NCLEX tipo prioritetų nustatymas ir delegavimas: pasiruošimo paketas

A nurse teaches a patient to use an incentive spirometer. Which statement shows a need for further teaching?

1. A“I will blow into it as hard and fast as I can.”
2. B“I will try to hold my breath for a few seconds at the top.”
3. C“I will breathe in slowly and deeply through the mouthpiece.”
4. D“I will use it several times every hour while awake.”

A nurse sees a colleague put a vial of an opioid into their own pocket instead of returning it. What should the nurse do?

1. ATell the patients to watch the colleague carefully
2. BReport it to the nurse manager according to policy
3. CSay nothing, because it is not their business
4. DAsk the colleague to share the vial with them

When should blood specimen tubes be labeled?

1. AAt the bedside, in front of the patient, right after collection
2. BBack at the station after all the samples are collected
3. CAt the nurses’ station before going to the patient, to save time
4. DBy the laboratory staff after the tubes arrive

A patient on chemotherapy develops shingles over several areas on both sides of the body. Which precautions are needed?

1. AAirborne and contact precautions until all lesions are crusted
2. BContact precautions only, with gloves for dressing changes
3. CStandard precautions only, with the lesions covered
4. DDroplet precautions until the pain settles

A patient taking spironolactone asks about using a salt substitute. What should the nurse explain?

1. AMost salt substitutes contain potassium and can raise the level too high
2. BSalt substitutes protect against the potassium loss caused by this drug
3. CSalt substitutes are safe because they contain only sodium chloride
4. DSalt substitutes are fine as long as the patient drinks more water

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

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

After a needlestick injury from a patient known to have HIV, why must the nurse report it immediately?

1. AThe nurse must be tested for HIV the same day to confirm infection
2. BThe needle must be sent for culture
3. CPost-exposure prophylaxis works best when started as soon as possible
4. DThe patient will need antibiotics

A seriously ill patient asks the nurse, "Am I dying?" What is the best initial response?

1. ATell the patient not to think about such things and to stay positive
2. BLeave and send the doctor without saying anything
3. CGently explore what the patient understands and what has prompted the question
4. DChange the subject quickly to keep them cheerful and avoid upsetting them

A patient arrives with suspected cardiac chest pain. How soon should a 12-lead ECG be recorded?

1. AWithin about 10 minutes of arrival
2. BWithin 2 hours of arrival
3. CThe following morning
4. DOnly after the troponin result is available

Which instruction from the registered nurse to a healthcare assistant (unlicensed assistive personnel) caring for a patient with COPD is most appropriate?

1. A"Listen to his chest after lunch and let me know what you can hear."
2. B"Teach him how to use his new inhaler this afternoon after his rest."
3. C"Turn his oxygen up to whatever he needs if he looks short of breath."
4. D"Tell me straight away if his SpO₂ is under 88% or he is more breathless."

A patient with a new ileal conduit has threads of mucus in their urine. What should the nurse explain?

1. AThis proves a serious kidney infection
2. BThis is a sign that the stoma is dying
3. CThis is normal, because the conduit is made from bowel
4. DThe kidneys have stopped working properly after surgery

Which statement correctly distinguishes spinal shock from neurogenic shock?

1. AThey are two names for exactly the same condition
2. BNeurogenic shock is caused by blood loss; spinal shock is caused by infection
3. CSpinal shock is low blood pressure; neurogenic shock is the loss of reflexes
4. DSpinal shock is lost reflexes; neurogenic shock is low BP and slow pulse

Why are antimotility drugs such as loperamide avoided in C. difficile infection?

1. AThey kill the normal bowel bacteria
2. BThey cause serious liver failure in most patients who take them
3. CThey make the stool sample test positive falsely
4. DThey may keep toxin in the bowel and risk toxic megacolon

Pacientui su ileostoma 6 valandas išskyrų nėra, jaučia mėšlungį, pilvo išsipūtimą, pykinimą, o stoma ištinusi. Ką turėtų įtarti slaugytojas?

1. ANormalų tylų laikotarpį su nauja ileostoma
2. BNedidelį odos bėrimą aplink stomą
3. CDehidrataciją dėl labai gausių ileostomos išskyrų
4. DStomos užsikimšimą, dažnai dėl maisto, kuriam reikia įvertinimo