Priorità e delega in stile NCLEX: pacchetto last-minute

Which infant with gastroenteritis should the nurse see first?

1. AAlert, crying with tears, had a wet diaper an hour ago
2. BTwo loose stools today, feeding well
3. CLethargic, sunken fontanel, no wet diaper for 8 hours
4. DMild diaper rash, otherwise playful

A patient who is 7 weeks pregnant has one-sided lower abdominal pain, pain in the shoulder tip, a heart rate of 120/min and a blood pressure of 88/54 mmHg. What is most likely?

1. AA ruptured ectopic pregnancy
2. BA normal early pregnancy
3. CA urinary tract infection
4. DSevere morning sickness

A parent will give a liquid antibiotic to a child at home. Which teaching is best?

1. AEstimate the dose by pouring into a cup
2. BUse a tablespoon for doses over 5 mL
3. CUse the oral syringe or dosing cup that comes with the medicine
4. DUse any teaspoon or tablespoon from the kitchen drawer at home

A patient is on contact precautions. Which task is appropriate for the nurse to delegate to assistive personnel?

1. ADeciding when the precautions can be stopped
2. BAssessing the wound for new signs of infection during the bath
3. CHelping the patient bathe while wearing a gown and gloves
4. DTeaching the family how to follow the precautions

In che modo il calcio gluconato endovenoso aiuta un paziente con iperkaliemia grave?

1. AStabilizza le membrane delle cellule cardiache senza abbassare il potassio
2. BAumenta l'eliminazione del potassio da parte dei reni
3. CSposta il potassio dal sangue alle cellule
4. DLega il potassio nell'intestino così che venga eliminato con le feci

The nurse teaches a patient about the HbA1c test. Which statement shows a need for further teaching?

1. A"My daily finger-stick readings still matter between the tests"
2. B"I must not eat anything for 12 hours before the HbA1c test"
3. C"A lower result means less risk of damage to my eyes and kidneys"
4. D"The test shows my average glucose over the past few months"

How is Helicobacter pylori infection usually treated?

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

Which finding suggests hypocalcaemia?

1. ASpasm of the hand when a blood pressure cuff is inflated on the arm
2. BA flapping tremor of the outstretched hands
3. CA slow, irregular pulse with nausea and yellow-tinged vision
4. DSevere thirst with a large urine output and constipation

Shortly after a permanent pacemaker is inserted via the subclavian vein, the patient becomes breathless with reduced breath sounds on that side. What complication should be suspected?

1. APneumothorax
2. BAsthma
3. CPulmonary oedema
4. DPericarditis

Un paziente con BPCO è dispnoico con SpO₂ 84% in aria ambiente. L'emogasanalisi mostra pH 7,30 e PaCO₂ elevata nonostante una terapia medica ottimale. Quale trattamento verrà probabilmente preso in considerazione?

1. ASedazione EV per rallentare la frequenza respiratoria
2. BOssigeno ad alta concentrazione con maschera senza reinalazione
3. CVentilazione non invasiva (NIV)
4. DSospensione dei broncodilatatori nebulizzati

Why is an ACE inhibitor often given to a patient with diabetes and albumin in the urine?

1. AIt protects the kidneys and reduces albumin loss
2. BIt raises potassium to protect the heart
3. CIt stops the kidneys from passing so much urine at night
4. DIt lowers the blood glucose to normal

A patient with a brain injury has a mean arterial pressure of 80 mmHg and an ICP of 25 mmHg. How should the nurse interpret this?

1. AThe ICP cannot affect brain perfusion if the blood pressure is normal
2. BThe cerebral perfusion pressure is 80 mmHg, which is normal
3. CThe cerebral perfusion pressure is 105 mmHg, which is too high
4. DThe cerebral perfusion pressure is 55 mmHg, below the usual target

Why are accurate fluid balance charts kept after major surgery?

1. ATo detect dehydration, fluid overload or kidney problems early
2. BTo check how far the patient has walked and how often they get out of bed
3. CTo record when visitors come and go
4. DTo decide which meal the patient will have next

Un paziente con PCA di oppioide riceve ossigeno con maschera. La SpO₂ è 97% e la frequenza respiratoria 11/min, ma ora è difficile da svegliare. Che cosa deve concludere l'infermiere?

1. AIl paziente sta semplicemente dormendo bene, perché il dolore è controllato
2. BLa dose della PCA va aumentata per mantenere comodo il paziente
3. CIl paziente è al sicuro, perché la saturazione di ossigeno è normale
4. DÈ probabile una tossicità da oppioidi; l'ossigeno può mascherare l'ipoventilazione