NCLEX tipo prioritetų nustatymas ir delegavimas: pasiruošimo paketas

A pregnant nurse is on the unit. Which patient should the charge nurse avoid assigning to her?

1. AA patient after a hip replacement
2. BA patient with a sealed radioactive implant for cervical cancer
3. CA patient with type 2 diabetes who needs insulin teaching before discharge
4. DA patient with a fractured wrist

Nuolatinio maitinimo per zondą metu pacientas staiga pradeda kosėti, dusti ir SpO₂ krenta. Koks pirmasis slaugytojo veiksmas?

1. APadidinti maitinimo greitį, kad greičiau baigtųsi
2. BSustabdyti maitinimą, pasodinti pacientą tiesiai ir įvertinti kvėpavimą
3. CPaguldyti pacientą, kad pailsėtų
4. DPraplauti zondą 50 mL vandens ir tęsti maitinimą kaip anksčiau

Which room lighting is safest at night for a patient at high risk of falls?

1. AComplete darkness so the patient sleeps more deeply
2. BOnly the light from the television screen
3. CBright overhead lights left on all night in the room
4. DA low night light that lights the path to the bathroom

A nurse teaches a patient about care of a surgical incision at home. Which statement shows a need for further teaching?

1. A“I will call the clinic if I get a fever or more pain around the wound.”
2. B“If the wound gets red and drains pus, I will wait for my appointment next month.”
3. C“I will wash my hands with soap before I touch or change the dressing.”
4. D“I will keep the dressing clean and dry as I was shown.”

A patient on a heparin infusion has an aPTT below the target range on the protocol. What should the nurse do?

1. AStop the infusion and give protamine sulfate as quickly as possible
2. BSwitch the infusion to oral warfarin without a prescription
3. CContinue the same rate and recheck the aPTT in a few days
4. DAdjust the rate as the protocol directs and recheck as scheduled

Pacientui be inkstų problemų ir su normalia EKG kalio koncentracija 6,2 mEq/L. Laboratorija pastebi, kad mėginys buvo hemolizuotas. Koks geriausias aiškinimas?

1. AKalis tikrai normalus ir tolesnių veiksmų nereikia
2. BRezultatas gali būti klaidingai didelis; įvertinti pacientą ir organizuoti pakartotinį mėginį
3. CNedelsiant gydyti insulinu ir gliukoze be tolesnių patikrinimų
4. DPacientas serga inkstų nepakankamumu

A patient taking a statin reports unexplained muscle pain and weakness. What should the nurse do?

1. AReport it, as statins can cause muscle damage
2. BReassure them that this is a sign the drug is working
3. CTell them to double the dose
4. DAdvise more vigorous exercise to work through it

Why can pulse oximetry be misleading in carbon monoxide poisoning?

1. ACarbon monoxide makes the oximeter read zero even in a well patient
2. BThe oximeter overheats in smoke-exposed patients
3. CCarbon monoxide only affects the heart rate reading
4. DStandard oximeters cannot tell carboxyhaemoglobin from oxyhaemoglobin

Why must inspired air be humidified for a patient with a tracheostomy?

1. AHumidified air contains more oxygen than dry air at the same flow
2. BHumidification prevents the cuff from deflating
3. CDry air is needed to stop secretions forming in the trachea
4. DThe nose and upper airway, which warm and moisten air, are bypassed

A nurse phones the doctor about a patient with pneumonia whose observations are worsening. Using SBAR, which statement is the clearest "recommendation"?

1. A"His heart rate is 124/min, his BP is 88/50 mmHg and he is confused."
2. B"He is 72 and was admitted yesterday with community-acquired pneumonia."
3. C"I am calling about the patient in bed 6."
4. D"I think he may have sepsis; please review him within 30 minutes."

Which measure best prevents catheter-associated urinary tract infection?

1. ADisconnect the bag regularly to empty it
2. BKeep the drainage bag above bladder level
3. CRemove the catheter as soon as it is no longer needed
4. DChange the catheter for a new one every day

A patient on IV gentamicin has a rising creatinine and a high trough level. What should the nurse do?

1. AGive the next dose early to clear the infection quickly
2. BStop measuring the drug levels
3. CHold the next dose and inform the prescriber
4. DEncourage more fluids and give the dose as planned

Which wound drain observation should be reported immediately?

1. ADrainage slowly falling each day
2. BA little dried blood around the drain site
3. CA sudden large volume of fresh red blood
4. DSmall amounts of pink serous fluid

A patient finds daily wound dressing changes very painful. What is the most effective nursing approach?

1. ADo the dressing quickly and give analgesia afterwards
2. BGive analgesia timed so it works during the dressing change
3. CAvoid analgesia so the patient can report any problems during the change
4. DChange the dressing less often than the plan says