NCLEX tipo prioritetų nustatymas ir delegavimas: pasiruošimo paketas

On a postpartum unit, which patient is the most appropriate to assign to an LPN/LVN?

1. AOne hour after birth with heavy bleeding and a boggy uterus
2. BSevere pre-eclampsia on a magnesium sulfate infusion
3. CDay 1 after an uncomplicated vaginal birth, stable vital signs
4. DA new admission transferred from the labor ward with a fever of 38,6 °C

Slaugytojo padėjėjas išmatavo gyvybinius rodiklius praėjus 15 minučių po paciento pirmosios morfino dozės. Jis praneša apie 10/min kvėpavimo dažnį ir sako, kad pacientą sunku pažadinti. Ką turėtų daryti slaugytojas?

1. APaskambinti gydytojui paskyrimų, prieš einant pas pacientą
2. BPaprašyti padėjėjo po 15 minučių pakartotinai išmatuoti kvėpavimo dažnį ir pranešti
3. CUžrašyti radinius ir pasakyti gydytojui per kitą suplanuotą ratą
4. DNedelsiant eiti, pažadinti pacientą, palaikyti kvėpavimą ir paruošti naloksoną pagal paskyrimą

Which information must be documented when a patient is restrained?

1. AThe reason, alternatives tried, type of restraint, times and regular assessments
2. BOnly the time the restraint was put on and the time it was taken off
3. COnly whether the family agreed to the restraint
4. DOnly the name of the nurse who applied it and the unit where it happened

Which patient should the nurse assess first?

1. AA patient who wants more alcohol hand rub in the room
2. BA patient with an MRSA wound due for a routine dressing change
3. CA patient on chemotherapy with a new temperature of 38,4 °C (101,1 °F)
4. DA patient with tuberculosis who is asking to have visitors

A patient taking phenazopyridine for bladder pain has bright orange urine. What should the nurse know about urine tests?

1. AThe drug improves the accuracy of all dipsticks
2. BThe dye can interfere with dipstick color readings
3. CThe color shows severe liver failure is present
4. DThe color proves blood is present in the urine

A patient's bedside glucose meter shows "HI" (above its measuring range). The patient is drowsy. What should the nurse do?

1. AAssume the meter is broken and give the usual insulin dose
2. BSend a venous sample to the lab and inform the provider at once
3. CRecord "HI" and repeat the meter test at the next scheduled time
4. DGive oral glucose in case the reading is wrong and the patient is low

For a patient in skin traction on the leg, which is correct?

1. AThe weights are removed whenever the patient feels uncomfortable
2. BThe rope is tied to the bed frame to keep it still
3. CThe weights rest on the floor overnight
4. DThe weights hang freely and do not rest on the bed or floor

Which route and site are recommended for the first dose of adrenaline (epinephrine) in anaphylaxis on a ward?

1. ASubcutaneous injection into the upper arm
2. BIntravenous bolus given by the nurse without monitoring
3. CIntramuscular injection into the anterolateral thigh
4. DOral tablet dissolved under the tongue

Kuri pneumonijos sunkumo skalė naudoja sumišimą, karbamidą, kvėpavimo dažnį, kraujospūdį ir amžių?

1. AWells skalė
2. BCHA₂DS₂-VASc
3. CNEWS2
4. DCURB-65

A conscious adult in the dining room is suddenly unable to speak, cough or breathe after a mouthful of food. What should the nurse do first?

1. ASweep blindly in the mouth with a finger
2. BLie them down on the floor and start chest compressions immediately
3. CEncourage them to drink a glass of water to wash the food down
4. DUp to five back blows, then up to five abdominal thrusts if needed

A patient takes an SGLT2 inhibitor. Which sick-day advice is correct?

1. APause the drug during illness with vomiting or poor intake
2. BStop drinking fluids while taking the drug
3. CKeep taking it as normal, whatever the illness
4. DDouble the dose during illness to control the glucose

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

Why is it important to prevent perioperative hypothermia?

1. AIt lowers the risk of pain after surgery
2. BIt reduces the amount of anaesthetic needed, which is unsafe
3. CIt increases bleeding, wound infection and heart complications
4. DIt makes patients wake up from the anaesthetic too quickly

A patient with cirrhosis takes spironolactone and furosemide. Which blood result should the nurse report before the next dose?

1. APotassium 6,0 mmol/L
2. BSodium 141 mmol/L
3. CSodium 138 mmol/L
4. DPotassium 4,2 mmol/L