Priorità e delega in stile NCLEX: pacchetto last-minute

Durante il triage START, un adulto non deambulante respira 22 volte al minuto, ha un polso radiale, esegue semplici comandi, ma ha un'evidente frattura della gamba. Quale categoria gli viene assegnata?

1. AVerde (minore)
2. BNero (atteso)
3. CGiallo (differito)
4. DRosso (immediato)

During an infusion of a thrombolytic drug for stroke, the patient develops a severe headache and starts vomiting. What should the nurse do first?

1. AGive a dose of aspirin for the headache
2. BSlow the infusion and give an antiemetic as prescribed
3. CContinue the infusion, because headache is expected
4. DStop the infusion and inform the provider at once

A new antibiotic is prescribed for a patient. What should the nurse check before giving the first dose?

1. AOnly the time of the patient’s last meal and drink
2. BOnly the patient’s blood pressure and pulse before giving the drug
3. CThe patient’s allergies, by checking the record and asking the patient
4. DThe patient’s preferred pharmacy

A 2-year-old living in a house built many decades ago has anemia, irritability and poor appetite. Which cause should the nurse suspect?

1. AA food allergy to cow’s milk proteins
2. BCarbon dioxide from a gas cooker
3. CLead poisoning from old paint dust or chips
4. DIron overload from eating too much red meat

A patient takes valproate (valproic acid) for epilepsy. Which tests are monitored regularly?

1. ATroponin and B-type natriuretic peptide
2. BSerum lithium and urine specific gravity
3. CLiver function tests and platelet count
4. DThyroid function and serum calcium

An older adult has bone pain, fatigue and frequent infections. Results show anemia, a calcium of 12,4 mg/dL (3,1 mmol/L), a raised total protein and a rising creatinine. Which condition should be suspected?

1. AIron-deficiency anemia
2. BAcute viral hepatitis
3. CPrimary hypothyroidism
4. DMultiple myeloma

Un paziente neutropenico dopo chemioterapia ha una temperatura di 38,3 °C. Qual è la priorità?

1. ATrattarlo come sepsi neutropenica e somministrare con urgenza antibiotici EV
2. BAttendere 24 ore per vedere se la febbre si risolve
3. CIncoraggiare il paziente a fare una passeggiata
4. DSomministrare solo paracetamolo e ricontrollare di nuovo la temperatura domani

A patient with a central venous catheter develops fever and rigors shortly after the line is flushed, with no other obvious source. What should be suspected?

1. AA pulmonary embolism
2. BAn allergic reaction to the saline flush
3. CA catheter-related bloodstream infection
4. DNormal response to line use

A peripheral cannula site is red, warm, tender and swollen along the vein. What should the nurse do?

1. ALeave it in place, as this is normal after 24 hours
2. BRemove the cannula, document and monitor the site
3. CCover the site and keep using it until it blocks
4. DFlush the cannula hard to clear it

A patient with end-stage COPD has severe breathlessness at rest despite optimal treatment and wants comfort-focused care. Which measure is recognised to help?

1. AStopping all medicines, including inhalers
2. BHigh-flow oxygen at 15 L/min whatever the oxygen saturation is
3. CEncouraging long walks to build fitness
4. DA low-dose opioid with a hand-held fan and calm positioning

Before surgery for a phaeochromocytoma, why is an alpha-blocker started before any beta-blocker?

1. AA beta-blocker alone can cause a dangerous rise in BP
2. BAlpha-blockers lower the blood glucose before surgery
3. CBeta-blockers given first would make the tumour grow faster
4. DThe order of the two drugs makes no difference

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

1. AUnderdrainage, so the drain should be lowered further
2. BNo concern, because more drainage always lowers the ICP safely
3. CAn infected drain, so the dressing should be removed
4. DOverdrainage of CSF, so act per protocol and inform the team

How can low-dose opioids help a patient with breathlessness from advanced cancer?

1. AThey increase the oxygen level in the blood
2. BThey open the airways like an inhaler
3. CThey cure the underlying lung disease
4. DThey reduce the feeling of breathlessness

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

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