تحديد الأولويات والتفويض بأسلوب NCLEX: حزمة المراجعة المكثفة

A patient has a serum potassium of 2,9 mEq/L. Which finding should the nurse expect?

1. AFlushed, warm skin and a slow heart rate
2. BMuscle weakness and U waves on the ECG
3. CTall, peaked T waves and muscle twitching
4. DA rise in urine output and thirst only

A dehydrated child is to receive IV fluids with added potassium. Which finding should the nurse confirm first?

1. AThat the child is passing urine
2. BThat the child’s temperature is normal
3. CThat the child is hungry
4. DThat the child can walk without help

Where should the dispersive (grounding) pad for electrosurgery be placed?

1. AOver an area with scar tissue or a tattoo, so that the pad does not slip
2. BOver a bony prominence such as the hip bone
3. COn clean, dry skin over a well-perfused muscle, close to the surgical site
4. DOn skin that is wet with antiseptic prep

A nurse has a needlestick from a patient with hepatitis B. The nurse finished the vaccine series and has a documented protective antibody level. Which statement is correct?

1. ANo reporting is needed because the nurse is immune
2. BNo hepatitis B treatment is needed, but the injury is still reported and followed up
3. CThe nurse must stop all patient care for six months
4. DHepatitis B immune globulin and a complete new vaccine series are both needed at once

يجري تسريب سوائل وريدية في الساعد الأيسر لمريض. من أين ينبغي أن تأخذ الممرضة عينة الدم؟

1. Aمن فوق موضع التسريب مباشرة في الذراع نفسها
2. Bمن أي وريد، لأن السائل لا يؤثر في النتائج
3. Cمن الذراع المقابلة
4. Dمن القنية الوريدية أثناء جريان السائل

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. AGradual replacement of free water over many hours
2. BRapid infusion of 3% saline to raise the volume
3. CA loop diuretic to remove the extra sodium quickly
4. DStrict fluid restriction to below 800 mL a day

What happens in third-degree (complete) heart block?

1. ANo impulses from the atria reach the ventricles, so they beat independently
2. BEvery impulse reaches the ventricles, but each one is slightly delayed
3. CThe ventricles beat very fast and regularly
4. DThe atria beat chaotically with no P waves, and the ventricular rate is irregular

During a general anaesthetic, a patient develops a rapidly rising temperature, muscle rigidity and rising carbon dioxide levels. What should be suspected?

1. AA normal response to surgery
2. BMalignant hyperthermia
3. CNeuroleptic malignant syndrome from antipsychotics
4. DPostoperative infection

During airway suctioning, when should suction be applied?

1. AOnly while inserting the catheter
2. BContinuously for at least 30 seconds
3. COnly while withdrawing the catheter
4. DBefore the catheter enters the airway

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

1. A"I will check before taking any new medicines or herbal remedies."
2. B"I will have regular INR blood tests."
3. C"If I miss a dose, I will take two the next day."
4. D"I will tell my dentist that I take warfarin."

Which picture fits Brown-Séquard syndrome?

1. AWeakness of both arms with normal strength in the legs
2. BWeakness on the same side and loss of pain on the opposite side
3. CParalysis of both legs, with normal sensation everywhere in the body
4. DLoss of all feeling but normal movement on both sides

A large pituitary tumour presses on the optic chiasm. Which visual field defect is most typical?

1. ALoss of the outer half of the field in both eyes
2. BComplete blindness in one eye only
3. CLoss of central vision in both eyes
4. DLoss of the inner half of the field in both eyes

أيّ إجراءات تساعد على منع متلازمة انحلال الورم لدى المرضى عاليي الخطورة؟

1. Aمكملات الكالسيوم والفوسفات يوميًا
2. Bإيقاف كل السوائل الوريدية والفموية أثناء العلاج الكيميائي
3. Cتقييد السوائل مع أقراص البوتاسيوم
4. Dترطيب وريدي مع الألوبيورينول أو الراسبوريكاز

Which preoperative blood result should the nurse report to the team before elective surgery?

1. AHaemoglobin 138 g/L (13,8 g/dL) in a man
2. BPotassium 2,9 mmol/L
3. CSodium 139 mmol/L
4. DFasting glucose 5,4 mmol/L (97 mg/dL)