NCLEX tipo prioritetų nustatymas ir delegavimas: pasiruošimo paketas

A nurse teaches a patient with heart failure. Which statement shows a need for further teaching?

1. A“I add extra salt to my food so it tastes better.”
2. B“I will call if my weight goes up quickly over a day or two.”
3. C“I will take my water tablet in the morning.”
4. D“I will weigh myself every morning after I use the toilet.”

A 2-month-old infant has a spiral fracture of the femur. The parents say the baby rolled off the sofa. What should the nurse recognize?

1. AA spiral fracture in an infant is always caused by birth trauma
2. BInfants of this age often roll off furniture and break bones in this way
3. CThe injury does not fit the infant’s development, so possible abuse must be reported
4. DNo further action is needed once the fracture is treated

Why does a nurse wear chemotherapy-tested gloves and a gown when emptying the urinal of a patient who recently had chemotherapy?

1. AThe body fluids can contain active drug for a time after treatment
2. BChemotherapy makes the urine strongly acidic and corrosive
3. CThe urine always contains infectious bacteria after chemotherapy
4. DThe patient is on airborne precautions after treatment

Only one airborne infection isolation room (negative pressure) is free. Which newly admitted patient should be placed in it?

1. AA patient with confirmed seasonal influenza and a cough
2. BA patient with C. difficile diarrhea
3. CA patient with an MRSA wound infection
4. DA patient with suspected active pulmonary tuberculosis

When several samples are drawn at the same venipuncture, which tubes or bottles are filled first?

1. ABlood culture bottles
2. BFluoride (glucose) tubes
3. CEDTA (complete blood count) tubes
4. DCoagulation (citrate) tubes

A patient with a heart murmur and fever has three sets of blood cultures, taken hours apart, all growing the same Streptococcus species. What does this suggest?

1. AA normal finding in patients with heart murmurs
2. BA urinary tract infection that has spread to the skin
3. CContamination of all three samples during collection
4. DPersistent bacteremia, as in infective endocarditis

Which ECG change is typical of hypokalaemia?

1. ATall, peaked T waves
2. BST elevation in leads II, III and aVF
3. CA very short PR interval with a delta wave
4. DFlattened T waves and prominent U waves

A healthcare assistant reports four observations. Which one needs the nurse's immediate action?

1. A"Mrs Jones would like a cup of tea and her glasses cleaned."
2. B"Mr Patel's breathing rate is 8 a minute and he's hard to wake."
3. C"Ms Ali has walked to the bathroom on her own."
4. D"Mr Chen's blood pressure is 128/80 as usual."

A patient who had a stroke has a weak swallow. Which measure most reduces the risk of aspiration pneumonia?

1. ALying flat for 30 minutes after eating to aid digestion
2. BGiving thin fluids quickly through a straw between meals
3. CGiving meals while the patient is drowsy
4. DA swallowing assessment and sitting upright for meals

On day 2 after a surgical tracheostomy, the tube falls out. The patient is breathing but distressed. What should the nurse do first?

1. ACall for expert help and give oxygen to both the face and the stoma
2. BLeave the patient alone while fetching a new tube
3. CForce the tube back through the stoma immediately with firm pressure
4. DCover the stoma completely with a sealed dressing and wait for help

A patient on insulin asks about drinking alcohol. Which advice is correct?

1. AAlcohol has no effect on blood glucose in people with diabetes
2. BAlcohol raises glucose, so extra insulin should be taken first
3. CAlcohol can cause hypos, even the next day, so eat carbs with it
4. DAlcohol should replace a meal on the days it is drunk

A patient with SIADH needs IV fluid. Which fluid is most likely to worsen the hyponatraemia?

1. A8,4% sodium bicarbonate
2. B3% saline
3. C20% human albumin
4. D5% glucose (dextrose, D5W)

Which complication is more typical of Crohn's disease than of ulcerative colitis?

1. ABleeding only from the rectum
2. BDisease that is cured by removing the colon
3. CInflammation limited to the rectal lining
4. DFistulas between the bowel and other organs

Hours after an oesophageal dilatation, a patient has chest pain, fever and crackling swelling under the skin of the neck. What should the nurse suspect?

1. AOesophageal perforation
2. BNormal discomfort after the procedure
3. CSimple reflux after the dilatation
4. DAn allergic reaction to the sedative