تحديد الأولويات والتفويض بأسلوب NCLEX: حزمة المراجعة المكثفة

بالغ مستقر لديه ألم بطني وعلامات حيوية طبيعية. سيحتاج إلى فحوص دم وتصوير مقطعي محوسب. أي مستوى ESI يناسب؟

1. Aالمستوى 5
2. Bالمستوى 3
3. Cالمستوى 4
4. Dالمستوى 1

A severely malnourished patient started nutrition two days ago and now has weakness and confusion. Which laboratory result should the nurse check first?

1. AThyroid hormone
2. BSerum amylase
3. CSerum cholesterol
4. DSerum phosphate

A family member will visit a patient on contact precautions. What should the nurse do?

1. ATell them visits are not allowed at all
2. BAsk them to wear an N95 respirator only, with no gown or gloves
3. CShow them how to use the gown and gloves and how to clean their hands
4. DTell them precautions only apply to staff

An audit shows poor hand hygiene compliance on a ward. Which plan is most likely to improve it?

1. AA combined approach with education, hand rub at every bedside, regular audits and feedback
2. BDisciplining staff who are seen not cleaning their hands, with no other change
3. CRemoving all sinks so staff must use hand rub
4. DA single poster about hand hygiene placed in the staff room

Which finding during a transfusion suggests transfusion-associated circulatory overload (TACO)?

1. ACrackles, hypertension and a raised BNP
2. BA low temperature and slow heart rate
3. CHives and itching without other signs
4. DBack pain with dark red urine output

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. AHypoglycemia from fasting
2. BHypovolemic shock
3. CAcute hemolytic transfusion reaction
4. DMalignant hyperthermia

A patient with leukaemia has a very low platelet count. Which nursing precaution is appropriate?

1. AUse a soft toothbrush and an electric razor
2. BTake temperatures rectally
3. CEncourage contact sports to keep fit
4. DGive medicines by intramuscular injection

A patient with known cirrhosis suddenly vomits large amounts of bright red blood and becomes tachycardic. What is the most likely cause?

1. AA Mallory-Weiss tear from a small amount of vomiting
2. BBleeding from ruptured oesophageal varices
3. CA lower GI bleed from diverticular disease
4. DSwallowed blood from a nosebleed

After an above-knee amputation, which measure helps prevent a hip flexion contracture?

1. ALying prone for periods and avoiding pillows under the stump
2. BKeeping a pillow under the stump at all times, day and night
3. CKeeping the hip bent to reduce stump swelling
4. DSitting in a chair for most of the day with the hips bent

An 84-year-old with heart failure becomes breathless with new crackles and a rising blood pressure during a blood transfusion. What should the nurse suspect?

1. AAn acute haemolytic reaction from wrong blood
2. BTransfusion-associated circulatory overload
3. CA mild febrile reaction
4. DNormal effects of the transfusion

A patient is due a rapid-acting insulin dose before lunch, but the meal trays are delayed. What should the nurse do?

1. AGive the insulin with a glass of water instead
2. BGive the insulin now and the meal when it comes
3. CWait to give the insulin until the meal arrives
4. DOmit the dose entirely for the rest of the day

مريض يتلقى تغذية معوية مستمرة ليلًا ويحصل على إنسولين متزامن مع التغذية. عند الساعة 02:00 ينسد الأنبوب وتتوقف التغذية. ما الخطر الرئيسي، وماذا ينبغي أن تفعل الممرضة؟

1. Aنقص سكر الدم؛ تفحص الغلوكوز كثيرًا وتتبع خطة التغطية بالغلوكوز
2. Bالحماض الكيتوني؛ توقف كل الإنسولين حتى الصباح
3. Cلا خطر؛ سيُخزَّن الإنسولين ببساطة إلى أن تُستأنف التغذية
4. Dفرط سكر الدم؛ تعطي جرعة إنسولين إضافية فورًا

Why is a gastrostomy tube with an internal bumper usually advanced and rotated regularly once the tract has healed?

1. ATo make the tube longer as the patient grows or gains weight
2. BTo check that the patient is still hungry
3. CTo stop the inner bumper becoming buried in the stomach wall
4. DTo remove any feed left in the stomach

مريضة مصابة بسرطان الثدي تصاب بتشوش وعطش وإمساك مع بوال. أيّ طارئة ورمية ينبغي النظر فيها؟

1. Aمتلازمة انحلال الورم
2. Bفرط كالسيوم الدم الناجم عن الورم الخبيث
3. Cنقص سكر الدم
4. Dانسداد الوريد الأجوف العلوي