NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

A patient’s chest tube becomes disconnected from the drainage system. What should the nurse do first?

1. ARemove the tube and cover the site
2. BWait for the provider to arrive before doing anything else
3. CPlace the end of the tube in a bottle of sterile water
4. DClamp the tube for the rest of the shift

A day after a femur fracture, a young patient becomes confused and breathless, with small red spots on the chest. What should the nurse suspect?

1. ANormal pain after a fracture
2. BAn allergic reaction to the cast
3. CFat embolism syndrome
4. DAlcohol withdrawal

A colleague has drawn up a medication and asks the nurse to give it to her patient. What should the nurse do?

1. AGive it, and document that the colleague prepared it
2. BGive it, as long as the syringe has a label with the drug name on it
3. CDecline, and give only medications that the nurse prepared or checked personally
4. DGive it, because the colleague is experienced

한 병동이 병동 상비약 장에 농축 염화칼륨 바이알을 보관하고 있습니다. 많은 안전 지침이 이를 권하지 않는 이유는?

1. A염화칼륨은 항상 경구로만 투여해야 한다
2. B희석하지 않은 농축액이 실수로 투여되면 심장이 멈출 수 있다
3. C염화칼륨은 너무 비싸서 병동 상비약으로 둘 수 없다
4. D염화칼륨 바이알은 개봉 후 하루 안에 유효기간이 지난다

A patient with hepatic encephalopathy is receiving lactulose. Which finding best shows that the treatment is effective?

1. ANo bowel movement for 2 days and calm sleep
2. BA rising serum ammonia with a slower flapping tremor
3. CTwo to three soft stools a day and clearer thinking
4. DSix to eight watery stools a day with dizziness

A patient recovering from acute tubular necrosis now passes 4–5 L of urine a day. Which electrolyte changes should the nurse watch for?

1. ANo changes, because the kidneys are now normal
2. BHigh calcium and high phosphate from bone loss
3. CHigh potassium and high sodium from retention
4. DLow potassium and low sodium from urine losses

베타차단제를 투여하기 전에 확인해야 할 가장 중요한 관찰 항목은?

1. A배변
2. B체온만
3. C심박수와 혈압
4. D혈당만

Which patient should the nurse assess first?

1. AA patient with asthma who can only speak in single words
2. BA patient with diabetes whose glucose is 11 mmol/L (198 mg/dL) before lunch
3. CA postoperative patient who rates their pain as 6/10
4. DA patient with COPD whose SpO₂ is 89% and within their target range

A patient is starting doxazosin, an alpha-blocker, for hypertension. Which advice is most important?

1. ATake it with a large glass of grapefruit juice to improve absorption
2. BStop it suddenly if the heart rate rises after the first few doses
3. CAvoid all potassium-containing foods
4. DTake the first dose at bedtime, as dizziness and fainting can occur

다비가트란을 복용 중인 환자에게 심한 위장관 출혈이 생겼습니다. 사용할 수 있는 특이적 역전제는?

1. A프로타민 황산염
2. B트라넥삼산 단독
3. C이다루시주맙
4. D피토메나디온(비타민 K)

A patient with diabetic neuropathy has an ulcer on the ball of the foot. Which measure is most important for healing?

1. ASoaking the foot in hot water daily
2. BWalking more to improve blood flow
3. CCovering it and checking it in a month
4. DTaking pressure off the ulcer

발프로산을 복용하는 간질 여성이 임신을 계획하고 있다고 말합니다. 가장 적절한 대응은?

1. A태아를 경련으로부터 보호하도록 용량을 두 배로 하라고 제안한다
2. B발프로산은 임신 전 기간 동안 안전하다고 안심시킨다
3. C갑자기 중단하지 말도록 조언하고 긴급 전문의 진료를 받게 한다
4. D오늘부터 발프로산을 완전히 끊으라고 말한다

Which group of findings suggests obstruction of the bile duct?

1. ARed urine, black stools and a high blood glucose
2. BPale urine, dark stools and a flapping tremor
3. CNormal skin colour with diarrhoea and fever
4. DJaundice, dark urine, pale stools and itching

A patient with diabetes has a foot ulcer. A sterile probe touches bone at the base of the ulcer. What should the nurse suspect?

1. AOsteomyelitis
2. BVenous insufficiency
3. CSimple dry skin
4. DA healing category 1 ulcer