NCLEX tipo prioritetų nustatymas ir delegavimas: pasiruošimo paketas

A patient with diabetes is unresponsive and has a blood glucose of 40 mg/dL (2,2 mmol/L). What should the nurse do first?

1. AGive IV dextrose or glucagon as prescribed
2. BWait 15 minutes and recheck the glucose
3. CPour orange juice into the patient’s mouth
4. DGive the scheduled dose of insulin

A patient is going home on a new oral anticoagulant. There is only a short time for teaching. Which topic is most important?

1. AHow to cook low-fat meals
2. BWhich television programs help with relaxation
3. CSigns of bleeding and when to seek help
4. DHow to choose comfortable walking shoes

When walking with axillary crutches, where should the patient’s weight be taken?

1. AOn the hands, with the crutch tops a few finger widths below the armpits
2. BOn the shoulders, with the crutches pressed upward
3. COn the elbows, kept bent at a right angle with the crutch tops tucked under the arms
4. DOn the armpits, resting on the crutch tops

A patient given naloxone for an opioid overdose wakes up. An hour later, the patient is drowsy again with slow breathing. What is the likely reason?

1. AThe patient is simply tired after the event
2. BNaloxone wears off sooner than many opioids, so the opioid effect returns
3. CNaloxone itself causes slow breathing and drowsiness once it has been given
4. DThe patient is now allergic to naloxone

Which technique is recommended for a capillary blood glucose test on an adult's finger?

1. AUse the same finger every time
2. BPrick the center of the fingertip
3. CSqueeze the finger very hard
4. DPrick the side of the fingertip

A patient taking an SGLT2 inhibitor has nausea and fast breathing. Glucose 190 mg/dL (10,5 mmol/L), pH 7,15, bicarbonate 10 mEq/L, blood ketones high. What is the most likely diagnosis?

1. ASimple fasting ketosis only
2. BRespiratory acidosis from COPD
3. CEuglycemic diabetic ketoacidosis
4. DHyperosmolar hyperglycemic state

How does CPAP help a patient with obstructive sleep apnoea?

1. AIt strengthens the breathing muscles during the day
2. BIt keeps the upper airway open during sleep with continuous air pressure
3. CIt removes excess carbon dioxide from the lungs by gentle suction
4. DIt delivers bronchodilator drugs deep into the lungs overnight

Netrukus po perpylimo pradžios pacientas pradeda dusti, švokšti, jam atsiranda hipotenzija ir veido patinimas. Ką slaugytojas turėtų padaryti pirmiausia?

1. ADuoti paracetamolio bei antihistamininio vaisto ir tęsti perpylimą
2. BGreitai užbaigti vienetą, kad sąlyčio laikas būtų kuo trumpesnis
3. CSustabdyti perpylimą, išlaikyti intraveninę prieigą ir kviesti skubią pagalbą
4. DSulėtinti perpylimą ir rodiklius pakartotinai patikrinti po valandos

How is orthostatic (postural) hypotension usually assessed?

1. ABP once sitting, then once lying down straight after a large meal
2. BBP in both arms at the same moment while sitting
3. CBP lying after rest, then again after 1 and 3 minutes standing
4. DBP only standing, after a brisk walk along the corridor

A smoker has severe shoulder and arm pain, a drooping eyelid, a small pupil and reduced sweating on the same side of the face. What should be suspected?

1. AA tumour at the apex of the lung (Pancoast tumour)
2. BA frozen shoulder with referred pain to the face
3. CA stroke affecting the brainstem on the opposite side
4. DA simple migraine

Which group of problems is typical of primary hyperparathyroidism?

1. AHeat intolerance, tremor, weight loss and diarrhoea
2. BKidney stones, bone pain, abdominal pain and low mood
3. CHair loss, weight gain and feeling cold
4. DMuscle cramps, tingling lips and seizures

A nurse teaches a young adult with newly diagnosed epilepsy. Which statement shows a need for further teaching?

1. A"As long as I take my tablets, I can swim alone."
2. B"I will take a shower rather than a bath."
3. C"I will keep a record of any seizures I have."
4. D"I will tell my friends what to do if I have a seizure."

Kurie požymiai rodo sunkų ūminį pankreatitą su kraujavimu į audinius?

1. AMėlynės aplink bambą ar šonus
2. BPurpurinis bėrimas ant delnų ir padų
3. CGeltonas nagų pakitimas
4. DLūpų, liežuvio ir veido tinimas

Pacientui, sergančiam plonosios žarnos nepraeinamumu, per nosies ir skrandžio zondą nuteka 2 l per dieną. Kuris slaugos dėmesys svarbiausias?

1. AZondo pašalinimas, kai nuteka 1 l, kad nebūtų netekčių
2. BLaisvas skysčių davimas per burną, kad pakeistų zondo pašalinamą kiekį
3. CZondo užspaudimas ilgam laikui skrandžio skysčiui išsaugoti
4. DTikslus skysčių balansas su pakeitimu į veną ir elektrolitų tikrinimu