Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Which action by a nursing assistant needs the nurse to step in?

1. ATaking an oral temperature just after the patient drank cold water
2. BLowering the bed to its lowest position and locking the wheels after care
3. CCleaning hands before entering the room
4. DPutting the call light within the patient’s reach

A child with sickle cell disease in a pain crisis develops chest pain, fever and an SpO₂ of 89%. What does this most likely mean?

1. AAnxiety that will settle with reassurance
2. BAcute chest syndrome, which needs urgent escalation and oxygen
3. CA minor chest infection that can safely wait until the morning round
4. DAn ordinary pain crisis that will improve with rest

Dlaczego w przypadku niektórych leków, takich jak wlewy insuliny i heparyny, stosuje się niezależne podwójne sprawdzenie?

1. AAby przyspieszyć proces przygotowania
2. BAby podzielić odpowiedzialność między dwie pielęgniarki w razie błędu
3. CDruga osoba sprawdzająca osobno wychwytuje przeoczone błędy
4. DPonieważ marnowanie tych leków jest bardzo kosztowne

A patient rescued from a house fire has a headache and confusion, but the pulse oximeter reads 99%. Why might this reading be misleading?

1. APulse oximeters always read falsely low after any kind of smoke exposure
2. BPulse oximetry cannot tell carbon monoxide-bound hemoglobin from oxygen-bound hemoglobin
3. CConfusion and headache make pulse oximetry readings inaccurate in every patient
4. DThe reading is accurate, so carbon monoxide poisoning is ruled out

A patient on a heparin infusion has blood in the urine and an aPTT far above the target. The nurse stops the infusion and informs the provider. Which antidote should the nurse anticipate?

1. ACalcium gluconate
2. BVitamin K (phytonadione)
3. CProtamine sulfate
4. DNaloxone

A patient receiving parenteral nutrition with lipid emulsion has a triglyceride level of 620 mg/dL (7,0 mmol/L). Why is this result important?

1. AIt shows the nutrition is fully effective
2. BIt raises the risk of acute pancreatitis
3. CIt means the patient needs more lipid
4. DIt is a normal fasting value for adults

For a patient in skin traction on the leg, which is correct?

1. AThe rope is tied to the bed frame to keep it still
2. BThe weights hang freely and do not rest on the bed or floor
3. CThe weights rest on the floor overnight
4. DThe weights are removed whenever the patient feels uncomfortable

Why is a patient kept under observation for several hours after successful treatment of anaphylaxis?

1. AAntihistamines cause dangerous drowsiness for 24 hours
2. BThe patient must stay until all allergy tests are complete
3. CAdrenaline always causes a heart attack hours later
4. DSymptoms can return later in a biphasic reaction

Jakie szczepienia zwykle zaleca się osobom z POChP?

1. ASzczepienie BCG co pięć lat
2. BWyłącznie coroczna dawka przypominająca przeciw tężcowi
3. CŻadnych szczepień, ponieważ wiadomo, że wywołują zaostrzenia
4. DCoroczne szczepienie przeciw grypie i pneumokokom

A patient being treated for infective endocarditis of the mitral valve suddenly develops slurred speech and weakness of the right arm. What is the most likely cause?

1. AA side effect of the IV antibiotic on the nerves
2. BAn embolus from a valve vegetation causing a stroke
3. CLow blood glucose from a reduced appetite
4. DA migraine aura triggered by the fever

Po operacji przysadki pacjent oddaje 400 mL moczu na godzinę przez trzy godziny, z niskim ciężarem właściwym. Co powinna podejrzewać pielęgniarka?

1. APrawidłową diurezę
2. BOstre uszkodzenie nerek
3. CMoczówkę prostą
4. DSIADH

Pacjent dochodzący do siebie po ostrej martwicy cewek nerkowych wchodzi w fazę wielomoczu i oddaje ponad 4 L moczu na dobę. Jaki jest główny problem pielęgniarski?

1. AHipoglikemia spowodowana nadmiarem insuliny
2. BOdwodnienie z niskim stężeniem potasu i sodu
3. CZaleganie moczu w rozdętym pęcherzu
4. DPrzeciążenie płynami z wysokim stężeniem potasu

Which treatment often relieves pain from a bone metastasis?

1. APalliative radiotherapy to the area
2. BComplete bed rest for a month
3. CA diet low in calcium and vitamin D
4. DIron supplements by mouth for several months

A patient with a severe flare of ulcerative colitis develops abdominal distension, fever and tachycardia, and the stool frequency has dropped. What should the nurse suspect?

1. AThe flare is getting better
2. BHaemorrhoids caused by diarrhoea
3. CToxic megacolon
4. DSimple constipation from low intake