Priorità e delega in stile NCLEX: pacchetto last-minute

Dopo la consegna, quale paziente deve vedere per primo l'infermiere?

1. AUn paziente con diabete la cui glicemia prima di colazione è 160 mg/dL (8,9 mmol/L)
2. BUn paziente con asma che usa i muscoli accessori e ha una SpO₂ dell'88%
3. CUn paziente a due giorni da una protesi d'anca con dolore 5/10
4. DUn paziente con polmonite, temperatura 38,2 °C, che ha ricevuto un antipiretico 30 minuti fa

Un paziente riceve nutrizione parenterale attraverso un accesso venoso centrale. Quale reperto richiede un intervento immediato?

1. AUna medicazione asciutta e integra sull'accesso
2. BSudorazione, tremore e glicemia di 62 mg/dL (3,4 mmol/L) dopo che l'infusione si è interrotta inaspettatamente
3. CUn aumento di peso di 0,2 kg da ieri
4. DUna glicemia di 150 mg/dL (8,3 mmol/L) mentre l'infusione è in corso

A patient needs to be moved up in bed and cannot help much. Which approach is safest?

1. AUse a friction-reducing sheet with enough staff, with the bed flat if tolerated
2. BHave one nurse pull the patient up by the arms
3. CAsk the patient to push up with their heels alone
4. DRaise the head of the bed fully and lift the patient up by the shoulders

Un infermiere che assiste un paziente in precauzioni da contatto si accorge che il camice ha uno strappo sulla manica. Che cosa deve fare?

1. AContinuare a lavorare, dato che lo strappo è piccolo e solo sulla manica
2. BAllontanarsi dal paziente, togliere i DPI in sicurezza sulla porta, pulirsi le mani e indossare un nuovo camice
3. CCoprire lo strappo con una striscia di nastro e proseguire
4. DIndossare un secondo camice sopra quello strappato

A patient on carbamazepine becomes confused and has a headache. Which laboratory result would most likely explain this?

1. AA high serum potassium
2. BA high serum calcium
3. CA low serum sodium
4. DA low serum magnesium

The nurse teaches a patient starting lithium. Which statement shows a need for further teaching?

1. A"I will tell my doctor if I have vomiting or diarrhea"
2. B"I will check with the pharmacist before taking ibuprofen"
3. C"I will cut out salt from my diet completely to stay healthy"
4. D"I will drink plenty of fluids, especially in hot weather"

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

1. ARespiratory alkalosis
2. BRespiratory acidosis
3. CMetabolic alkalosis
4. DMetabolic acidosis

A conscious patient with hypoglycaemia was given fast-acting carbohydrate. On re-check 15 minutes later the blood glucose is 3,6 mmol/L (65 mg/dL). What should the nurse do next?

1. AGive another dose of fast-acting carbohydrate and recheck
2. BGive a long-acting carbohydrate snack only and recheck tomorrow
3. CTake no action because the level is rising
4. DGive a dose of subcutaneous insulin

A patient who had a leg amputation says they feel burning pain in the missing foot. What is the best response?

1. AExplain that burning pain in the missing foot shows wound infection
2. BTell the patient the pain must be imaginary as the foot has gone
3. CExplain that phantom limb pain is real and arrange treatment
4. DAdvise that it will be ignored until it stops

A smoker has severe shoulder and arm pain, a drooping eyelid, a small pupil and reduced sweating on the same side of the face. What should be suspected?

1. AA tumour at the apex of the lung (Pancoast tumour)
2. BA stroke affecting the brainstem on the opposite side
3. CA simple migraine
4. DA frozen shoulder with referred pain to the face

Before checking a capillary glucose, why should the patient wash their hands with soap and water?

1. ASugar on the skin can give a falsely high reading
2. BSoap makes the blood flow faster from the finger
3. CWashing prevents all infection from the lancet
4. DWashing lowers the glucose in the blood

A patient in thyroid storm has a temperature of 40 °C (104 °F). Which measure for the fever is usually avoided?

1. ACooling blankets
2. BAspirin
3. CParacetamol (acetaminophen)
4. DFanning with cool air

A patient with a new colostomy asks what to eat at home. Which advice is most appropriate?

1. AAvoid all fruit and vegetables for the rest of their life
2. BDrink as little fluid as possible to reduce output
3. CEat only liquids until the stoma is removed
4. DEat a normal, balanced diet and introduce foods gradually

A patient with active cancer on chemotherapy develops new swelling and pain in one calf. Why must this be reported promptly?

1. AThe swelling shows the cancer has gone
2. BIt is only a muscle strain from walking
3. CCalf swelling is a normal effect of chemotherapy
4. DCancer and its treatment greatly increase clot risk