Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A parent of a child with influenza talks with the nurse. Which statement shows a need for further teaching?

1. A“I will give my child aspirin to bring the fever down.”
2. B“I will keep my child home from school and away from others while unwell.”
3. C“I will call if my child has trouble breathing.”
4. D“I will give my child plenty of fluids.”

A chemical cleaning fluid splashes into a patient’s eye. What should the nurse do first?

1. AFlush the eye with plenty of water or saline straight away
2. BGive antibiotic eye drops first
3. CRub the eye gently with a clean tissue to remove the chemical
4. DCover the eye with a dry patch and wait for the provider

A nurse finds a used needle in a patient’s bed linen. What should the nurse do?

1. AFold it into the linen and send it to the laundry
2. BLeave it where it is for the housekeeping staff to remove later in the day
3. CRecap it with two hands before throwing it away
4. DPick it up by the hub or with forceps, put it in a sharps container and report it

A patient with suspected sepsis has orders for blood cultures and an IV antibiotic. What is the correct order of actions?

1. AWait for the culture results before starting the antibiotic
2. BGive the antibiotic first so that treatment starts, and take the cultures the next day
3. CGive the antibiotic and take the cultures an hour later
4. DDraw the blood cultures first, then give the antibiotic without delay

A patient on a heparin infusion has an aPTT below the target range on the protocol. What should the nurse do?

1. ASwitch the infusion to oral warfarin without a prescription
2. BContinue the same rate and recheck the aPTT in a few days
3. CAdjust the rate as the protocol directs and recheck as scheduled
4. DStop the infusion and give protamine sulfate as quickly as possible

A health care worker's hepatitis B tests show: HBsAg negative, anti-HBs positive, anti-HBc positive. What does this mean?

1. ANot immune and never exposed to the virus
2. BCurrent chronic hepatitis B infection
3. CImmunity from vaccination only, never infected
4. DPast infection that has resolved, with immunity

Pacjent z marskością wątroby staje się splątany i senny, z drżeniem trzepoczącym rąk. Jakie powikłanie jest prawdopodobne?

1. AUdar
2. BWyłącznie upojenie alkoholowe
3. CEncefalopatia wątrobowa
4. DHipoglikemia wywołana insuliną

A patient with stress incontinence is taught self-care. Which statement shows a need for further teaching?

1. A"I'll cut down on caffeine."
2. B"I'll try to lose some weight if I can."
3. C"I'll do my pelvic floor exercises every day."
4. D"I'll drink as little as possible so I don't leak."

Dlaczego pacjentom z ciężką POChP zaleca się jedzenie małych, częstych posiłków?

1. ACzęste posiłki bezpośrednio zapobiegają zakażeniom dróg oddechowych
2. BDuże posiłki powodują trwałe zwężenie dróg oddechowych
3. CPełny żołądek ogranicza ruchy przepony, a jedzenie męczy
4. DMałe posiłki zmniejszają częstość potrzebnego użycia inhalatorów

Po cewnikowaniu serca przez tętnicę promieniową, która ocena jest najważniejsza?

1. ASzmery jelitowe i obwód brzucha co godzinę po badaniu
2. BKrążenie, czucie i ruch ręki oraz miejsce wkłucia
3. CCiężar właściwy moczu co cztery godziny
4. DWielkość źrenic i reakcja na światło co 15 minut

A patient with advanced CKD asks how to manage indigestion. Which option should they avoid?

1. AAvoiding large meals late in the evening
2. BEating smaller, more frequent meals
3. CMagnesium-containing antacids
4. DRaising the head of the bed at night

A prescription reads "Insulin 10U". Why is this a safety problem?

1. AThere is no problem as long as the nurse can read it
2. B"U" can be misread as a zero, giving a tenfold dose
3. C"U" means the insulin must be given intravenously
4. DInsulin doses must always be written in millilitres

A nasogastric feeding tube appears blocked. What is usually the first step?

1. ACut the end of the tube to release the blockage inside it
2. BPush the guidewire back in to clear it
3. CUse a small 5 mL syringe with firm pressure
4. DFlush gently with warm water in a 50 mL enteral syringe

A patient on warfarin has a major upper GI bleed with an INR of 5. Which treatment should the nurse anticipate to reverse the warfarin?

1. AOral aspirin to balance the clotting system quickly
2. BProtamine sulfate on its own
3. CMore warfarin to stabilise the INR
4. DProthrombin complex concentrate with IV vitamin K