تحديد الأولويات والتفويض بأسلوب NCLEX: حزمة المراجعة المكثفة

Which patient on an addiction unit should the nurse see first?

1. ALast drink one week ago; asking about support groups
2. BLast drink this morning; asking when lunch will arrive
3. CIn recovery for a year; came to the clinic today for a routine check and a repeat prescription
4. DLast drink two days ago; now shaking, sweating, heart rate 124/min and seeing insects

A patient with a severe asthma attack had a PaCO₂ of 32 mmHg (4,3 kPa) on arrival. An hour later it is 46 mmHg (6,1 kPa), and the patient seems tired. What does this suggest?

1. AThe patient is hyperventilating even more than before and needs calming
2. BThe asthma is improving, because the PaCO₂ is now near normal
3. CRespiratory muscle fatigue with possible impending respiratory failure
4. DA laboratory error that should be ignored

When should the transparent dressing over a peripheral IV site be changed?

1. AOnly when the IV catheter is removed, whatever its state
2. BEvery hour, so the site can be cleaned again
3. CWhen it is damp, loose or visibly soiled
4. DOnly when the patient asks for a new dressing

A competent patient at high risk of falls insists on walking to the bathroom alone. What is the best nursing approach?

1. ATell the patient that walking alone is against hospital law
2. BExplain the risks, agree on ways to reduce them, respect the decision and document
3. CRemove the patient’s shoes and walking aid so that they cannot walk alone
4. DApply wrist restraints so the patient stays in bed

When should a blood specimen tube be labeled?

1. AAt the nurses' station, after all samples for the shift are drawn
2. BBefore entering the room, so tubes are ready for the next patients
3. CAt the bedside, in the patient's presence, using two identifiers
4. DIn the laboratory, by the staff who receive the unlabeled sample

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

1. Aالبوتاسيوم طبيعي بالتأكيد ولا يحتاج إلى متابعة
2. Bقد تكون النتيجة مرتفعة كاذبًا؛ يُقيَّم المريض وتُرتَّب عينة جديدة
3. Cالمعالجة فورًا بالإنسولين والغلوكوز دون مزيد من الفحوص
4. Dالمريض مصاب بفشل كلوي

لماذا يُقاس اللاكتات في المصل لدى مريض يُشتبه بإصابته بالإنتان؟

1. Aلأنه يقيس سكر الدم لدى المريض
2. Bلأنه يحدد المضاد الحيوي الذي يجب إعطاؤه
3. Cلأنه يبيّن ما إذا كان لدى المريض عدوى في المسالك البولية
4. Dلأن ارتفاع اللاكتات يدل على ضعف تروية الأنسجة وعلى خطر أعلى

ممرضة غير متأكدة مما إذا كانت الجرعة الموصوفة من دواء عالي الخطورة صحيحة. ما الإجراء الأكثر أمانًا؟

1. Aحجب الجرعة والتحقق أولًا مع الواصف أو الصيدلي
2. Bسؤال المريض عما إذا كانت الجرعة تبدو كالمعتاد ثم إعطاؤها
3. Cإعطاء نصف الجرعة حلًا وسطًا حتى يتوفر الطبيب
4. Dإعطاء الجرعة لأن الطبيب وقّع الوصفة

After an arterial blood gas sample is taken from the radial artery, what should the nurse do?

1. AMassage the site to help the bruising fade
2. BBend the wrist sharply upwards to stop the bleeding
3. CLeave the site uncovered without pressure
4. DApply firm pressure to the site for several minutes

Ten days after cardiac surgery, a patient has a fever, a red sternal wound with discharge and a clicking feeling in the chest when coughing. What should the nurse suspect?

1. ANormal wound healing with some expected discharge
2. BCostochondritis caused by forceful coughing
3. CSternal wound infection with an unstable sternum
4. DPericarditis from the operation

Why is pyridostigmine often taken about 30–60 minutes before meals by patients with myasthenia gravis?

1. ATo improve the strength of chewing and swallowing at mealtimes
2. BTo reduce stomach acid so the food is digested better
3. CTo stop the drug from irritating an empty stomach later on
4. DTo lower the blood glucose rise after eating a meal

Three days after a stroke, a patient with dysphagia on a modified diet has a temperature of 38,2 °C (100,8 °F), a respiratory rate of 24/min and crackles at the right lung base. What should the nurse do?

1. AGive paracetamol (acetaminophen) and continue the modified diet as before
2. BEncourage more fluids by mouth to treat the fever
3. CSuspect aspiration pneumonia, stop oral intake and escalate for review
4. DRecord the findings and recheck them at the next routine observation

Which measure helps reduce the risk of delirium in an older surgical patient?

1. AKeeping the room dark during the day
2. BGiving a sleeping tablet every night
3. CMaking sure they have their glasses and hearing aids
4. DMoving them to a new bed space each night to reduce boredom

A patient with diabetes has rapidly spreading redness around a small wound, severe pain out of proportion, fever and crackling under the skin. What should the nurse suspect?

1. ANecrotising fasciitis
2. BMild contact dermatitis
3. CA simple insect bite
4. DA healing venous ulcer