Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Two nursing assistants argue loudly at the station about their assignments. What is the charge nurse’s best first step?

1. AChange both of their assignments without any discussion
2. BReport them to human resources at once
3. CMeet both of them privately to hear each side
4. DIgnore it and hope they sort it out

After a cervical spinal cord injury, a patient has a blood pressure of 80/50 mmHg, a heart rate of 48/min and warm, dry skin. What is most likely?

1. ASeptic shock
2. BCardiac tamponade
3. CHypovolemic shock
4. DNeurogenic shock

Why must visible dirt be removed from equipment before it is disinfected?

1. ADirt makes the disinfectant react and work too strongly on the surface
2. BCleaning first is only needed for metal items
3. CDisinfectants only work on wet surfaces
4. DOrganic matter can shield organisms and weaken the disinfectant

Pacjent w poczekalni oddziału ratunkowego ma kaszel od sześciu tygodni, nocne poty, utratę masy ciała i krew w plwocinie. Co powinna zrobić pielęgniarka w pierwszej kolejności?

1. APoprosić pacjenta, by czekał w poczekalni do wywołania
2. BZałożyć pacjentowi maskę i przenieść go do izolatki do zakażeń przenoszonych drogą powietrzną
3. CWdrożyć środki ostrożności przeciwko transmisji przez kontakt, z fartuchem i rękawiczkami dla personelu
4. DUmieścić pacjenta we wspólnym boksie z zasłoniętą zasłoną

An older adult with chronic kidney disease takes glyburide (glibenclamide, a sulfonylurea) and has repeated low glucose readings. Why is this a concern?

1. AThe drug stops working entirely when the kidneys fail
2. BThe drug causes high potassium that lowers the glucose
3. CThe drug makes the glucose meter read falsely low
4. DThe drug and its metabolites build up and cause long lows

A patient has a sodium of 150 mEq/L, a glucose of 180 mg/dL and a BUN of 28 mg/dL. Using the formula 2 × Na + glucose/18 + BUN/2,8, what is the calculated serum osmolality?

1. AAbout 285 mOsm/kg, which is normal
2. BAbout 320 mOsm/kg, which is high
3. CAbout 358 mOsm/kg, which is high
4. DAbout 300 mOsm/kg, which is normal

How should a nurse communicate with a patient who has impaired hearing?

1. AShout loudly from the end of the bed so they can hear
2. BFace the patient, speak clearly and reduce background noise
3. CSpeak very quickly to save time
4. DTalk to the patient's relative instead of to the patient directly

A patient with small cell lung cancer has hyponatraemia, concentrated urine and no signs of dehydration. Which condition and first measure fit best?

1. ASIADH, often managed first with fluid restriction
2. BCushing's syndrome, managed with potassium
3. CDehydration, managed with an IV fluid bolus
4. DDiabetes insipidus, managed with extra fluids

A patient takes both digoxin and furosemide. Why does the nurse watch the potassium level closely?

1. ALow potassium increases the risk of digoxin toxicity
2. BPotassium has no link with either medicine
3. CLow potassium makes digoxin stop working completely
4. DHigh potassium is the main effect of furosemide

Which instruction from the registered nurse to a healthcare assistant (unlicensed assistive personnel) caring for a patient with COPD is most appropriate?

1. A"Tell me straight away if his SpO₂ is under 88% or he is more breathless."
2. B"Turn his oxygen up to whatever he needs if he looks short of breath."
3. C"Teach him how to use his new inhaler this afternoon after his rest."
4. D"Listen to his chest after lunch and let me know what you can hear."

A kidney transplant recipient asks about travel vaccines. Which statement is correct?

1. ALive vaccines are usually avoided
2. BAll vaccines are completely safe after a transplant
3. CVaccines will cause the kidney to be rejected
4. DOnly live vaccines are effective after a transplant

Pielęgniarka opiekuje się czterema pacjentami. Którego pacjenta należy zobaczyć w pierwszej kolejności?

1. APacjenta dializowanego otrzewnowo z przejrzystym płynem odpływającym
2. BPacjenta ze stabilną niedoczynnością tarczycy, któremu należy podać lewotyroksynę
3. CPacjenta z przewlekłą chorobą nerek, który pyta o lek wiążący fosforany
4. DPacjenta po kraniotomii, u którego prawa źrenica jest nowo rozszerzona i wolno reaguje

Which statement about moist wound healing is correct?

1. AA moist, not wet, wound bed helps cells move and heal faster
2. BWounds should be soaked in water for hours every day
3. CWounds heal fastest when left to dry out and form a scab
4. DA wet wound bed always prevents infection

Pacjent uratowany z pożaru domu ma SpO₂ 99% na powietrzu, ale ból głowy, splątanie i wiśniowoczerwone usta. Co powinna zrobić pielęgniarka?

1. APodać 100% tlen przez maskę bez zwrotnego oddychania i zlecić oznaczenie karboksyhemoglobiny
2. BLeczyć ból głowy paracetamolem i obserwować pacjenta przez noc
3. CPodać tlen 2 L/min przez kaniulę nosową i ponownie ocenić za godzinę
4. DOdłączyć tlen, ponieważ wysycenie tlenem jest całkowicie prawidłowe