NCLEX tipo prioritetų nustatymas ir delegavimas: pasiruošimo paketas

One hour after a vaginal birth, the nurse finds a soft, boggy uterus and heavy bleeding. What is the first action?

1. AOffer a meal and fluids
2. BEncourage the patient to rest quietly
3. CApply an ice pack to the perineum
4. DMassage the fundus

Two days after starting haloperidol, a patient suddenly develops painful neck twisting and the eyes roll upwards. What should the nurse anticipate?

1. AA higher dose of haloperidol to calm the patient and stop the movements quickly
2. BNo action, because the spasm is a sign of improvement
3. CPhysical restraint until the spasm passes
4. DAn anticholinergic drug, such as benztropine or procyclidine, as prescribed

A parent says, “I tell my son his medicine is candy so he takes it.” What should the nurse teach?

1. AIt only matters for medicines that taste bitter or are hard to swallow
2. BIt is fine as long as the medicine is kept in the fridge
3. CDo not call medicine candy, because the child may take it when no one is watching
4. DThis is a good idea and makes giving medicine easier

Kuris veiksmas geriausiai užkerta kelią netinkamo vartojimo būdo klaidai su epidurine infuzija?

1. APažymėti epidurinę liniją ir naudoti ją su atskiru, tik jai skirtu infuzomatu
2. BVisas linijas sujuosti lipnia juosta, kad atrodytų tvarkingai
3. CNaudoti laisvą intraveninę jungtį, jei epidurinė jungtis užsikemša
4. DVisoms paciento infuzijoms naudoti tokio paties tipo infuzomatą ir sistemas

Kada reikėtų imti kraujo pasėlius pacientui, kuriam įtariamas sepsis?

1. APo pirmųjų trijų antibiotiko dozių
2. BTik jei karščiavimas trunka ilgiau nei tris dienas
3. CPrieš pirmąją antibiotiko dozę, per daug jos nevėlinant
4. DBet kuriuo metu, nes antibiotikai rezultato neveikia

Pacientas, sergantis širdies nepakankamumu, vartoja lizinoprilį, spironolaktoną ir kalio papildą. Šiandien kalis yra 6,0 mEq/L. Koks labiausiai tikėtinas paaiškinimas?

1. AKartu vartojami keli kalį didinantys vaistai
2. BSpironolaktonas sukelia kalio netekimą
3. CLizinoprilis mažina kalį
4. DKalio papildai neturi įtakos koncentracijai serume

A patient on peritoneal dialysis notices the drained fluid has become cloudy and has abdominal pain. What is likely?

1. AConstipation
2. BNormal dialysis fluid
3. CA urinary tract infection
4. DPeritonitis

A patient going home after chemotherapy is taught about infection. Which statement shows a need for further teaching?

1. A"I will wash my hands well before eating and after using the toilet."
2. B"I will check my temperature if I feel unwell or shivery at home."
3. C"I will phone the helpline if I have a fever or shivering."
4. D"If I get a temperature, I'll take paracetamol and wait until my next clinic."

Kas yra išstūmimo frakcija?

1. AKraujo tūris, kurį širdis išpumpuoja per minutę
2. BKiekvieno susitraukimo metu išstumiamo skilvelio kraujo procentinė dalis
3. CKraujo tūris, išpumpuojamas per vieną širdies susitraukimą
4. DKairiojo skilvelio slėgis diastolinio prisipildymo pabaigoje

After four days of antibiotics for pneumonia, a patient still has fever and pleuritic pain. There is dullness and reduced breath sounds at the right base. What complication should be suspected?

1. ANormal recovery from pneumonia
2. BAn allergic reaction to the antibiotic
3. CA parapneumonic effusion or empyema
4. DAsthma triggered by the infection

A patient with Alzheimer's disease starts donepezil. Which side effects should the nurse look for?

1. AA persistent dry cough and a raised potassium
2. BWeight gain, high glucose and swollen ankles
3. CNausea, diarrhoea and a slow heart rate
4. DDry mouth, constipation and a fast heart rate

A patient with renal colic has normal kidney function and no other contraindications. Which drug is usually the first choice for pain?

1. AA benzodiazepine such as diazepam
2. BOral paracetamol (acetaminophen) alone
3. CAn oral antihistamine such as cetirizine
4. DAn NSAID such as diclofenac

Why do patients with major burns lose so much fluid in the first 24–48 hours?

1. ALeaky capillaries let plasma move into the tissues
2. BPatients drink far too little in hospital in the first days
3. CThe burned skin absorbs fluid from the air
4. DThe kidneys stop making urine completely

A colleague suggests giving a saline injection to see whether a patient's pain is "real". What is the best response?

1. AIt is a good idea, as long as the patient is not told about it afterwards
2. BDeceptive placebos are unethical and do not show pain is "fake"
3. CIt should be done only for patients with chronic pain
4. DIt is acceptable if a senior nurse gives the saline