Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A nurse teaches a patient who has started warfarin. Which statement shows a need for further teaching?

1. A“I will tell my dentist and pharmacist that I take warfarin.”
2. B“I will keep my INR blood test appointments.”
3. C“I will use a soft toothbrush.”
4. D“If I miss a dose, I will take two the next day.”

A patient receiving comfort-focused end-of-life care is distressed by breathlessness. Which approach is most appropriate?

1. AStart a series of aggressive tests to find the exact cause of the breathlessness
2. BGive prescribed opioids and use positioning and a fan to relieve breathlessness
3. CWithhold all opioids because they may slow breathing
4. DLeave the patient alone so they can rest

A nurse who never had BCG vaccine has a positive tuberculin skin test for the first time. The chest x-ray is clear and there are no symptoms. What does this most likely mean?

1. AA failed test that must be repeated next year
2. BActive TB, which needs airborne isolation
3. CLatent TB infection, which is not contagious
4. DImmunity to TB from a past exposure

A nurse cannot find a confused patient who was in their room 15 minutes ago. What should the nurse do first?

1. AAlert staff and security at once, following the missing-patient procedure
2. BCall the family to ask whether the patient has gone home on their own
3. CDocument the absence at the end of the shift
4. DWait an hour in case the patient comes back

How should a blood sample for serum ammonia be handled?

1. ALeft at room temperature for several hours first
2. BShaken firmly to mix it before it is sent away
3. CKept warm and sent with the next routine batch
4. DPlaced on ice and sent to the laboratory at once

A patient with severe hypertriglyceridemia has a measured sodium of 128 mEq/L, but a measured serum osmolality is normal, and the patient has no symptoms. What is the most likely explanation?

1. ATrue hyponatremia from SIADH that needs fluid restriction
2. BHyponatremia caused by severe hyperglycemia in diabetes
3. CHyponatremia caused by drinking far too much water
4. DPseudohyponatremia, an artifact caused by very high lipids

Why should a urinary catheter drainage bag be kept below the level of the bladder?

1. ATo keep the urine warm
2. BTo stop the catheter from falling out
3. CTo make the bag easier for the nurse to empty
4. DTo prevent urine flowing back into the bladder

A patient has a full-thickness burn all the way round the forearm. Which complication must be watched for closely?

1. ALoss of circulation to the hand as swelling builds under tight burned skin
2. BHypoglycaemia caused by the body using glucose to heal the burn
3. CExcessive bleeding from the burn surface needing an urgent blood transfusion
4. DDelayed hair growth on the arm

Jaka ocena jest niezbędna przed zastosowaniem terapii uciskowej w żylnym owrzodzeniu podudzia?

1. AZdjęcie rentgenowskie klatki piersiowej i EKG
2. BWskaźnik kostka–ramię (ABPI)
3. CMorfologia krwi i CRP
4. DWymaz z rany do posiewu i antybiogramu

A patient taking warfarin for AF falls and hits their head. An hour later they are drowsy and have vomited. What is the priority?

1. AEncourage sleep and check observations at the next routine time
2. BWithhold tonight's warfarin and review tomorrow
3. CUrgent escalation for CT of the head and anticoagulant reversal
4. DGive paracetamol (acetaminophen) and a light meal

U pacjenta z AKI przez cewnik moczowy nic nie odpływa. Które szybkie badanie przyłóżkowe pomaga wykluczyć przyczynę pozanerkową?

1. ASprawdzić cewnik pod kątem załamań lub zatkania i wykonać skan pęcherza
2. BWysłać próbkę moczu do posiewu i czekać na wynik z laboratorium
3. COd razu podać duży bolus płynu dożylnego
4. DZachęcić pacjenta do wypicia dwóch litrów wody

A patient's glucose is 6,2 mmol/L (112 mg/dL) at 03:00 and 12 mmol/L (216 mg/dL) before breakfast. No hypoglycaemia occurred overnight. What is the most likely explanation?

1. AThe meter is faulty and should be replaced
2. BA large snack eaten in the night by mistake
3. CThe dawn phenomenon from early-morning hormones
4. DThe Somogyi effect from a night-time hypo

Jak duży powinien być otwór wycięty w worku stomijnym?

1. ADowolny rozmiar, o ile stomia jest zakryta
2. BOkoło 2 cm większy niż stomia dookoła
3. COkoło 2–3 mm większy niż stomia dookoła
4. DNieco mniejszy niż stomia, dla szczelnego dopasowania

Which patient has the highest risk of postoperative nausea and vomiting?

1. AA smoker who has never had nausea after surgery
2. BA male smoker having a short procedure without opioids
3. CA non-smoking woman with motion sickness who will need opioids
4. DA man with no history of nausea having local anaesthetic only