تحديد الأولويات والتفويض بأسلوب NCLEX: حزمة المراجعة المكثفة

A patient with a head injury is being monitored. Which set of findings suggests rising intracranial pressure?

1. ALow temperature, fast breathing and a strong appetite
2. BRising systolic pressure, slow pulse and irregular breathing
3. CFalling blood pressure, a fast pulse and warm, flushed dry skin
4. DNormal blood pressure, normal pulse and clear speech

Six hours after surgery, a patient has not passed urine, feels the urge to go and has a firm swelling above the pubic bone. What is the most likely problem?

1. AA normal effect of the anesthetic
2. BAcute kidney injury with no urine made
3. CUrinary retention
4. DDehydration from fasting before surgery

A patient has a non-violent restraint. In most nursing policies, how often at minimum is it released for range of motion, toileting and skin care?

1. AAt least every 2 hours
2. BOnce a day, during the bath
3. COnly when the patient asks for it
4. DOnce every 12-hour shift

لاحظت ممرضة أنها سحبت الدواء الخطأ، لكنها أدركت ذلك قبل إعطائه. ماذا ينبغي أن تفعل؟

1. Aإعطاء الدواء على أي حال لأنه سُحب بالفعل
2. Bعدم قول شيء، لأن المريض لم يتأذَّ
3. Cالإبلاغ فقط إذا تكرر الخطأ نفسه في القسم
4. Dالتخلص منه وتحضير الدواء الصحيح والإبلاغ عن حادث وشيك

A patient's potassium is 7,0 mEq/L. Which ECG change would the nurse expect?

1. ATall, peaked T waves
2. BProminent U waves
3. CDelta waves before the QRS
4. DFlattened T waves

A patient receiving parenteral nutrition with lipid emulsion has a triglyceride level of 620 mg/dL (7,0 mmol/L). Why is this result important?

1. AIt raises the risk of acute pancreatitis
2. BIt shows the nutrition is fully effective
3. CIt is a normal fasting value for adults
4. DIt means the patient needs more lipid

A patient taking a statin reports unexplained muscle pain and weakness. What should the nurse do?

1. ATell them to double the dose
2. BReport it, as statins can cause muscle damage
3. CReassure them that this is a sign the drug is working
4. DAdvise more vigorous exercise to work through it

A nurse teaches a patient with asthma about a new inhaled steroid "preventer". Which statement shows a need for further teaching?

1. A"I will use it every day even when I feel well."
2. B"I will rinse my mouth after using it."
3. C"I'll keep my reliever inhaler with me."
4. D"I will only use it when I'm wheezy."

After an above-knee amputation, which measure helps prevent a hip flexion contracture?

1. ASitting in a chair for most of the day with the hips bent
2. BKeeping a pillow under the stump at all times, day and night
3. CLying prone for periods and avoiding pillows under the stump
4. DKeeping the hip bent to reduce stump swelling

On a ventilated patient, the end-tidal CO₂ waveform suddenly drops to zero. What should the nurse suspect first?

1. ATube displacement, disconnection or obstruction
2. BNormal variation that needs no action
3. CA rise in the patient's body temperature over the last hour
4. DA sudden improvement in the patient's lung function

A patient with Alzheimer's disease starts donepezil. Which side effects should the nurse look for?

1. ADry mouth, constipation and a fast heart rate
2. BNausea, diarrhoea and a slow heart rate
3. CWeight gain, high glucose and swollen ankles
4. DA persistent dry cough and a raised potassium

A patient with Addison's disease has been vomiting for a day. They are confused, with BP 78/40 mmHg, sodium 126 mmol/L and potassium 6,0 mmol/L. What is the priority?

1. AA fluid restriction for the low sodium
2. BIV hydrocortisone straight away, plus IV fluids
3. COral hydrocortisone and an antiemetic by mouth
4. DIV potassium to correct the electrolytes

لماذا يُفضَّل غالبًا التسكين المنتظم (المجدول) على الجرعات «عند الحاجة» في الأيام الأولى بعد الجراحة الكبرى؟

1. Aلأنه يتيح إعطاء جرعات تفوق الحد اليومي الأقصى
2. Bلأنه يبقي مستويات الدواء ثابتة ويمنع ذرى الألم الشديدة
3. Cلأنه يمنع كل الآثار الجانبية للأفيونيات تمامًا
4. Dلأنه يلغي الحاجة إلى تقييم ألم المريض خلال النهار

مريض لديه فغر لفائفي بلا خرج منذ 6 ساعات، مع ألم تقلصي وانتفاخ وغثيان وتورم في الفغر. ماذا ينبغي أن تشتبه الممرضة؟

1. Aفترة هدوء طبيعية لفغر لفائفي جديد
2. Bانسداد في الفغر، غالبًا من الطعام، يحتاج إلى مراجعة
3. Cجفاف من خرج لفائفي غزير جدًا
4. Dطفح جلدي بسيط حول الفغر