NCLEX tipo prioritetų nustatymas ir delegavimas: pasiruošimo paketas

A patient has a serum potassium of 6,8 mEq/L. Which action comes first?

1. AGive the patient’s scheduled potassium supplement
2. BRecheck the level next week
3. CPlace the patient on a cardiac monitor
4. DEncourage foods high in potassium

A day after a femur fracture, a young patient becomes confused and breathless, with small red spots on the chest. What should the nurse suspect?

1. AAlcohol withdrawal
2. BNormal pain after a fracture
3. CAn allergic reaction to the cast
4. DFat embolism syndrome

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

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

An audit shows poor hand hygiene compliance on a ward. Which plan is most likely to improve it?

1. ADisciplining staff who are seen not cleaning their hands, with no other change
2. BA single poster about hand hygiene placed in the staff room
3. CA combined approach with education, hand rub at every bedside, regular audits and feedback
4. DRemoving all sinks so staff must use hand rub

Digoksiną vartojančio paciento koncentracija 2,8 ng/mL, o širdies susitraukimų dažnis 52/min. Koks geriausias slaugytojo veiksmas?

1. ASulaikyti dozę ir informuoti skiriantįjį gydytoją
2. BDuoti dozę, nes širdies susitraukimų dažnis didesnis nei 50/min
3. CDuoti dvigubą dozę ritmui pataisyti
4. DDuoti dozę ir koncentraciją patikrinti po mėnesio

The nurse teaches a patient who is starting warfarin. Which statement shows a need for further teaching?

1. A"I will have my INR checked as often as I am told to"
2. B"I will keep my intake of green leafy vegetables about the same"
3. C"If I miss a dose, I will take two tablets the next day"
4. D"I will tell my dentist and pharmacist that I take warfarin"

How is Helicobacter pylori infection usually treated?

1. AAntacids alone, taken after every meal for a month
2. BA single dose of paracetamol and a bland diet for a week
3. CA combination of antibiotics with a proton pump inhibitor
4. DSurgery to remove the stomach

After a high spinal cord injury, a patient has low blood pressure with a slow heart rate and warm, dry skin. What is most likely?

1. ANeurogenic shock
2. BCardiac tamponade
3. CSeptic shock
4. DHypovolaemic shock

How big should a suction catheter be compared with the tracheostomy or endotracheal tube?

1. ANo more than half the internal diameter of the tube
2. BAny size, as the diameter does not matter
3. CExactly the same diameter as the tube, for a tight fit
4. DLarger than the tube, so that it clears it completely

A patient with a COPD exacerbation has been on NIV for two hours. They are now more drowsy, and the pH has fallen further despite a good mask fit. What should the nurse do?

1. AContinue NIV unchanged and repeat the blood gas tomorrow morning
2. BRemove the mask and give nebulised bronchodilators only from now on
3. CEscalate urgently for review of intubation or a ceiling of care
4. DGive a sedative to help the patient tolerate the mask

An 85-year-old care home resident becomes newly confused and is falling more often. A UTI is one possibility. Why?

1. AOlder adults often show infection as confusion
2. BA UTI cannot occur in people over 80
3. CConfusion is the only symptom of a UTI at any age
4. DUrinary infections always cause a high fever in older adults

Why might a frail 88-year-old with type 2 diabetes have a less strict HbA1c target?

1. ABecause older people cannot use any glucose medicines
2. BTo save money on blood tests and drugs
3. CBecause diabetes cannot damage older people
4. DTo reduce the risk of hypos, falls and confusion

During the first infusion of a monoclonal antibody such as rituximab, which problem is most important to watch for?

1. AA rise in platelet count above normal
2. BSevere constipation within the first hour of starting the infusion
3. CSudden hair loss during the infusion
4. DAn infusion reaction, such as fever, rigors or breathlessness

A nurse teaches a carer about overnight tube feeding at home. Which statement shows a need for further teaching?

1. A"I'll flush the tube with water before and after his medicines."
2. B"I'll check the external length mark on the tube every day."
3. C"I'll let him lie flat so he sleeps better while the feed runs."
4. D"I'll stop the feed and call if he coughs or struggles to breathe."