تحديد الأولويات والتفويض بأسلوب NCLEX: حزمة المراجعة المكثفة

A nurse teaches foot care to a patient with diabetes. Which statement shows a need for further teaching?

1. A“I will dry well between my toes after washing.”
2. B“I will wear shoes that fit well, even at home.”
3. C“I will check the soles of my feet every day with a mirror.”
4. D“I will soak my feet in hot water every evening.”

A patient has a new spinal cord injury at C4. Which assessment is the priority?

1. ABreathing effort and ability to cough
2. BAbility to feed themselves
3. CBowel sounds in all four abdominal quadrants
4. DSkin over the sacrum and heels

Before helping a patient from bed into a wheelchair, what should the nurse do with the wheelchair?

1. APlace it on the patient’s weaker side so that side is supported
2. BLock the brakes and place it close to the bed on the patient’s stronger side
3. CLeave the brakes off so the chair can move along with the patient during the pivot
4. DPlace it at the foot of the bed, facing away

Minutes after the first IV dose of an antibiotic starts, the patient develops wheezing, hives and low blood pressure. What should the nurse do first?

1. ARecord the new allergy in the chart
2. BSlow the infusion rate
3. CGive an oral antihistamine
4. DStop the infusion

A patient taking a statin reports new, unexplained muscle pain and weakness. Which laboratory test would the nurse expect to be ordered?

1. ACreatine kinase (CK)
2. BCardiac troponin
3. CSerum ammonia
4. DSerum lipase

A frail older adult in a nursing home has been drinking very little during a heat wave. She is confused, and her sodium is 158 mEq/L. Which treatment would the nurse expect?

1. AA loop diuretic to remove the extra sodium quickly
2. BStrict fluid restriction to below 800 mL a day
3. CGradual replacement of free water over many hours
4. DRapid infusion of 3% saline to raise the volume

A patient with DKA has an arterial blood gas showing a low pH and a low bicarbonate. Which disturbance is this?

1. AMetabolic alkalosis
2. BRespiratory acidosis
3. CRespiratory alkalosis
4. DMetabolic acidosis

A nurse is teaching a patient who is starting warfarin. Which statement shows a need for further teaching?

1. A"I will report black stools or unusual bruising."
2. B"I will keep my INR blood test appointments."
3. C"I will tell my dentist that I take warfarin."
4. D"I can take aspirin if I get a headache."

Why should a long-acting beta-2 agonist (LABA) never be used alone in asthma?

1. AIt works only when it is taken together with a course of antibiotics
2. BIt always causes immediate severe bronchospasm when used on its own
3. CIt cannot be inhaled without a nebuliser
4. DWithout an inhaled steroid, it is linked with severe and fatal attacks

A nurse phones the doctor about a patient with pneumonia whose observations are worsening. Using SBAR, which statement is the clearest "recommendation"?

1. A"I am calling about the patient in bed 6."
2. B"He is 72 and was admitted yesterday with community-acquired pneumonia."
3. C"I think he may have sepsis; please review him within 30 minutes."
4. D"His heart rate is 124/min, his BP is 88/50 mmHg and he is confused."

بعد حلّ الخثرة الوريدي للسكتة، أيّ المراقبات هي الأهم في أول 24 ساعة؟

1. Aالوزن اليومي وميزان السوائل فقط
2. Bذروة التدفق وتشبع الأكسجين كل ساعة
3. Cفحوص عصبية متكررة وضغط الدم
4. Dأصوات الأمعاء ومحيط البطن كل ساعة

بعد يومين من إصابة الحبل الشوكي عند C5، يصبح المريض قلقًا ومعدل تنفسه 30/min وسعته الحيوية في انخفاض. ماذا ينبغي أن تفعل الممرضة؟

1. Aإعادة فحص السعة الحيوية بعد نحو 12 ساعة
2. Bالتصعيد العاجل: فقد تسبب وذمة الحبل فشلًا تنفسيًا
3. Cإضجاع المريض مع إمالة الرأس للخلف لفتح المجرى الهوائي
4. Dإعطاء مهدئ لإبطاء التنفس وتخفيف القلق

For which stoma can colostomy irrigation be considered?

1. AAn established descending or sigmoid colostomy
2. BAn ileal conduit draining urine
3. CA new ileostomy in the first week
4. DAny stoma that has liquid or very loose output

An immobile patient on opioids drinks very little. Which laxative choice is least appropriate?

1. AA stool softener with a stimulant laxative
2. BA stimulant laxative taken regularly
3. CA bulk-forming laxative used on its own
4. DAn osmotic laxative such as a macrogol