Priorità e delega in stile NCLEX: pacchetto last-minute

A patient’s urinary catheter has drained no urine for two hours, and the lower abdomen is swollen. What should the nurse do first?

1. ACheck the tubing for kinks or obstruction
2. BRemove the catheter and wait for the patient to void
3. CGive a prescribed diuretic straight away
4. DEncourage the patient to drink more water

Which patient finding after a total knee replacement needs the nurse’s action first?

1. APain of 4/10 when the physiotherapist bends the knee during the morning session
2. BAsks for an ice pack to help with swelling around the knee
3. CSudden calf pain and swelling in the operated leg, with new breathlessness
4. DA small amount of dried blood on the dressing

Before a blood transfusion is started, which check is required?

1. AThe patient’s identity is checked against the blood product and its paperwork at the bedside
2. BOne nurse checks the blood product against the order at the nurses’ station
3. CThe nurse checks only that the bag number matches the order
4. DThe patient signs the blood bag label to confirm their name before it is hung

A nurse teaches an older adult about preventing falls at home. Which statement shows a need for further teaching?

1. A“I had grab bars put in next to the toilet.”
2. B“I keep small rugs in the hall so my feet stay warm.”
3. C“I use night lights between my bedroom and the bathroom.”
4. D“I wear shoes with non-slip soles around the house.”

A patient on warfarin has an INR of 7,8 and a nosebleed. Which medication would the nurse expect the provider to prescribe?

1. ANaloxone hydrochloride
2. BAcetylcysteine
3. CVitamin K (phytonadione)
4. DProtamine sulfate

A patient has fatigue, weight loss, darkening of the skin and low blood pressure. Results: sodium 130 mEq/L, potassium 5,6 mEq/L. Which test pattern would confirm primary adrenal insufficiency (Addison disease)?

1. AHigh cortisol with a high ACTH
2. BLow cortisol with a low ACTH
3. CLow cortisol with a high ACTH
4. DHigh cortisol with a low ACTH

How is Helicobacter pylori infection usually treated?

1. AA combination of antibiotics with a proton pump inhibitor
2. BA single dose of paracetamol and a bland diet for a week
3. CSurgery to remove the stomach
4. DAntacids alone, taken after every meal for a month

Why can sepsis be missed in older adults?

1. AThey may have no fever and present with confusion, falls or reduced mobility
2. BOlder adults always have a very high fever
3. CBlood tests are not useful in older people
4. DOlder adults cannot develop sepsis because their immune system is weaker

After thrombolysis for a myocardial infarction, which complication is the nurse most concerned to detect?

1. AConstipation from bed rest
2. BA high blood glucose caused by the thrombolytic drug itself
3. CBleeding, including a sudden change in neurological status
4. DA skin rash appearing at the sites of the ECG electrodes

After positive end-expiratory pressure (PEEP) is increased on a ventilated patient, the blood pressure falls. What is the most likely reason?

1. APEEP causes immediate blood loss from the alveolar capillaries
2. BPEEP lowers the blood oxygen level
3. CHigher chest pressure reduces venous return to the heart
4. DPEEP directly weakens the heart muscle and its contraction

A man starts tamsulosin for BPH. Which teaching point is most important?

1. ATake it with grapefruit juice to make it work better
2. BStand up slowly, because it can make you dizzy
3. CStop it if the urine stream improves
4. DExpect the drug to shrink the prostate within a day

A patient has erratic glucose readings. The nurse finds a soft, rubbery lump where they always inject. What is the most important teaching?

1. ADouble the insulin dose because the lump blocks the insulin
2. BMassage the lump firmly after every injection
3. CKeep injecting into the lump, because it hurts less there
4. DUse healthy sites and check glucose often, as less insulin may be needed

Quale punteggio si usa per valutare il rischio in un'emorragia GI superiore prima dell'endoscopia?

1. APunteggio di Glasgow-Blatchford
2. BPunteggio di Wells per la TVP
3. CGlasgow Coma Scale
4. DPunteggio di rischio di lesioni da pressione di Waterlow

Quale paziente ha il rischio più alto di depressione respiratoria da PCA postoperatoria di oppioide?

1. AUn paziente con punteggio del dolore 8/10, ben sveglio e vigile
2. BUn paziente senza altri problemi medici che riceve paracetamolo
3. CUn paziente anziano naïve agli oppioidi con apnee notturne che assume anche un sedativo
4. DUn giovane che usa regolarmente oppioidi da molti mesi