Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient has a serum potassium of 2,9 mEq/L. Which finding should the nurse expect?

1. AMuscle weakness and U waves on the ECG
2. BA rise in urine output and thirst only
3. CTall, peaked T waves and muscle twitching
4. DFlushed, warm skin and a slow heart rate

A patient with suspected sepsis has four prescribed orders. Which should usually be done first?

1. ARepeat the lactate in six hours
2. BTake blood cultures
3. CGive the IV antibiotic
4. DArrange a chest X-ray for later today

Why is blood glucose control important around the time of surgery?

1. AGlucose levels only affect patients who have type 1 diabetes
2. BHigh glucose impairs white cell function and raises the risk of surgical site infection
3. CLow glucose is needed around surgery so that the wound edges close more quickly
4. DHigh glucose makes anesthetic drugs work for much longer and delays waking up

A nurse has worked three long shifts in a row and feels exhausted. The manager asks the nurse to stay for another shift. What is the most appropriate response?

1. AAgree, but skip the independent medication checks to save energy on the shift
2. BExplain that fatigue would make care unsafe and decline the extra shift
3. CAgree without telling anyone about the fatigue
4. DAgree and drink extra coffee to stay alert

A patient with central diabetes insipidus starts desmopressin. Which laboratory result is most important to monitor for an adverse effect?

1. ASerum potassium, which may rise too high
2. BSerum calcium, which may rise too high
3. CSerum sodium, which may fall too low
4. DSerum glucose, which may rise very high

U pacjenta otrzymującego wlew heparyny liczba płytek spada z 260 do 110 × 10³/µL w 7. dobie. Które działanie jest najwłaściwsze?

1. AZgłosić to natychmiast: możliwa jest małopłytkowość poheparynowa
2. BKontynuować wlew i zwiększyć szybkość zgodnie z protokołem
3. CNie podejmować działań, ponieważ liczba jest nadal tuż powyżej 100 × 10³/µL
4. DPrzetoczyć płytki i kontynuować heparynę

Pacjent z niewydolnością serca ma różową, pienistą plwocinę i trzeszczenia nad obydwoma płucami. Co się dzieje?

1. AKrwawienie z górnego odcinka przewodu pokarmowego
2. BOstry obrzęk płuc
3. COdma opłucnowa
4. DNapad astmy

During a general anaesthetic, a patient develops a rapidly rising temperature, muscle rigidity and rising carbon dioxide levels. What should be suspected?

1. APostoperative infection
2. BA normal response to surgery
3. CNeuroleptic malignant syndrome from antipsychotics
4. DMalignant hyperthermia

U pacjenta stwierdzono podwyższone stężenie peptydu natriuretycznego typu B (BNP lub NT-proBNP). Co to głównie odzwierciedla?

1. ARozciągnięcie i przeciążenie ciśnieniowe komór
2. BZapalenie wątroby wywołane zastojem
3. CNiedokrwienne uszkodzenie mięśnia sercowego
4. DUszkodzenie mięśni szkieletowych po upadku

Ten days after cardiac surgery, a patient has a fever, a red sternal wound with discharge and a clicking feeling in the chest when coughing. What should the nurse suspect?

1. ANormal wound healing with some expected discharge
2. BCostochondritis caused by forceful coughing
3. CPericarditis from the operation
4. DSternal wound infection with an unstable sternum

Po operacji przysadki pacjent oddaje 400 mL moczu na godzinę przez trzy godziny, z niskim ciężarem właściwym. Co powinna podejrzewać pielęgniarka?

1. AMoczówkę prostą
2. BOstre uszkodzenie nerek
3. CPrawidłową diurezę
4. DSIADH

A patient with an acute stroke has a glucose of 15 mmol/L (270 mg/dL). They do not have known diabetes. What is appropriate?

1. AGive glucose gel to stabilise the level
2. BIgnore it, because stress always raises glucose
3. CReport it and monitor glucose, as it can worsen outcome
4. DStop all IV fluids to lower the glucose

Which technique is correct when giving a prefilled low molecular weight heparin injection?

1. ARub the site firmly afterwards to help absorption
2. BLeave the air bubble in and inject into a skin fold
3. CExpel the air bubble first and inject into the deltoid muscle
4. DInject into a vein in the back of the hand

A patient with active cancer on chemotherapy develops new swelling and pain in one calf. Why must this be reported promptly?

1. ACancer and its treatment greatly increase clot risk
2. BThe swelling shows the cancer has gone
3. CIt is only a muscle strain from walking
4. DCalf swelling is a normal effect of chemotherapy