NCLEX tipo prioritetų nustatymas ir delegavimas: pasiruošimo paketas

A nurse sees a nursing assistant leave a confused patient’s bed in the highest position after care. What should the nurse do?

1. AWrite it in the assistant’s yearly review only
2. BAsk the family to lower the bed when they next visit
3. CLeave it because the patient is asleep
4. DLower the bed now and remind the assistant why it matters

A nurse teaches a patient to inject enoxaparin at home. Which statement shows a need for further teaching?

1. A“I will tell my doctor if I notice unusual bruising or bleeding.”
2. B“I will rub the area after the injection to help it absorb.”
3. C“I will change the injection site each time.”
4. D“I will inject into the fat of my abdomen, away from the navel.”

Which toy is safest for a toddler?

1. AA balloon to play with when an adult is out of the room
2. BA toy with small magnets that come out easily
3. CA bag of marbles to sort by color
4. DA large toy with no small parts that can come off

A patient on long-term high-dose corticosteroids asks for the nasal spray influenza vaccine. What should the nurse explain?

1. AThe nasal spray is the best choice for people on steroids, because it is not injected
2. BPeople on steroids should never have any influenza vaccine
3. CThe nasal spray is a live vaccine, so the injected inactivated vaccine is used instead
4. DEither type is fine, as long as it is given in the morning

A patient receives repeated nebulized albuterol (salbutamol) for severe asthma. Which laboratory change should the nurse watch for?

1. AA fall in blood glucose
2. BA rise in serum sodium
3. CA rise in serum calcium
4. DA fall in serum potassium

Paciento vankomicino slenkstinė koncentracija yra 28 mcg/mL; skiriančiojo gydytojo nustatytas tikslas yra 15–20 mcg/mL. Kita dozė tuoj turi būti duota. Koks geriausias veiksmas?

1. ADuoti dvigubą dozę, kad kursas baigtųsi greičiau
2. BDozę suleisti per trumpesnį laiką, kad ekspozicija sumažėtų
3. CSulaikyti dozę, informuoti skiriantįjį gydytoją ir patikrinti inkstų funkciją
4. DDuoti dozę pagal grafiką ir slenkstinę koncentraciją patikrinti po savaitės

Why is blood pressure monitored closely in a patient with an epidural infusion?

1. ABlood pressure readings show whether the catheter is infected
2. BThe epidural pump uses the blood pressure to set the rate
3. CThe local anaesthetic can block sympathetic nerves and cause hypotension
4. DEpidurals always cause severe hypertension that needs regular treatment

A patient due a blood transfusion is not wearing an identity band. What should the nurse do?

1. ACheck the name on the bed and proceed
2. BNot start until a correct identity band is in place and identity is confirmed
3. CAsk the patient to state their name and date of birth, then start straight away
4. DAsk another patient to confirm who the patient is

Why is pyridoxine (vitamin B6) often given with isoniazid?

1. ATo prevent orange discolouration of urine
2. BTo prevent gout attacks
3. CTo prevent peripheral neuropathy
4. DTo prevent loss of colour vision

A nurse reviews inhaler use with a patient who has asthma and uses a separate steroid preventer inhaler and a salbutamol reliever. Which statement shows a need for further teaching?

1. A"I use my steroid inhaler when I start to wheeze."
2. B"I use my steroid inhaler every day, even when I feel well."
3. C"I carry my blue reliever inhaler with me."
4. D"I rinse my mouth after the steroid inhaler."

A patient's fistula starts to bleed at home after the needles were removed. What should they do first?

1. APress firmly on the site with clean gauze
2. BRaise the arm and let it bleed freely
3. CWait for the next dialysis session
4. DApply a tight tourniquet above the fistula

A patient with AKI has a low urine sodium and concentrated urine. What does this suggest?

1. ADiabetes insipidus, with too little ADH
2. BAcute tubular necrosis, with damaged and leaking tubules
3. CA post-renal blockage, with urine backed up
4. DA pre-renal cause, with kidneys holding salt and water

Which long-term effect must be monitored in patients receiving anthracyclines such as doxorubicin?

1. APermanent high blood glucose
2. BExcess growth of body hair
3. CDamage to the heart muscle
4. DLoss of the sense of smell

While a central line is disconnected, a patient suddenly becomes breathless with chest pain and hypotension. Air embolism is suspected. What should the nurse do first?

1. ASit the patient fully upright and flush the line
2. BGive the patient a drink and observe for an hour
3. CRemove the central line straight away and leave the site open to the air
4. DClamp the line, lie the patient left side down, head low; give oxygen