swallowed a button battery. Why is this urgent?

1. AIt always passes through the gut without harm
2. BIt is only harmful if several batteries are swallowed
3. CIt can burn through the lining of the esophagus within hours
4. DThe only risk is poisoning from heavy metals years later

A flexible bronchoscope contacts mucous membranes but does not enter sterile tissue. Which level of processing is required at a minimum between patients?

1. AHigh-level disinfection
2. BLow-level disinfection
3. CCleaning with soap and water only
4. DWiping with an alcohol wipe

패혈증이 의심되는 환자의 혈액 배양은 언제 채취해야 하나요?

1. A항생제는 결과에 영향을 주지 않으므로 아무 때나
2. B항생제를 세 번 투여한 뒤
3. C열이 3일 넘게 지속될 때만
4. D첫 항생제 투여 전에, 투여를 크게 지연시키지 않으면서

A patient with acute kidney injury after severe dehydration has a rising creatinine. Which urine findings support a prerenal cause rather than acute tubular necrosis (ATN)?

1. ALow urine sodium and concentrated urine with a high specific gravity
2. BHigh urine sodium and dilute urine with muddy brown granular casts
3. CWhite cell casts with positive nitrites on the dipstick
4. DRed cell casts with heavy protein loss in the urine

For a patient in skin traction on the leg, which is correct?

1. AThe rope is tied to the bed frame to keep it still
2. BThe weights are removed whenever the patient feels uncomfortable
3. CThe weights rest on the floor overnight
4. DThe weights hang freely and do not rest on the bed or floor

A nurse teaches a patient with asthma about a new inhaled steroid "preventer". Which statement shows a need for further teaching?

1. A"I'll keep my reliever inhaler with me."
2. B"I will only use it when I'm wheezy."
3. C"I will rinse my mouth after using it."
4. D"I will use it every day even when I feel well."

A patient with a long QT interval develops a polymorphic ventricular tachycardia that twists around the baseline but still has a pulse. Which drug is used first?

1. AIntravenous adenosine
2. BIntravenous potassium chloride as a bolus
3. CIntravenous magnesium sulfate
4. DOral digoxin

A patient is going home after a spontaneous pneumothorax treated with a chest drain. Which advice is correct?

1. AStop smoking and do not fly until a doctor confirms full resolution
2. BTake up scuba diving to strengthen the lungs
3. CFly home as soon as possible so they can recover in comfort there
4. DExpect it never to happen again, so no follow-up is needed

When a patient sticks out their tongue, it points to the right. Which nerve is affected?

1. AThe left hypoglossal nerve (XII)
2. BThe left trigeminal nerve (V)
3. CThe right hypoglossal nerve (XII)
4. DThe right facial nerve (VII)

The nurse has four patients with diabetes. Which one needs to be seen first?

1. AA patient waiting for a routine HbA1c test
2. BA patient with a glucose of 14 mmol/L (252 mg/dL) who feels well and is eating
3. CA newly diagnosed patient asking about which foods to eat
4. DA patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused

Which finding means a patient is usually ready to leave recovery for the ward?

1. AAwake, with a clear airway, stable observations and controlled pain
2. BSystolic BP falling steadily over the last hour, with a rising pulse rate
3. CPain score 9/10 and vomiting repeatedly
4. DStill drowsy and needing a jaw thrust to breathe

After a fall, a patient with advanced dementia is agitated, grimacing and guarding the hip, and cannot rate the pain. What should the nurse do?

1. AWait until a relative can confirm the pain
2. BUse an observational pain tool, give analgesia and reassess
3. CAssume there is no pain because none is reported
4. DGive a sedative to treat the agitation and avoid giving any analgesia