Priorità e delega in stile NCLEX: pacchetto last-minute

Which infant with gastroenteritis should the nurse see first?

1. AMild diaper rash, otherwise playful
2. BAlert, crying with tears, had a wet diaper an hour ago
3. CTwo loose stools today, feeding well
4. DLethargic, sunken fontanel, no wet diaper for 8 hours

A patient is going home on a new oral anticoagulant. There is only a short time for teaching. Which topic is most important?

1. AHow to cook low-fat meals
2. BWhich television programs help with relaxation
3. CSigns of bleeding and when to seek help
4. DHow to choose comfortable walking shoes

Which information must be documented when a patient is restrained?

1. AThe reason, alternatives tried, type of restraint, times and regular assessments
2. BOnly the time the restraint was put on and the time it was taken off
3. COnly the name of the nurse who applied it and the unit where it happened
4. DOnly whether the family agreed to the restraint

Un reparto tiene flaconi di cloruro di potassio concentrato nell'armadio delle scorte. Perché molte linee guida di sicurezza lo sconsigliano?

1. AIl cloruro di potassio deve sempre essere somministrato per bocca
2. BIl concentrato non diluito somministrato per errore può fermare il cuore
3. CI flaconi di cloruro di potassio scadono entro un giorno dall'apertura
4. DIl cloruro di potassio è troppo costoso per essere tenuto come scorta generale di reparto

Un paziente in infusione di eparina ha un aPTT di 110 secondi; il target del protocollo è 1,5–2,5 volte il controllo di 30 secondi. Che cosa deve fare l'infermiere?

1. AAumentare la velocità di infusione, perché il risultato è sopra l'intervallo target
2. BSomministrare la vitamina K come prescritto e continuare l'infusione
3. CContinuare senza modifiche e ripetere l'aPTT la mattina dopo
4. DSeguire il protocollo dell'eparina, controllare eventuali sanguinamenti e informare il medico

An 82-year-old woman without a catheter has a urine culture growing bacteria, but no fever, urinary symptoms or change in mental state. What is the best interpretation?

1. AA urinary tract infection that needs urgent IV antibiotics
2. BAsymptomatic bacteriuria, usually not treated with antibiotics
3. CPyelonephritis, which needs admission and IV fluids today
4. DContamination, so the culture must be repeated every week

For a patient in skin traction on the leg, which is correct?

1. AThe rope is tied to the bed frame to keep it still
2. BThe weights are removed whenever the patient feels uncomfortable
3. CThe weights rest on the floor overnight
4. DThe weights hang freely and do not rest on the bed or floor

A nurse phones a doctor about a deteriorating patient using SBAR. Which statement belongs in the "R" section?

1. A"He was admitted three days ago with pneumonia."
2. B"I am calling about Mr Smith, who is breathless."
3. C"Please review him within the next 15 minutes."
4. D"His blood pressure is 85/50 and he is confused."

A patient on ramipril is to start sacubitril/valsartan for heart failure. What is the key safety point?

1. AThe ACE inhibitor dose should be doubled during the change
2. BThe ACE inhibitor must be stopped first, with a gap before starting
3. CSacubitril/valsartan is safe to start on the same morning
4. DBoth drugs should be taken together each day for the best effect

On the first day after abdominal surgery, a patient has a temperature of 37,8 °C, SpO₂ 93% on air and reduced breath sounds at both bases. They have stayed in bed because of pain. What is the most likely cause and response?

1. AAtelectasis: give analgesia, deep breathing and mobilisation
2. BNormal recovery; no action is needed
3. CPulmonary oedema: restrict all oral fluids and give a diuretic
4. DWound infection: open the wound fully and swab it for culture

How does bladder training help urge incontinence?

1. AThe patient drinks as little as possible
2. BThe patient goes to the toilet every 15 minutes
3. CThe time between voids is slowly increased
4. DA catheter is used every night

Un paziente ha episodi di forte cefalea, sudorazione, palpitazioni e pressione arteriosa molto alta. Quale condizione va considerata?

1. AFeocromocitoma
2. BDiabete insipido
3. CMalattia di Addison
4. DIpotiroidismo

Why do patients with major burns lose so much fluid in the first 24–48 hours?

1. AThe kidneys stop making urine completely
2. BPatients drink far too little in hospital in the first days
3. CThe burned skin absorbs fluid from the air
4. DLeaky capillaries let plasma move into the tissues

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. BA healing category 1 ulcer
3. CSimple dry skin
4. DVenous insufficiency