NCLEX tipo prioritetų nustatymas ir delegavimas: pasiruošimo paketas

Stabilus suaugusysis su normaliais gyvybiniais rodikliais turi rankos įpjovimą, kuriam reikia siūlių, ir daugiau nieko. Koks ESI lygis tinka?

1. A4 lygis
2. B2 lygis
3. C3 lygis
4. D5 lygis

Which patient needs airborne precautions rather than droplet precautions?

1. AA child with chickenpox (varicella)
2. BAn adult with influenza
3. CA child with pertussis (whooping cough)
4. DA teenager with mumps

Kuris vertinimas svarbiausias, kai pacientui užrišti riešų fiksavimo dirželiai?

1. APaciento maisto ir gėrimų pageidavimai dienai
2. BPaciento klausos abiem ausimis tikrinimas laikrodžiu
3. CKraujotakos, jutimo ir odos už fiksavimo priemonės vertinimas
4. DPaciento ūgis ir svoris

Pacientas, sergantis sunkia demencija, naktį savarankiškai kelia iš lovos ir du kartus buvo nukritęs. Kuris planas tinkamiausias?

1. AKiekvieną naktį duoti raminamąjį, kad pacientas liktų lovoje
2. BPer naktį pririšti pacientą prie kėdės
3. CŽema lova, lovos signalizacija, vedimas į tualetą pagal grafiką, naktinė lemputė ir neslystančios kojinės
4. DKeturi pakelti atitvarai ir naktį uždarytos durys ramybei

A urine culture report states "mixed growth of three organisms, likely contamination." What is the nurse's best response?

1. ADiscard the report, because a mixed growth is always normal
2. BRecord the result as a confirmed urinary tract infection
3. CInform the provider and arrange a new, correctly collected sample
4. DStart treatment for all three organisms with three antibiotics

The nurse teaches a patient with iron-deficiency anemia who is starting oral iron. Which statement shows a need for further teaching?

1. A"I can take it with orange juice to help absorption"
2. B"I'll take my iron tablet with a big glass of milk"
3. C"My stools may look darker while I take the tablets"
4. D"I'll keep the tablets out of reach of the children"

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

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

Pacientui, kuriam ūmiai kraujuoja iš virškinamojo trakto, ŠSD 120/min, o kraujospūdis 90/60 mmHg. Kas yra slaugos prioritetas pakvietus pagalbą?

1. ADuoti sotų valgį energijai atkurti
2. BSkatinti vieną nueiti į tualetą
3. CUžtikrinti plataus spindžio intraveninę prieigą ir pasiruošti skysčių ar kraujo pakaitai
4. DAtidėti veiksmus, kol bus patikrinta išmatų spalva

Kuris patarimas padeda išvengti GVT per ilgą skrydį ar po operacijos?

1. ASėdėti sukryžiavus kojas patogumui
2. BReguliariai mankštinti čiurnas ir gerti pakankamai skysčių
3. CDėvėti standžias elastines juostas tuoj žemiau kelio
4. DMažiau gerti, kad nereikėtų eiti į tualetą

A patient receiving noradrenaline (norepinephrine) through a peripheral cannula has pale, cold skin around the site. What should the nurse do?

1. AContinue the infusion, as this is expected
2. BStop it at that site, inform the team and follow the extravasation policy
3. CIncrease the rate so the drug enters the vein faster and leaks less
4. DMassage the area firmly to spread the drug out into the surrounding tissue

Why is good blood pressure control important in chronic kidney disease?

1. AIt raises the haemoglobin level in the blood
2. BIt slows the decline in kidney function
3. CIt lowers the blood glucose
4. DIt cures chronic kidney disease

At bedtime, a patient was given their rapid-acting insulin by mistake instead of their long-acting insulin. What should the nurse do?

1. ASay nothing, because the patient is asleep and seems fine
2. BTell the prescriber and check glucose often overnight
3. CGive glucagon now, before the glucose has fallen
4. DGive the long-acting dose as well and check glucose at breakfast

Which is a common side effect of opioids, especially when given by epidural or spinal route?

1. AHair growth
2. BItching
3. CIncreased hunger
4. DRinging in the ears

After two days of large volumes of IV 5% glucose, a postoperative patient becomes confused with a headache. Sodium is 124 mmol/L. What is the likely cause?

1. AHyponatraemia from hypotonic fluids
2. BNormal confusion after any anaesthetic
3. CHypernatraemia from too much salt
4. DHypoglycaemia from the glucose