Priorità e delega in stile NCLEX: pacchetto last-minute

Which SBAR recommendation is the clearest?

1. A“I just wanted to let you know about him.”
2. B“I would like you to see him within 15 minutes and consider a fluid bolus.”
3. C“I will keep watching him and call again tomorrow.”
4. D“He seems a bit off tonight, so maybe you could come up and do something about it.”

Durante il triage START, un adulto non respira. Le vie aeree vengono riposizionate e la vittima continua a non respirare. Qual è la categoria corretta?

1. ANero (deceduto o atteso)
2. BGiallo, e tornare più tardi
3. CRosso, e iniziare subito la RCP
4. DRosso, perché l'assenza di respiro è il reperto più urgente

How should a newborn be moved through hospital corridors?

1. AIn the arms of any visitor who offers to help
2. BIn a bassinet, not carried in the arms
3. CCarried in the nurse’s arms for comfort
4. DOn the mother’s lap in a wheelchair, without staff

A patient dies after a wrong-drug error, and the hospital carries out a root cause analysis. What is its main focus?

1. AEstimating the legal costs for the hospital
2. BFinding the system and process weaknesses that allowed the error
3. CDeciding whether to tell the family about the error
4. DIdentifying which staff member made the error and should be disciplined

When blood is drawn from a central venous catheter, why is a small volume of blood usually discarded first, according to policy?

1. ATo check that the catheter tip is still in the right vein
2. BTo lower the patient's hemoglobin for a blood transfusion
3. CTo remove blood clots that form in all central lines
4. DTo avoid diluting the sample with flush or infusion fluid

Un paziente in infusione di eparina ha una conta piastrinica che scende da 260 a 110 × 10³/µL al giorno 7. Quale azione è più appropriata?

1. ASomministrare una trasfusione di piastrine e continuare l'eparina
2. BContinuare l'infusione e aumentare la velocità secondo protocollo
3. CNon fare nulla, perché la conta è ancora appena sopra 100 × 10³/µL
4. DSegnalarlo subito: è possibile una trombocitopenia indotta da eparina

Which lifestyle advice helps a patient with gastro-oesophageal reflux disease?

1. AAvoid large meals late in the evening and raise the head of the bed
2. BLie down straight after each meal to let the food settle
3. CWear tight belts to support the stomach
4. DEat one very large meal a day rather than several small ones

Which finding suggests hypocalcaemia?

1. AA slow, irregular pulse with nausea and yellow-tinged vision
2. BSpasm of the hand when a blood pressure cuff is inflated on the arm
3. CA flapping tremor of the outstretched hands
4. DSevere thirst with a large urine output and constipation

Why is a raised serum lactate concerning in a patient with shock?

1. AIt means the kidneys are working harder than normal to clear fluid
2. BIt shows only that the patient has eaten a large meal in the past hour
3. CIt suggests tissues are short of oxygen and using anaerobic metabolism
4. DIt confirms a bacterial infection is present

During CPR on an adult, a nurse notices a colleague compressing at about 140/min and leaning on the chest between compressions. Which correction is most appropriate?

1. ASlow to 100–120/min and allow full chest recoil
2. BPress more gently, to a depth of about 2 cm
3. CStop compressions until a pulse is felt
4. DSpeed up to about 160/min to improve the blood flow

A stroke patient speaks fluently, but the words make little sense, and they do not follow simple instructions. Which type of aphasia is this?

1. AExpressive (Broca's) aphasia
2. BGlobal aphasia with no speech at all
3. CReceptive (Wernicke's) aphasia
4. DDysarthria from facial weakness

A patient with type 1 diabetes has a seizure on the ward. Their capillary glucose is 1,9 mmol/L (34 mg/dL). They cannot swallow. What is the most appropriate treatment?

1. AAn antiepileptic drug only, because seizures need seizure treatment
2. BGlucose gel squeezed into the mouth during the seizure
3. CA rapid-acting insulin dose to stabilise the glucose
4. DIV glucose or IM glucagon, then recheck the glucose

Why is the time a surgical limb tourniquet is inflated carefully recorded?

1. AThe tourniquet slowly loses all its air after one minute
2. BLong inflation can cause nerve and muscle damage
3. CIt shows how long the anaesthetic gas was used
4. DThe surgeon is paid per minute of use

A patient with diabetes has a foot ulcer. A sterile probe touches bone at the base of the ulcer. What should the nurse suspect?

1. AOsteomyelitis
2. BSimple dry skin
3. CVenous insufficiency
4. DA healing category 1 ulcer