تحديد الأولويات والتفويض بأسلوب NCLEX: حزمة المراجعة المكثفة

Which infant with gastroenteritis should the nurse see first?

1. AAlert, crying with tears, had a wet diaper an hour ago
2. BTwo loose stools today, feeding well
3. CMild diaper rash, otherwise playful
4. DLethargic, sunken fontanel, no wet diaper for 8 hours

Weeks after a kidney transplant, a patient has a fever, less urine and tenderness over the new kidney. What should the nurse suspect?

1. AA side effect of eating salty food
2. BDehydration from drinking too much
3. CNormal healing of the transplant
4. DRejection of the transplant

An infant has had a cleft lip repair. Why are elbow restraints often used?

1. ATo hold the IV line in place during feeds and stop it being pulled out
2. BTo prevent the infant from sucking a pacifier
3. CTo stop the infant’s hands reaching the mouth while still allowing arm movement
4. DTo keep the infant from rolling over in the crib

A nurse teaches an older adult about preventing falls at home. Which statement shows a need for further teaching?

1. A“I keep small rugs in the hall so my feet stay warm.”
2. B“I had grab bars put in next to the toilet.”
3. C“I use night lights between my bedroom and the bathroom.”
4. D“I wear shoes with non-slip soles around the house.”

An older adult takes lisinopril and furosemide and recently started daily ibuprofen for knee pain. The creatinine has risen from 1,0 to 1,8 mg/dL (88 to 159 µmol/L). What is the most likely cause?

1. ANormal aging of the kidneys over a period of a few weeks
2. BThe NSAID reduces kidney blood flow on top of the other two drugs
3. CA laboratory error, since ibuprofen has no effect on the kidney
4. DMore activity has increased the patient's muscle mass quickly

مريض بلا مشاكل كلوية وتخطيط قلب طبيعي، بوتاسيومه 6,2 mEq/L. يعلّق المختبر بأن العينة منحلّة (hemolyzed). ما أفضل تفسير؟

1. Aالمريض مصاب بفشل كلوي
2. Bالبوتاسيوم طبيعي بالتأكيد ولا يحتاج إلى متابعة
3. Cقد تكون النتيجة مرتفعة كاذبًا؛ يُقيَّم المريض وتُرتَّب عينة جديدة
4. Dالمعالجة فورًا بالإنسولين والغلوكوز دون مزيد من الفحوص

A rising serum creatinine most often indicates:

1. ADehydration of the skin only
2. BReduced kidney function
3. CImproved liver function
4. DIncreased muscle strength

يُدخَل مريض لديه حرق يشمل 30% من مساحة سطح الجسم. أي مضاعفة مبكرة هي الأكثر إثارة للقلق في أول 24 ساعة؟

1. Aالتندب والتقفعات
2. Bالإمساك
3. Cصدمة نقص الحجم بسبب فقد السوائل
4. Dقرح الضغط الناتجة عن طول عدم الحركة

يستخدم مريض مصاب بالربو منشق الإسعاف أكثر من ثلاث مرات في الأسبوع. ماذا يوحي ذلك؟

1. Aلم يعد منشق الإسعاف فعالًا ويجب إيقافه
2. Bالسيطرة على الربو ضعيفة ويحتاج العلاج إلى مراجعة
3. Cلم تعد هناك حاجة إلى المنشق الوقائي
4. Dالربو مسيطر عليه جيدًا بالخطة الحالية

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

Which nursing care is most important for a patient with diabetes insipidus?

1. AStrict fluid balance, daily weight and free access to water
2. BA strict fluid restriction to reduce the amount of urine passed
3. CWeighing the patient once a month
4. DGiving a loop diuretic to clear extra fluid

A kidney transplant recipient has had vomiting and diarrhoea for two days. Why should the transplant team be contacted?

1. AThe tablets will make the vomiting stop
2. BThe patient may not be absorbing their immunosuppressants
3. CThe kidney will start to produce far too much urine
4. DVomiting proves that rejection has already happened

Which wound drain observation should be reported immediately?

1. ADrainage slowly falling each day
2. BA little dried blood around the drain site
3. CA sudden large volume of fresh red blood
4. DSmall amounts of pink serous fluid

A nurse teaches a patient after a laparoscopic fundoplication for reflux. Which statement shows a need for further teaching?

1. A"I should eat smaller meals for a while after the operation."
2. B"Some difficulty swallowing can happen in the early weeks."
3. C"I'll eat soft, moist food at first and chew it well."
4. D"Fizzy drinks will help me bring up wind after meals."