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. AGive a prescribed diuretic straight away
2. BEncourage the patient to drink more water
3. CRemove the catheter and wait for the patient to void
4. DCheck the tubing for kinks or obstruction

Un paziente dopo un intervento maggiore ha una diuresi di 15 mL/h da due ore, una frequenza cardiaca di 115/min e mani fredde. Che cosa deve fare per prima l'infermiere?

1. AValutare i segni di shock, come un sanguinamento, e segnalare
2. BAspettare altre due ore per vedere se la diuresi migliora
3. CIncoraggiare il paziente a bere più acqua e ricontrollare più tardi
4. DLavare il catetere e ricontrollare la diuresi domani mattina

Why can side rails be dangerous for a confused, restless patient?

1. AThe patient may climb over them or get trapped in gaps
2. BSide rails always cause pressure injuries
3. CSide rails stop staff from reaching the patient in an emergency
4. DSide rails make the bed move by itself

Un paziente con demenza grave si alza da solo dal letto di notte ed è caduto due volte. Quale piano è più appropriato?

1. ALegare il paziente alla sedia per tutta la notte
2. BUn sedativo ogni notte per tenere il paziente a letto
3. CQuattro sponde alzate, con la porta chiusa di notte per avere silenzio
4. DLetto basso, allarme del letto, giri per accompagnare in bagno, luce notturna e calze antiscivolo

A patient taking phenazopyridine for bladder pain has bright orange urine. What should the nurse know about urine tests?

1. AThe drug improves the accuracy of all dipsticks
2. BThe color proves blood is present in the urine
3. CThe color shows severe liver failure is present
4. DThe dye can interfere with dipstick color readings

A patient stopped long-term prednisone suddenly a week ago. Now: blood pressure 78/46 mm Hg, sodium 128 mEq/L, potassium 4,6 mEq/L, glucose 58 mg/dL (3,2 mmol/L). Which condition is most likely?

1. ASyndrome of inappropriate ADH (SIADH)
2. BCushing syndrome from steroid excess
3. CPrimary hyperaldosteronism (Conn syndrome)
4. DAcute adrenal insufficiency (adrenal crisis)

An older adult has left lower abdominal pain, fever and a raised CRP. Which condition is most likely?

1. AGastric ulcer
2. BDiverticulitis
3. CBiliary colic
4. DAppendicitis

A patient going home with a leg cast is taught about cast care. Which statement shows a need for further teaching?

1. A"I will come back if my toes go numb or turn blue."
2. B"I will keep my leg raised on pillows for the first few days."
3. C"I will keep the cast dry."
4. D"I can push a knitting needle down the cast to scratch an itch."

Come va somministrata l'enoxaparina sottocutanea da una siringa preriempita?

1. ANella stessa sede addominale ogni giorno, poi massaggiata
2. BNell'addome, lasciando la bolla d'aria, senza massaggiare
3. CCome bolo endovenoso rapido attraverso una cannula
4. DNel muscolo deltoide, dopo aver prima espulso la bolla d'aria

Four surgical patients need VTE prevention. For which patient is mechanical prophylaxis alone most appropriate?

1. AA patient with cancer having bowel surgery
2. BAn obese patient after hip surgery
3. CA patient who had a brain haemorrhage two days ago
4. DA patient after an uncomplicated knee replacement

Which long-term risk should a kidney transplant recipient be taught to reduce with sun protection?

1. AHair loss
2. BSkin cancer
3. CKidney stones
4. DGout

Two days after surgery, an 80-year-old woman is quiet, sleepy, slow to answer and eating little. Her daughter says she is "not herself". What should the nurse suspect?

1. ASimple low mood about being in hospital
2. BHypoactive delirium
3. CThe start of Alzheimer's disease
4. DNormal tiredness after an operation

Quali misure aiutano a prevenire la sindrome da lisi tumorale nei pazienti ad alto rischio?

1. AIdratazione EV con allopurinolo o rasburicasi
2. BIntegratori giornalieri di calcio e fosfato
3. CRestrizione dei liquidi con compresse di potassio
4. DSospensione di tutti i liquidi EV e orali durante la chemioterapia

A patient with haematemesis becomes drowsy and starts to vomit blood again. What is the immediate priority?

1. ATurn the patient onto their side to protect the airway
2. BComplete the admission paperwork and medication history
3. CSend a stool sample for faecal occult blood testing
4. DGive a large glass of iced water to slow the bleeding