Prioriteren en delegeren in NCLEX-stijl: samenvattingspakket

A patient reports pain of 8/10. Before giving the prescribed as-needed analgesic, what does the nurse do first?

1. AGive the strongest analgesic on the chart straight away
2. BAsk the nursing assistant to reposition the patient
3. CAssess the location, character and onset of the pain and the vital signs
4. DTell the patient to wait until the next scheduled dose is due in two hours

Using ESI, a stable adult with abdominal pain will need blood tests and a CT scan, but has a heart rate of 130/min. Which statement is correct?

1. AThe patient is level 5 because the pain is not severe
2. BThe nurse should consider level 2 because of the danger-zone vital sign
3. CThe patient is level 4 because the blood tests and the scan count as one resource
4. DVital signs never change the ESI level

A patient has leftover opioid tablets after surgery. Which advice about disposal is best?

1. AKeep them in an unlocked drawer at home in case of future pain
2. BLeave them in the bathroom cabinet indefinitely
3. CReturn them to a pharmacy or an approved take-back site
4. DGive them to a friend or relative who has back pain

Which action by assistive personnel requires the nurse to step in?

1. AGoing from one patient’s bed to the next while wearing the same gloves
2. BWashing hands with soap and water after leaving a C. difficile room
3. CPutting soiled linen straight into a laundry bag at the bedside
4. DRemoving gloves and then cleaning the hands with alcohol rub

A patient has had severe watery diarrhea for 4 days. Which laboratory pattern would the nurse expect?

1. ALow potassium and low bicarbonate
2. BHigh sodium and high calcium
3. CLow glucose and high magnesium
4. DHigh potassium and high bicarbonate

A patient with cirrhosis and ascites has fever and abdominal tenderness. The ascitic fluid neutrophil count is 400 cells/mm³. What does this indicate?

1. ASpontaneous bacterial peritonitis
2. BBleeding into the abdominal cavity
3. CMalignant ascites from cancer
4. DNormal ascitic fluid in cirrhosis

Een patiënt die warfarine gebruikt, heeft een INR ver boven de streefwaarde en blauwe plekken. Welk middel kan worden voorgeschreven om het effect op te heffen?

1. AProtaminesulfaat
2. BNaloxon
3. CVitamine K
4. DAcetylsalicylzuur

A patient due a blood transfusion is not wearing an identity band. What should the nurse do?

1. ACheck the name on the bed and proceed
2. BNot start until a correct identity band is in place and identity is confirmed
3. CAsk the patient to state their name and date of birth, then start straight away
4. DAsk another patient to confirm who the patient is

Waarom worden patiënten met ernstige COPD aangemoedigd kleine, frequente maaltijden te eten?

1. AFrequente maaltijden voorkomen direct luchtweginfecties
2. BEen volle maag beperkt het middenrif en eten is vermoeiend
3. CGrote maaltijden laten de luchtwegen blijvend vernauwen
4. DKleine maaltijden verminderen hoe vaak inhalatoren nodig zijn

A ventilated patient with severe ARDS is to be turned prone. What is the main reason, and the key nursing risk?

1. AIt treats infection; the risk is fever
2. BIt improves oxygenation; risks are pressure injury and tube displacement
3. CIt lowers the blood pressure; the main risk is rebound hypertension
4. DIt improves digestion and gut motility; the main risk is constipation

A patient on ciclosporin or tacrolimus asks about grapefruit juice. Which advice is correct?

1. AAvoid it, because it can raise the drug levels
2. BDrink it with each dose to improve the absorption
3. CIt has no effect on these drugs
4. DDrink it daily to protect the kidney

Which statement correctly distinguishes spinal shock from neurogenic shock?

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

Which statement about pain in older adults is correct?

1. AOpioids must never be used in people over 70
2. BPain is a normal part of ageing and does not need any treatment at all
3. COlder adults feel less pain because nerves wear out
4. DThey may under-report pain, so active assessment is needed

A patient admitted for an elective general anaesthetic mentions that they ate a slice of toast 3 hours ago. What should the nurse do?

1. AGive a large drink to wash the food through
2. BInform the anaesthetist, as surgery may be delayed
3. CAsk the patient to try to vomit to empty the stomach
4. DSay nothing, since toast is a light food