Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Which newborn finding needs prompt reporting?

1. AMild jaundice that first appears on the third day
2. BBluish hands and feet in the first hours
3. CMilia (small white spots) on the nose
4. DJaundice that appears within the first 24 hours

An 85-year-old resident becomes newly confused and is falling, but has no fever. Which cause should the nurse consider first?

1. ABoredom from not having enough activities
2. BAn infection, such as a urinary tract infection, presenting atypically
3. CNormal aging that needs no assessment
4. DA sudden worsening of long-standing dementia that needs no tests

A patient has highly contagious viral conjunctivitis. Which teaching is most important?

1. AWash hands often and do not share towels, pillows or eye drops
2. BRub the eyes gently to remove the discharge
3. CWear a surgical mask whenever someone else is in the room
4. DKeep using the same contact lenses to protect the eyes

Pielęgniarka nie jest pewna, czy jałowa rękawiczka dotknęła brzegu jałowego pola. Jakie jest prawidłowe postępowanie?

1. AKontynuować, ponieważ pielęgniarka nie ma pewności
2. BUznać rękawiczkę za skażoną i ją wymienić
3. CZapytać pacjenta, czy to widział
4. DPrzetrzeć rękawiczkę alkoholem

Pacjent przyjmujący warfarynę z powodu migotania przedsionków ma INR 1,4. Co to oznacza?

1. APacjent ma wysokie ryzyko krwawienia i potrzebuje natychmiast witaminy K
2. BDawka jest dokładnie właściwa i nie wymaga zmiany
3. CPacjent nie musi już przyjmować warfaryny
4. DLeczenie przeciwzakrzepowe jest poniżej celu, więc większe jest ryzyko zakrzepów i udaru

A young man has a swollen knee after minor trauma. His aPTT is prolonged, but his PT/INR and platelet count are normal. Which condition fits best?

1. ADisseminated intravascular coagulation
2. BImmune thrombocytopenia (ITP)
3. CVitamin K deficiency from poor diet
4. DHemophilia A (factor VIII deficiency)

What should a patient starting oral iron tablets be told?

1. AThey must take the tablets with strong tea
2. BTheir urine will turn bright green
3. CTheir stools may turn dark or black
4. DThe tablets will cause weight loss

A seriously ill patient asks the nurse, "Am I dying?" What is the best initial response?

1. AGently explore what the patient understands and what has prompted the question
2. BChange the subject quickly to keep them cheerful and avoid upsetting them
3. CLeave and send the doctor without saying anything
4. DTell the patient not to think about such things and to stay positive

Before the first treatment dose of a low-molecular-weight heparin for a PE, what does the nurse need to make sure of?

1. AA chest drain is in place
2. BThe patient has fasted for 12 hours
3. CThe patient's blood glucose is above 10 mmol/L (180 mg/dL)
4. DAn accurate, recent body weight is recorded

A patient with life-threatening asthma has not responded to repeated nebulised salbutamol (albuterol), ipratropium and steroids. Which drug is commonly given intravenously next?

1. AMorphine
2. BMetoprolol
3. CIntravenous furosemide
4. DMagnesium sulfate

Before a haemodialysis catheter is used, why is the lock solution withdrawn from each lumen?

1. AIt contains concentrated anticoagulant
2. BIt contains the patient's urine
3. CIt contains air that keeps the line open
4. DIt contains a strong antibiotic that must be kept

Which patient on a stroke unit is most at risk of falling?

1. AA patient with a left-hemisphere stroke who has expressive aphasia and waits for help
2. BA patient with a TIA whose symptoms resolved completely yesterday
3. CA patient with mild dysarthria who walks steadily with a frame
4. DA patient with a right-hemisphere stroke who is impulsive and denies having weakness

Jakie działania pomagają zapobiegać zespołowi rozpadu guza u pacjentów wysokiego ryzyka?

1. ANawodnienie dożylne z allopurynolem lub rasburykazą
2. BOgraniczenie płynów z tabletkami potasu
3. CCodzienne suplementy wapnia i fosforanów
4. DZatrzymanie wszystkich płynów dożylnych i doustnych podczas chemioterapii

After signing the consent form, a patient tells the nurse, "I don't really understand what they are going to do." What should the nurse do?

1. AInform the surgeon so that the procedure can be explained again
2. BReassure the patient that the surgeon knows best
3. CIgnore the comment because the form is already signed
4. DExplain the surgical risks in detail without involving the surgeon