Prioriteren en delegeren in NCLEX-stijl: samenvattingspakket

During an IV vancomycin infusion, a patient develops flushing and itching of the face and neck. What should the nurse do first?

1. AApply a warm compress to the face and neck
2. BStop or slow the infusion and inform the provider
3. CIgnore it, because flushing is always harmless and passes
4. DSpeed up the infusion to finish it quickly

A patient has a heart rate of 38/min, feels dizzy and has a blood pressure of 80/50 mmHg. Which drug is usually given first, as prescribed?

1. ADigoxin
2. BDiltiazem
3. CAtropine
4. DMetoprolol

In een patiëntenkamer ontstaat een kleine brand in een afvalbak terwijl de patiënt in bed ligt. Wat doet de verpleegkundige als eerste?

1. ADe ramen openen om de rook te laten verdwijnen
2. BDe leidinggevende bellen om de brand te melden
3. CDe dichtstbijzijnde brandblusser gaan zoeken
4. DDe patiënt uit het directe gevaar halen

The laboratory reports that a blood sample labeled with one patient’s name has a blood group different from that patient’s previous result. What is the most likely problem and response?

1. AA laboratory machine fault, so no action is needed
2. BA wrong-patient sample, so the test is repeated and the event reported
3. CA normal change in the patient’s blood group over the years since the last test
4. DThe previous result was wrong, so it is deleted

In countries that screen all pregnant women (such as the US), a vaginal-rectal swab is taken at about 36–37 weeks. Which organism is it screening for?

1. ACandida albicans
2. BGroup B Streptococcus
3. CStaphylococcus aureus
4. DHepatitis B virus

A patient has eaten very little for 2 weeks and has received broad-spectrum antibiotics. The INR is now 2,3 without warfarin, and the platelets are normal. What is the most likely cause?

1. AVitamin K deficiency
2. BImmune thrombocytopenia
3. CHemophilia A
4. DIron-deficiency anemia

Why should a urinary catheter drainage bag be kept below the level of the bladder?

1. ATo make the bag easier for the nurse to empty
2. BTo prevent urine flowing back into the bladder
3. CTo keep the urine warm
4. DTo stop the catheter from falling out

Which action is most important in protecting a patient with severe neutropenia from infection?

1. AKeeping fresh flowers and plants in the room to help the patient's mood
2. BStrict hand hygiene by everyone who has contact with the patient
3. CGiving routine intramuscular injections
4. DTaking rectal temperatures regularly

Welke kenmerken beschrijven het best een arterieel beenulcus?

1. APijnlijk, bleek, als uitgestanst ulcus op de tenen met zwakke voetpulsaties
2. BOppervlakkig, vochtig ulcus boven de binnenenkel met bruine huid
3. CNattend ulcus op het scheenbeen met indrukbaar oedeem van het been
4. DPijnloos ulcus onder de bal van de voet met dikke eelt eromheen

A patient on spironolactone and an ACE inhibitor has a potassium of 6,8 mmol/L (6,8 mEq/L) with peaked T waves. What is usually given first to protect the heart?

1. AA dose of digoxin
2. BOral potassium supplements
3. CIntravenous calcium gluconate or chloride
4. DAn IV furosemide bolus as the only treatment

A patient with a spinal cord injury can still feel a light touch around the anus. What does this show?

1. AThe injury is complete, and recovery is not possible
2. BThe sensation is only a spinal reflex and has no real meaning for recovery
3. CThe injury is incomplete, which suggests a better chance of recovery
4. DThe patient has an injury of the brain, not the cord

Which task for a stroke patient can a registered nurse safely delegate to a healthcare assistant (nursing assistant)?

1. ACarrying out the first bedside water swallow screen after admission
2. BAssessing a new weakness the patient reports in the leg
3. CRepositioning the patient every two hours as set out in the care plan
4. DTeaching the patient how to take a new anticoagulant

Aspirate from a nasogastric tube has a pH of 7. What should the nurse do?

1. ADo not use it; re-test later or arrange an X-ray as per policy
2. BStart the feed slowly and watch the patient closely for coughing
3. CGive the medicines but not the feed
4. DFlush with 50 mL of air and start the feed

Why is an SGLT2 inhibitor such as dapagliflozin usually withheld before surgery?

1. AIt interacts with all general anaesthetic gases and stops them working
2. BIt raises the risk of ketoacidosis, even with near-normal glucose
3. CIt makes the patient's potassium dangerously high
4. DIt causes the surgical wound to bleed more