Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Które stwierdzenie świadczy o prawidłowym rozumieniu odpowiedzialności w delegowaniu?

1. A„Gdy już deleguję zadanie, przestaje być moją sprawą.”
2. B„Jeśli zadanie pójdzie źle, odpowiada tylko asystent.”
3. C„Asystent pielęgniarski odpowiada za to, czy zadanie słusznie delegowano.”
4. D„Pozostaję odpowiedzialna za decyzję o delegowaniu i za sprawdzenie wyniku.”

A patient has central chest pain that started 30 minutes ago at rest and has not eased with rest or nitroglycerin. What does this suggest?

1. AStable angina that will pass without treatment
2. BA possible myocardial infarction that needs urgent action
3. CIndigestion that is best treated with an antacid and a glass of milk
4. DMuscle strain that needs a warm compress

A parent calls because a toddler has swallowed some household cleaner. The child is awake and breathing normally. What should the nurse advise first?

1. AContact the local poison advice service now for specific advice
2. BWait to see whether any symptoms develop over the next day
3. CMake the child vomit, using a finger at the back of the throat
4. DGive syrup of ipecac from the medicine cabinet

Which position is especially dangerous for a patient in physical restraints?

1. ALying face down (prone)
2. BSitting upright in bed
3. CLying on the back with the head raised
4. DLying on the side

Który czynnik najprawdopodobniej zwiększy stężenie litu u pacjenta?

1. APrzyjmowanie każdej dawki z posiłkiem zamiast przed nim
2. BOdwodnienie lub nagłe zmniejszenie podaży sodu
3. CPicie większej niż zwykle ilości płynów w upalną pogodę
4. DSpożywanie większej niż zwykle ilości soli przez kilka dni

A patient without diabetes in the ICU with sepsis has a glucose of 260 mg/dL (14,4 mmol/L) and an HbA1c of 5,2%. What is the best interpretation?

1. AStress hyperglycemia from acute illness
2. BLong-standing undiagnosed type 2 diabetes
3. CType 1 diabetes from autoimmune damage
4. DA meter error, because HbA1c is normal

A very anxious patient breathes rapidly for a long period. Which change is expected?

1. AMetabolic alkalosis from vomiting
2. BRespiratory alkalosis from a low PaCO₂
3. CMetabolic acidosis from a low bicarbonate
4. DRespiratory acidosis from a high PaCO₂

A patient with long-standing COPD has an arterial blood gas with pH 7,37, a raised PaCO₂ and a raised bicarbonate. How is this best described?

1. ACompensated respiratory acidosis
2. BMixed metabolic and respiratory alkalosis
3. CAcute respiratory acidosis
4. DUncompensated metabolic alkalosis

Why is pyridoxine (vitamin B6) often given with isoniazid?

1. ATo prevent orange discolouration of urine
2. BTo prevent gout attacks
3. CTo prevent loss of colour vision
4. DTo prevent peripheral neuropathy

During a thrombolytic infusion for an MI, the patient develops a sudden severe headache, vomiting and new confusion. What should the nurse do first?

1. AGive a second dose to finish the treatment
2. BSlow the infusion and give an antiemetic
3. CStop the infusion and call for urgent medical help
4. DContinue the infusion, as headache is a common side effect

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

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

A haemodialysis patient missed their last two sessions. They are breathless, with crackles, and the potassium is 6,9 mmol/L. What is the priority?

1. AUrgent dialysis, with cardiac monitoring meanwhile
2. BLarge IV fluid boluses to improve the circulation
3. CA routine dialysis session at the next planned slot
4. DOral potassium supplements and rest

Which long-term effect must be monitored in patients receiving anthracyclines such as doxorubicin?

1. APermanent high blood glucose
2. BDamage to the heart muscle
3. CLoss of the sense of smell
4. DExcess growth of body hair

Which preoperative task can a registered nurse usually delegate to a healthcare assistant (nursing assistant)?

1. AAssessing the patient's understanding of the surgery
2. BDeciding whether abnormal results need reporting
3. CTeaching the patient how to use a PCA pump
4. DRecording baseline vital signs