Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Którego pacjenta pielęgniarka powinna zobaczyć jako pierwszego po raporcie?

1. APacjenta, który chce pomocy w prysznicu, zanim przyjdą goście
2. BPacjenta przyjmującego lek moczopędny, który oddał 400 mL moczu od godz. 08:00
3. CPacjenta z chorobą zwyrodnieniową stawów, który zgłasza poranną sztywność każdego ranka
4. DPacjenta ze świeżym opatrunkiem gipsowym, który mówi, że stopa jest drętwa, a palce zimne

A patient in labor is receiving oxytocin, and the fetal monitor shows repeated late decelerations. What should the nurse do first?

1. AEncourage the patient to start pushing
2. BStop the oxytocin infusion
3. CPlace the patient flat on her back
4. DIncrease the oxytocin rate

A patient is admitted to an inpatient mental health unit. Why are personal belongings checked?

1. ATo find out what the patient likes to wear during the hospital stay
2. BTo decide which family members may visit
3. CTo make a list of valuable items for insurance
4. DTo remove items that could be used to harm self or others

A toddler has bruises of different ages and a burn, and the parent’s explanation does not fit the injuries. What should the nurse do?

1. ADocument only and say nothing to anyone
2. BWait until there is clear proof of abuse before reporting anything at all
3. CConfront the parent and ask them to admit to abuse
4. DReport the concern following child-protection (safeguarding) procedures

A patient with type 2 diabetes has a target HbA1c below 7% (53 mmol/mol). Today's result is 7,8% (62 mmol/mol). What is the best interpretation?

1. AAverage glucose over the past months has been above the target
2. BThe result shows today's fasting glucose is above the target
3. CThe patient has had frequent episodes of severe hypoglycemia
4. DGlucose control has been excellent for the past several months

A patient with blood pressure that is hard to control has a potassium of 2,9 mEq/L, a sodium of 144 mEq/L and a raised serum bicarbonate, without taking a diuretic. Which condition is most likely?

1. APrimary adrenal insufficiency
2. BCentral diabetes insipidus
3. CPrimary hyperaldosteronism
4. DSyndrome of inappropriate ADH

After a total hip replacement through a posterior approach, which movement should the patient usually avoid in the early weeks?

1. AWalking short distances with a frame and a physiotherapist
2. BDoing gentle ankle exercises
3. CLying on their back
4. DBending the hip beyond 90 degrees or crossing the legs

A catheterised postoperative patient has passed only 10 mL of urine in the last two hours. What should the nurse check first?

1. AThe patient's cholesterol level from the admission bloods
2. BWhether the patient has eaten breakfast
3. CThe patient's weight from last year
4. DThat the catheter and tubing are not kinked or blocked

Pacjent z astmą używa inhalatora doraźnego częściej niż trzy razy w tygodniu. Co to sugeruje?

1. ALek doraźny przestał działać i należy go odstawić
2. BKontrola astmy jest słaba i leczenie wymaga przeglądu
3. CInhalator zapobiegawczy nie jest już potrzebny
4. DAstma jest dobrze kontrolowana przy obecnym planie leczenia

A nurse teaches a patient with heart failure who takes ramipril and spironolactone. Which statement shows a need for further teaching?

1. A"I will weigh myself every morning after I go to the toilet."
2. B"I will use a salt substitute instead of ordinary salt."
3. C"I will call if I gain weight quickly or get more breathless."
4. D"I will avoid ibuprofen for my joint pain."

What is the main purpose of continuous bladder irrigation after a transurethral resection of the prostate (TURP)?

1. ATo treat a urinary infection after the operation
2. BTo measure the size of the bladder
3. CTo give the patient extra fluids
4. DTo stop blood clots from blocking the catheter

The nurse has four renal patients. Which one needs to be seen first?

1. AA patient with a creatinine slightly above their usual level
2. BA patient with mild itching from uraemia who wants a cream
3. CA patient with a potassium of 6,8 mmol/L who reports palpitations
4. DA patient with CKD asking about their phosphate binder

Why are carbohydrate drinks often given before surgery in enhanced recovery programmes?

1. ATo reduce insulin resistance and improve recovery
2. BTo replace the need for any IV fluids afterwards
3. CTo make the bowels open before the operation
4. DTo raise the blood pressure during the anaesthetic

Using the adult rule of nines, what is the total burn area of the whole right arm plus the whole front of the trunk (both with partial-thickness burns)?

1. A27%
2. B45%
3. C36%
4. D18%