NCLEX tipo prioritetų nustatymas ir delegavimas: pasiruošimo paketas

Which practice makes a shift handover safest?

1. AA quick chat in the corridor with no notes taken
2. BLeaving a sticky note on the computer screen for the next nurse
3. CA structured format, such as SBAR, with time for questions
4. DHanding over only the patients who had problems during the shift

Pacientas, sergantis širdies nepakankamumu, dūsta, abiejuose plaučiuose girdimi karkalai. Kuri veiksmų eilė teisinga?

1. APirmiausia pasverti pacientą, tada po keturių valandų iš naujo įvertinti kvėpavimą
2. BPirmiausia duoti paskirtus geriamuosius vaistus, tada pasodinti pacientą
3. CPasodinti tiesiai, duoti deguonies pagal paskyrimą, tada kviesti gydytoją
4. DPaguldyti pacientą ilsėtis, tada pradėti palaikomuosius skysčius į veną

A nurse finds an unlabeled syringe of clear fluid on the medication counter. What should the nurse do?

1. AAsk nearby staff and use it if someone recognizes it
2. BDiscard it, because its contents cannot be confirmed
3. CLabel it with the most likely drug name
4. DGive it to the patient whose medication is due

A patient rescued from a house fire has a headache and confusion, but the pulse oximeter reads 99%. Why might this reading be misleading?

1. AConfusion and headache make pulse oximetry readings inaccurate in every patient
2. BThe reading is accurate, so carbon monoxide poisoning is ruled out
3. CPulse oximeters always read falsely low after any kind of smoke exposure
4. DPulse oximetry cannot tell carbon monoxide-bound hemoglobin from oxygen-bound hemoglobin

A woman with hyperemesis gravidarum has vomited for 3 days. Which urine finding would the nurse expect?

1. ANitrites
2. BBilirubin
3. CRed cell casts
4. DKetones

A nursing student has a positive interferon-gamma release assay (IGRA) for tuberculosis, no symptoms and a normal chest X-ray. What does this most likely mean?

1. AA false result, as the test does not detect TB
2. BPast BCG vaccination only, with no infection
3. CActive pulmonary TB, which is contagious
4. DLatent TB infection, which is not contagious

How does ulcerative colitis differ from Crohn's disease?

1. AUlcerative colitis typically causes patchy "skip" lesions
2. BUlcerative colitis can affect any part of the gut from mouth to anus
3. CUlcerative colitis affects only the colon, continuously from the rectum
4. DUlcerative colitis always affects the full thickness of the bowel wall

A patient who has had a kidney stone is taught about prevention. Which statement shows a need for further teaching?

1. A"I will drink less water so I don't need to pass urine as often."
2. B"I will try to pass pale urine."
3. C"I will aim to drink plenty of fluids spread through every day."
4. D"I will follow the diet advice for my stone type."

Kodėl nitratai labai atsargiai vartojami esant dešiniojo skilvelio infarktui?

1. ADešinysis skilvelis priklauso nuo priešapkrovos, todėl kraujospūdis gali staigiai kristi
2. BNitratai neįsisavinami, kai pažeistas dešinysis skilvelis
3. CNitratai sukelia infarkto išplitimą į kairįjį skilvelį
4. DNitratai šio tipo infarkto metu sukelia pavojingą hiperkalemiją

A nurse receives handover on four patients. Which patient should be seen first?

1. AA patient with COPD on 1 L/min whose SpO₂ has been 89% and stable throughout the night
2. BA patient with pneumonia on IV antibiotics who now has a temperature of 38,2 °C
3. CA patient with asthma who wants a reliever inhaler before a walk
4. DA patient on day 1 after surgery who is newly restless, RR 30/min, SpO₂ 88% on 4 L/min

A patient with Alzheimer's disease starts donepezil. Which side effects should the nurse look for?

1. AA persistent dry cough and a raised potassium
2. BNausea, diarrhoea and a slow heart rate
3. CWeight gain, high glucose and swollen ankles
4. DDry mouth, constipation and a fast heart rate

A prescription reads "Insulin 10U". Why is this a safety problem?

1. AThere is no problem as long as the nurse can read it
2. B"U" means the insulin must be given intravenously
3. CInsulin doses must always be written in millilitres
4. D"U" can be misread as a zero, giving a tenfold dose

A patient received IV morphine 20 minutes ago and the surgical consent form has not been signed. What should the nurse do?

1. AAsk the patient to sign quickly before they get sleepier
2. BAsk a relative to sign instead of the patient
3. CSign the form on the patient's behalf as a witness
4. DTell the surgeon, as the patient may not be able to consent now

Pacientui, sergančiam plaučių vėžiu, ištinsta veidas, išsiplečia kaklo venos, o dusulys stiprėja gulint. Kuri skubi būklė tikėtina?

1. AViršutinės tuščiosios venos obstrukcija
2. BNugaros smegenų suspaudimas
3. CMasinė plautinė embolija
4. DPiktybinio naviko sukelta hiperkalcemija