Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Which patient should the RN see first after receiving a report from the night nurse?

1. ADay 3 after bowel surgery, wants a shower and hair wash before breakfast
2. BDay 1 after bowel surgery, new chest pain and heart rate 110/min
3. CDay 2 after bowel surgery, asking to start a soft diet
4. DDay 4 after bowel surgery, waiting for discharge teaching

A 2-month-old infant has a spiral fracture of the femur. The parents say the baby rolled off the sofa. What should the nurse recognize?

1. ANo further action is needed once the fracture is treated
2. BThe injury does not fit the infant’s development, so possible abuse must be reported
3. CA spiral fracture in an infant is always caused by birth trauma
4. DInfants of this age often roll off furniture and break bones in this way

An order reads “Give potassium chloride by IV push.” What should the nurse do?

1. ANot give it, and contact the prescriber, because it is never given by IV push
2. BGive it slowly by IV push over two minutes while watching the cardiac monitor
3. CGive half by IV push and the rest later
4. DDilute it in a small syringe and push it

A patient on contact precautions for MRSA has become withdrawn and says, “Everyone avoids me.” What is the best nursing action?

1. AStop the precautions for a few days so the patient feels less isolated and alone
2. BKeep visits short to limit the risk of spreading MRSA
3. CExplain why the precautions are needed and plan regular, unhurried time in the room
4. DAsk the provider for a sedative to help the patient cope

A patient with hepatic encephalopathy is receiving lactulose. Which finding best shows that the treatment is effective?

1. ATwo to three soft stools a day and clearer thinking
2. BSix to eight watery stools a day with dizziness
3. CNo bowel movement for 2 days and calm sleep
4. DA rising serum ammonia with a slower flapping tremor

A patient's AST is about twice the ALT, both moderately raised, and the GGT is high. Which cause is most likely?

1. AGallstone blocking the bile duct
2. BAcute viral hepatitis A
3. CAcute myocardial infarction
4. DAlcohol-related liver disease

A patient is admitted with cellulitis of the leg. Why might the nurse mark the edge of the redness on the skin?

1. ATo monitor whether the infection is spreading or improving
2. BTo mark the site for an injection
3. CTo show the surgeon exactly where to make the incision
4. DTo help the patient find the sore area

An adult with capacity refuses a blood transfusion for religious reasons, even though it may save their life. What should the nurse do?

1. AAsk a family member to consent instead
2. BRespect the refusal, check it is informed and document it, and inform the team
3. CSedate the patient so the transfusion can be given
4. DGive the transfusion while the patient is asleep, as it is in their best interests

Pacjent ma ból w środku klatki piersiowej i STEMI w EKG. Co to zwykle wymaga?

1. AWyniku troponiny przed podjęciem jakiejkolwiek decyzji o leczeniu
2. BPrzyjęcia na oddział i powtórzenia EKG następnego ranka
3. CDoustnego beta-blokera i wypisu, jeśli ból ustąpi
4. DPilnej reperfuzji, najlepiej przez pierwotną PCI

82-letni pacjent z pozaszpitalnym zapaleniem płuc jest od niedawna splątany, ma częstość oddechów 32/min, ciśnienie 88/52 mmHg i mocznik 9 mmol/L. Co to wskazuje?

1. AWynik CURB-65 równy 3: wyłącznie rutynowe przyjęcie na oddział ogólny
2. BWynik CURB-65 równy 5: wysokie ryzyko wymagające pilnej oceny starszego lekarza
3. CWynik CURB-65 równy 1: nadaje się do doustnych antybiotyków w domu
4. DPrawidłową reakcję na zakażenie u osoby starszej

Which measure best detects a decline in breathing in a patient with Guillain–Barré syndrome?

1. ADaily chest X-rays
2. BRegular forced vital capacity measurements
3. CPeak flow before and after a bronchodilator
4. DOxygen saturation alone

A man with chronic urinary retention is catheterised. Over the next hours he passes very large volumes of urine. What is the main nursing concern?

1. AA urinary infection caused by the high flow of urine
2. BA rise in blood glucose from the urine
3. CFluid and electrolyte loss from post-obstructive diuresis
4. DRupture of the bladder from the catheter

In the SBAR communication tool, what belongs under "A"?

1. AThe nurse's assessment of what the problem is
2. BThe address and phone number of the patient's next of kin
3. CThe patient's admission date only
4. DA list of the patient's allergies only

While a central line is disconnected, a patient suddenly becomes breathless with chest pain and hypotension. Air embolism is suspected. What should the nurse do first?

1. AClamp the line, lie the patient left side down, head low; give oxygen
2. BGive the patient a drink and observe for an hour
3. CRemove the central line straight away and leave the site open to the air
4. DSit the patient fully upright and flush the line