NCLEX 유형 우선순위 설정과 위임: 벼락치기 팩

LPN/LVN에게 배정하기 가장 적절한 환자는 누구인가요?

1. A적혈구 첫 단위를 수혈받으려는 환자
2. B30분 전 새로운 흉통으로 입원한 환자
3. C경구 약물이 필요한 안정된 만성 심부전 환자
4. D회복실에서 도착하여 초기 사정이 필요한 환자

A nurse returns to the station to find four messages. Which one is answered first?

1. AA family member wants an update on their father’s progress
2. BThe laboratory is calling with a critical potassium result of 2.6 mEq/L
3. CA colleague asks to swap shifts with them next week because of a family wedding
4. DThe pharmacy asks when the next delivery should be scheduled

A patient with delirium is at risk of falls and of pulling out lines. Which option is less restrictive than restraints?

1. AA sedative given every few hours as needed
2. BFour side rails raised and the door closed so the patient stays in bed
3. CA vest restraint applied for the whole night
4. DA trained sitter or video monitoring with staff nearby

According to the “Swiss cheese” model of error, why do errors reach patients?

1. ATechnology fails more often than people do
2. BPatients often do not follow their care instructions
3. CWeaknesses in several layers of defense line up at the same time
4. DOne careless person makes a mistake that no system could stop

A patient takes valproate (valproic acid) for epilepsy. Which tests are monitored regularly?

1. ALiver function tests and platelet count
2. BThyroid function and serum calcium
3. CTroponin and B-type natriuretic peptide
4. DSerum lithium and urine specific gravity

During surgery under general anesthesia, a patient develops a rising end-tidal CO₂, muscle rigidity and tachycardia, then a high potassium and a rising temperature. Which condition is most likely?

1. AHypovolemic shock
2. BAcute hemolytic transfusion reaction
3. CMalignant hyperthermia
4. DHypoglycemia from fasting

갑상샘 수술 후 환자가 입 주위 저림과 근육 경련을 호소합니다. 어떤 전해질 문제를 의심해야 하나요?

1. A고칼륨혈증
2. B고마그네슘혈증
3. C고나트륨혈증
4. D저칼슘혈증

임종을 앞둔 환자가 의식이 없고 목의 분비물 때문에 시끄럽게 그르렁거리는 호흡을 합니다. 적절한 접근은?

1. A체위를 바꾸고, 처방된 분비 억제제를 고려하며, 가족을 지지한다
2. B밤새 10분마다 깊은 구인두 흡인을 시작한다
3. C분비물을 묽게 하고 제거하도록 빠른 정맥 수액을 시작한다
4. D가족에게 환자가 질식하고 있어 인공호흡이 필요하다고 말한다

A patient with a mechanical heart valve asks to switch from warfarin to apixaban. What is the correct response?

1. AAspirin alone can replace warfarin once the valve has healed
2. BAny anticoagulant works equally well once the valve is in place
3. CMechanical valves do not need anticoagulation after the first month
4. DDirect oral anticoagulants are not used for mechanical valves

During CPR on an adult, a nurse notices a colleague compressing at about 140/min and leaning on the chest between compressions. Which correction is most appropriate?

1. AStop compressions until a pulse is felt
2. BSpeed up to about 160/min to improve the blood flow
3. CSlow to 100–120/min and allow full chest recoil
4. DPress more gently, to a depth of about 2 cm

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?

1. A3, abnormal flexion
2. B4, withdraws from pain
3. C5, localises to pain
4. D6, obeys commands

제2형 당뇨병이 있는 고령 환자의 혈당이 48 mmol/L, 삼투압 365 mOsm/kg이고 의미 있는 케톤은 없으며 혼돈이 있습니다. 첫 번째 우선순위는?

1. A치료 중 저혈당을 막기 위한 경구 포도당
2. B삼투압, 나트륨, 혈당을 면밀히 확인하며 신중한 정맥 수액
3. C한 시간 안에 혈당을 정상으로 낮추는 많은 양의 정맥 인슐린 일시 투여
4. D뇌부종을 피하기 위한 엄격한 수분 제한

Why are antimotility drugs such as loperamide avoided in C. difficile infection?

1. AThey cause serious liver failure in most patients who take them
2. BThey make the stool sample test positive falsely
3. CThey kill the normal bowel bacteria
4. DThey may keep toxin in the bowel and risk toxic megacolon

A competent adult who is a Jehovah's Witness refuses blood transfusion before major surgery. What should the nurse do?

1. ARespect the decision, document it and inform the team
2. BCancel the surgery without discussing it
3. CAsk the family to override the decision
4. DPlan to transfuse secretly during the operation if it becomes needed