تحديد الأولويات والتفويض بأسلوب NCLEX: حزمة المراجعة المكثفة

After a hip replacement using a posterior approach, which statement shows a need for further teaching?

1. A“I will not bend my hip past 90 degrees.”
2. B“I will keep a pillow between my knees when I lie on my side in bed.”
3. C“I will use a raised toilet seat at home.”
4. D“I will cross my legs when I sit, so I am more comfortable.”

A chemical cleaning fluid splashes into a patient’s eye. What should the nurse do first?

1. ARub the eye gently with a clean tissue to remove the chemical
2. BCover the eye with a dry patch and wait for the provider
3. CFlush the eye with plenty of water or saline straight away
4. DGive antibiotic eye drops first

A colleague has drawn up a medication and asks the nurse to give it to her patient. What should the nurse do?

1. AGive it, as long as the syringe has a label with the drug name on it
2. BGive it, because the colleague is experienced
3. CDecline, and give only medications that the nurse prepared or checked personally
4. DGive it, and document that the colleague prepared it

A patient with depression has suddenly become calm and is giving away personal possessions. What does this suggest?

1. AThat the patient wants to make new friends on the unit
2. BThat the patient is now ready for discharge today
3. CThat the depression has resolved and observation can be reduced
4. DA possibly increased suicide risk that needs immediate assessment

A patient with central diabetes insipidus starts desmopressin. Which laboratory result is most important to monitor for an adverse effect?

1. ASerum potassium, which may rise too high
2. BSerum glucose, which may rise very high
3. CSerum calcium, which may rise too high
4. DSerum sodium, which may fall too low

وصلت أربع نتائج مخبرية. أي منها ينبغي أن تتصرف الممرضة بشأنه أولًا؟

1. Aبوتاسيوم 6,6 mEq/L لدى مريض بمرض كلوي مزمن لديه ضعف عضلي جديد
2. Bصوديوم 137 mEq/L لدى مريض أُدخل أمس بذات الرئة
3. Cغلوكوز 140 mg/dL (7,8 mmol/L) بعد وجبة لدى مريض سكري
4. Dهيموغلوبين 11,8 g/dL (118 g/L) لدى مريض بمرض كلوي مزمن

A pressure ulcer shows full-thickness tissue loss with exposed bone. Which category (stage) is this?

1. ACategory 3
2. BCategory 2
3. CCategory 4
4. DCategory 1

A patient rescued from a house fire has soot around the mouth, singed nasal hairs and a hoarse voice. What is the main concern?

1. AHypothermia from the fire service water
2. BA minor throat infection
3. CDehydration from sweating
4. DAirway swelling from inhalation injury

How is a patient usually positioned for a thoracentesis?

1. ALying on the affected side with the head down
2. BSitting upright and leaning forward over a table
3. CFlat on the back with the legs raised
4. DProne with the arms by the sides

After four days of antibiotics for pneumonia, a patient still has fever and pleuritic pain. There is dullness and reduced breath sounds at the right base. What complication should be suspected?

1. AAn allergic reaction to the antibiotic
2. BAsthma triggered by the infection
3. CA parapneumonic effusion or empyema
4. DNormal recovery from pneumonia

أيّ أثر جانبي ينبغي تثقيف المريض الذي يتناول الفينيتوئين طويل الأمد بشأنه؟

1. Aتساقط الشعر في فروة الرأس لدى كل المرضى تقريبًا
2. Bنقص الوزن وعدم تحمل الحرارة
3. Cفقدان سمع تدريجي دائم
4. Dفرط نمو اللثة، لذا تهم نظافة الفم الجيدة

A patient with SIADH needs IV fluid. Which fluid is most likely to worsen the hyponatraemia?

1. A5% glucose (dextrose, D5W)
2. B3% saline
3. C20% human albumin
4. D8,4% sodium bicarbonate

Which rule about the sterile field is correct?

1. AThe area below a gowned person's waist is sterile
2. BSterile items can be passed across a non-sterile area freely
3. CA sterile pack stays sterile even when it is wet
4. DIf sterility is in doubt, the item is treated as contaminated

A nurse teaches a carer about overnight tube feeding at home. Which statement shows a need for further teaching?

1. A"I'll stop the feed and call if he coughs or struggles to breathe."
2. B"I'll flush the tube with water before and after his medicines."
3. C"I'll let him lie flat so he sleeps better while the feed runs."
4. D"I'll check the external length mark on the tube every day."