NCLEX tipo prioritetų nustatymas ir delegavimas: pasiruošimo paketas

Two hours after birth, the nurse finds the uterus firm but above the umbilicus and pushed to the right. What should the nurse do first?

1. AAsk the patient to lie still for another hour
2. BGive a dose of oxytocin straight away
3. CMassage the uterus firmly for ten minutes
4. DHelp the patient empty her bladder

A patient who is 7 weeks pregnant has one-sided lower abdominal pain, pain in the shoulder tip, a heart rate of 120/min and a blood pressure of 88/54 mmHg. What is most likely?

1. ASevere morning sickness
2. BA urinary tract infection
3. CA normal early pregnancy
4. DA ruptured ectopic pregnancy

A patient has a weak left leg. Which instruction about using a cane is correct?

1. AKeep the cane well out to the side, away from the body
2. BMove the cane and the right leg forward together
3. CHold the cane in the left hand, on the weaker side
4. DHold the cane in the right hand, on the stronger side

Which patient should the nurse assess first?

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

An older adult takes lisinopril and furosemide and recently started daily ibuprofen for knee pain. The creatinine has risen from 1,0 to 1,8 mg/dL (88 to 159 µmol/L). What is the most likely cause?

1. AMore activity has increased the patient's muscle mass quickly
2. BA laboratory error, since ibuprofen has no effect on the kidney
3. CThe NSAID reduces kidney blood flow on top of the other two drugs
4. DNormal aging of the kidneys over a period of a few weeks

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. AActive pulmonary TB, which is contagious
2. BPast BCG vaccination only, with no infection
3. CLatent TB infection, which is not contagious
4. DA false result, as the test does not detect TB

How does ulcerative colitis differ from Crohn's disease?

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

A patient is taught to self-inject low-molecular-weight heparin. Which statement shows a need for further teaching?

1. A"I will change the injection site each time."
2. B"I will inject into the fatty tissue of my abdomen."
3. C"I will report any unusual bleeding or bruising."
4. D"I will rub the area firmly after the injection."

The telemetry monitor suddenly shows a chaotic waveform resembling ventricular fibrillation, but the patient is talking and brushing their teeth. What should the nurse do first?

1. AStart chest compressions straight away and call the arrest team
2. BDeliver an immediate defibrillation shock before checking anything
3. CGive IV amiodarone as a bolus
4. DCheck the patient and the electrodes, as this is likely artefact

A patient with life-threatening asthma has not responded to repeated nebulised salbutamol (albuterol), ipratropium and steroids. Which drug is commonly given intravenously next?

1. AMetoprolol
2. BMorphine
3. CIntravenous furosemide
4. DMagnesium sulfate

Gydant DKA gliukozė nukrinta žemiau maždaug 14 mmol/l (apie 250 mg/dl), bet ketonų vis dar daug. Kas paprastai daroma?

1. APrie skysčių pridedama gliukozės; insulinas tęsiamas
2. BVisi skysčiai į veną nutraukiami, kad nebūtų skysčių pertekliaus
3. CInsulino infuzija nedelsiant nutraukiama
4. DPacientas pavalgo ir intraveninis gydymas nutraukiamas

The nurse has four patients. Which one needs to be seen first?

1. AA patient on insulin for DKA whose potassium is now 2,9 mmol/L
2. BA patient with hypothyroidism asking when to take levothyroxine
3. CA patient with Parkinson's disease whose next dose is due in two hours
4. DA patient with stable CKD waiting for a renal diet review

Kuri skalė naudojama viršutinio virškinamojo trakto kraujavimo rizikai įvertinti prieš endoskopiją?

1. AWaterlow pragulų rizikos skalė
2. BGlazgo-Blatchfordo skalė
3. CWells GVT skalė
4. DGlazgo komos skalė

An immobile patient on opioids drinks very little. Which laxative choice is least appropriate?

1. AA bulk-forming laxative used on its own
2. BA stool softener with a stimulant laxative
3. CA stimulant laxative taken regularly
4. DAn osmotic laxative such as a macrogol