Priorità e delega in stile NCLEX: pacchetto last-minute

A patient with heart failure gained 2 kg (about 4 lb) since yesterday and is more breathless when lying down. What should the nurse do first?

1. AAssess the lungs, oxygen saturation and swelling, then inform the provider
2. BEncourage extra fluids to correct the weight change
3. CLay the patient flat to help them breathe more easily
4. DRecord the weight on the chart and recheck it at the next weekly weigh-in

Four stable patients need routine morning care. To reduce the spread of infection, which patient should the nurse visit first?

1. AA patient with C. difficile diarrhea
2. BA patient with an MRSA wound infection
3. CA patient with influenza on droplet precautions
4. DA patient with neutropenia after chemotherapy

Un paziente in terapia con un diuretico è ad alto rischio di caduta e si alza spesso di notte. Quale misura è più utile?

1. AAccompagnamento programmato in bagno, con campanello e ausilio per la deambulazione a portata di mano
2. BDire al paziente di non bere nulla dopo pranzo
3. CSomministrare il diuretico prima di dormire, così agisce durante la notte
4. DTenere la stanza completamente buia di notte per favorire il sonno

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

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

A patient has a calcium of 7,0 mg/dL (1,75 mmol/L) and tingling around the mouth. Which nursing measure is most appropriate?

1. APut seizure precautions in place and report the result
2. BLimit dairy products until the level falls again
3. CEncourage 3 L of fluid per day to dilute the calcium
4. DPromote walking to move calcium back into the bone

A patient with blood pressure that is hard to control has a potassium of 2,9 mEq/L, a sodium of 144 mEq/L and a raised serum bicarbonate, without taking a diuretic. Which condition is most likely?

1. APrimary hyperaldosteronism
2. BPrimary adrenal insufficiency
3. CCentral diabetes insipidus
4. DSyndrome of inappropriate ADH

Which of these is a non-drug measure that can help relieve pain?

1. ARepositioning and distraction
2. BRestricting visitors completely
3. CTelling the patient that the pain is not real
4. DKeeping the patient awake all night

A patient faints during cannulation, with a slow pulse and pallor, and recovers quickly when laid flat. There is no rash, wheeze or swelling. What is most likely?

1. AA stroke
2. BA hypoglycaemic coma
3. CVasovagal syncope
4. DAnaphylaxis

A patient in cardiac rehabilitation asks how hard to exercise. Which simple guide is commonly taught?

1. AExercise so they are a little breathless but can still talk
2. BExercise until chest pain starts, then stop
3. CExercise only until the heart rate rises even slightly
4. DExercise until they are too breathless to speak at all

Un paziente in terapia con apixaban per fibrillazione atriale è in programma per un intervento elettivo. Quale affermazione rispecchia la pratica corretta?

1. ASi sospende due settimane prima dell'intervento e si sostituisce con warfarin
2. BSi sospende per un tempo definito, in base al rischio di sanguinamento e alla funzione renale
3. CSi prosegue sempre fino alla mattina dell'intervento
4. DSi sospende e poi si inverte con vitamina K per via orale

Un paziente in terapia con carbimazolo per ipertiroidismo riferisce mal di gola e febbre. Che cosa deve fare l'infermiere?

1. ARichiedere con urgenza un emocromo completo per cercare un'agranulocitosi
2. BRaddoppiare la dose per controllare più velocemente la tiroide
3. CConsigliare gargarismi con acqua salata e proseguire il farmaco per una settimana
4. DRassicurare il paziente, perché il farmaco non ha effetti collaterali gravi sul sangue

Near the end of a haemodialysis session, a patient has painful leg cramps and a falling blood pressure. What is the most likely cause?

1. AAn allergic reaction to the needles
2. BNot enough fluid is being removed
3. CFluid is being removed too quickly
4. DThe dialysate is too cold

How should a patient with facial burns usually be positioned?

1. ALying flat with the head lower than the feet
2. BLying face down on the pillow to protect the airway
3. CWith the head of the bed raised to reduce swelling
4. DIn any position that keeps the face covered

Un paziente con cirrosi e ascite ha una nuova febbre, dolorabilità addominale e confusione in peggioramento. Quale complicanza va sospettata?

1. ASemplice stitichezza
2. BPeritonite batterica spontanea
3. CNormale progressione dell'ascite
4. DPancreatite acuta