NCLEX-RN 이것만이라도 보고 가자! : Emergency / Critical Care │ Nurse Haley

🚨 Emergency / Critical Care by Nurse Haley

안녕하세요! 오늘의 간호사 Haley 입니다 👩‍⚕️ 이 글은 시험 전날/당일에 빠르게 훑어보는 응급·중환자 핵심 포인트만 모았습니다. NCLEX-RN 시험 1,2일 전에 숙지하고 가시면 좋아요!

Type	Typical Findings	First Nursing Actions
Hypovolemic	Bleeding/dehydration; ↑HR, ↓BP, cool clammy, oliguria	• 2 large-bore IV, rapid isotonic fluids (NS/LR) • Control bleeding, monitor mental status & urine
Cardiogenic	MI/HF; pulmonary edema, crackles, ↑JVP	• O₂, cautious fluids, inotropes (as ordered), diuretics • High-Fowler, ECG monitoring
Septic	Warm skin → later cool; fever, hypotension, lactate↑	• Cultures → broad ABX, 30 mL/kg crystalloid • Vasopressor if MAP<65 after fluids
Anaphylactic	Urticaria, wheeze, stridor, hypotension	• IM Epinephrine first! O₂, airway 준비 • Antihistamine, steroid, neb bronchodilator
Neurogenic	Spinal injury; hypotension with bradycardia, warm dry skin	• Airway & spinal immobilization, fluids • Vasopressor as ordered; atropine for severe bradycardia

⚠️ NCLEX 핵심포인트:
- Shock 공통: Airway → O₂ → IV access → Fluids → Monitor
- MAP < 65 = 저관류. 소변 < 0.5 mL/kg/hr 주의.

Time	Bundle Elements	Nursing Notes
Within 1 hour	Measure lactate; draw cultures; broad ABX; 30 mL/kg crystalloid for hypotension or lactate ≥4	• Culture 먼저, ABX는 즉시 시작 • 재평가 & lactate 재측정
Persistent hypotension	Start vasopressors to maintain MAP ≥65 (NE 1st-line)	• Arterial line 모니터링 고려 • UO, mentation, skin perfusion 추적

💡 Exam Tip: “restless + tachycardia + hypotension” → 초기 쇼크 사인. Culture는 항생제보다 먼저 채취!

Topic	Key Points	Nursing Focus
Adult CPR	Rate 100–120/min; depth 2 in (5 cm); 30:2; minimize pause	• High-quality compressions 우선 • O₂ & monitor 준비, IV/IO access
Shockable rhythms	VF / pulseless VT → Defibrillation 즉시	• Defib → CPR → rhythm check 반복 • Epi q3–5min, Amiodarone 고려
Unstable tachy with pulse	SVT/Afib with RVR, VT with pulse → Synchronized cardioversion	• 동기화 버튼 확인(SYNC) • 진정/진통 준비
Asystole/PEA	Defib 대상 아님; CPR + Epinephrine	• Hs & Ts 원인 교정(저혈량, 저산소, K⁺, 혈전 등)

⚠️ NCLEX 핵심포인트:
- VF/pVT = Defib, Unstable tachy = Synchronized cardioversion
- Asystole/PEA = Defib 금지, CPR + Epi

Condition	Key Findings	Nursing Actions
Airway compromise	Stridor, use of accessory muscles, silent chest	• Call for help, O₂, prepare advanced airway • Position: head tilt-chin lift (no trauma), jaw thrust (trauma)
ARDS	Refractory hypoxemia, bilateral infiltrates	• Low tidal volume, high PEEP(주로 의료진 지시) • Prone positioning 보조, skin & pressure care
Vent safety	High pressure alarm = kink/secretions, Low = disconnection	• Suction/비결찰 확인, 회로 연결 상태 즉시 점검

💡 Exam Tip: “silent chest”는 더 위험! 즉시 평가·개입.

Pattern	ABG	Examples
Respiratory Acidosis	pH↓, PaCO₂↑, HCO₃⁻ N/↑	Hypoventilation, COPD exacerbation
Respiratory Alkalosis	pH↑, PaCO₂↓	Hyperventilation, anxiety, pain
Metabolic Acidosis	pH↓, HCO₃⁻↓	DKA, diarrhea, lactic acidosis
Metabolic Alkalosis	pH↑, HCO₃⁻↑	Vomiting, NG suction, diuretics

⚠️ NCLEX 핵심포인트:
- DKA → metabolic acidosis, compensatory Kussmaul
- Ventilator 문제 시: 먼저 환자(airway/호흡)부터 평가!

정리: 오늘의 간호사 Haley

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