Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Które zadanie pielęgniarka powinna delegować asystentowi pielęgniarskiemu u pacjenta objętego profilaktyką upadków?

1. APomoc pacjentowi w dojściu do toalety co 2 godziny zgodnie z planem
2. BNauczenie rodziny, jak zapobiegać upadkom w domu
3. COcenę i zapisywanie wyniku ryzyka upadku pacjenta każdego ranka
4. DPodjęcie decyzji, czy alarm łóżkowy jest nadal potrzebny

Objaw u którego pacjenta jest najpilniejszy?

1. APacjenta, na którego wynik liczby płytek się czeka
2. BPacjenta na wlewie heparyny, który ma nowe splątanie i silny ból głowy
3. CPacjenta przyjmującego warfarynę z INR 2,5, który ma otrzymać zwykłą dawkę wieczorną
4. DPacjenta po operacji kolana z małym siniakiem w miejscu wstrzyknięcia

A patient with a respiratory infection has a raised procalcitonin level. What does this most suggest?

1. AA purely viral illness
2. BAn allergic reaction to a recent medication
3. CDehydration from poor intake
4. DA bacterial rather than a viral infection

A nurse floated to an unfamiliar unit is asked to manage a device they have never been trained to use. What should the nurse do?

1. ATell the charge nurse and ask for help or a change of assignment
2. BDo it anyway, using only the device manual and the instructions on the screen
3. CAsk the patient or the family to explain how the device works
4. DLeave the device untouched and not tell anyone

Which technique is recommended for a capillary blood glucose test on an adult's finger?

1. APrick the center of the fingertip
2. BSqueeze the finger very hard
3. CUse the same finger every time
4. DPrick the side of the fingertip

Ten days after chemotherapy, a patient has a platelet count of 9 × 10³/µL and reports a sudden severe headache and blurred vision. What is the priority?

1. AEncourage the patient to drink more fluids and check the blood pressure later
2. BGive acetaminophen (paracetamol) for the headache and reassess in 1 hour
3. CDim the lights and encourage rest, as headaches are common after chemotherapy
4. DAssess neurological status and report it at once as possible brain bleeding

A nurse finds a patient lying on the floor beside the bed. What should be done first?

1. ALift the patient straight back into bed so they are comfortable
2. BCheck the patient for injuries before moving them
3. CPhone the patient's family
4. DComplete the incident report form

U pacjenta z urazem rdzenia kręgowego na poziomie Th4 nagle pojawia się pulsujący ból głowy, bardzo wysokie ciśnienie tętnicze i pocenie się powyżej poziomu urazu. Jakie jest pierwsze działanie?

1. APosadzić pacjenta i sprawdzić, czy pęcherz nie jest pełny lub cewnik niedrożny
2. BPodać duży bolus płynów dożylnie i ponownie zmierzyć ciśnienie
3. CPodać lek uspokajający i zmierzyć ciśnienie ponownie za cztery godziny
4. DUłożyć pacjenta płasko i unieść nogi, by poprawić perfuzję mózgu

Suspected pulmonary TB is being investigated. How are sputum samples usually collected?

1. ASeveral samples, ideally including early-morning sputum
2. BOne sample of saliva collected at any time of the day
3. CA swab from the nose only
4. DA single sample after the first week of treatment

A patient who has had a total laryngectomy becomes breathless and needs oxygen. How should it be given?

1. AVia nasal cannula at 2 L/min
2. BVia a standard face mask over the nose and mouth
3. CVia a non-rebreather mask over the mouth only
4. DVia a mask or humidified device over the neck stoma

A patient uses a continuous glucose monitor. Which statement is correct?

1. AIt makes finger-prick checks unnecessary in every situation
2. BIt measures glucose directly in the blood every second of the day
3. CIt works by giving small doses of insulin automatically
4. DIt reads glucose in fluid under the skin, a little behind blood glucose

A patient with Guillain–Barré syndrome has a blood pressure that swings between 80/50 and 190/100 mmHg and a heart rate that changes suddenly. What does this suggest?

1. AA faulty blood pressure cuff that should be replaced and the readings ignored
2. BAnxiety that will settle with reassurance alone
3. CAutonomic dysfunction, which needs continuous cardiac monitoring
4. DA drug reaction that means all medicines must stop

When breaking bad news, what is the first step in frameworks such as SPIKES?

1. ASet up a private setting with enough time
2. BAsk the family to decide what the patient should be told
3. CGive all treatment options before checking understanding
4. DGive the diagnosis as quickly as possible in the corridor

At the end of an operation, the final count shows one swab missing. What should happen?

1. ATell the surgeon, search, and X-ray if it is not found
2. BRecord the count as correct to avoid a delay
3. CLet the patient leave and search the theatre later
4. DClose the wound, as the swab was probably thrown away