Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient has a new plaster cast that is still drying. How should the nurse handle it?

1. AWith the palms of the hands, not the fingertips
2. BWith the fingertips, pressing firmly to test it
3. CBy covering it tightly with a plastic sheet
4. DBy resting it directly on a hard surface

Którego pacjenta uwagi wymaga pielęgniarka w pierwszej kolejności?

1. APacjenta, który mówi, że to „najgorszy ból głowy w moim życiu”, który zaczął się nagle, z ciśnieniem tętniczym 170/100 mmHg
2. BPacjenta z przewlekłym bólem pleców, który prosi o okład ciepły
3. CPacjenta ze znanymi migrenami, który ma ból głowy podobny do zwykłych
4. DPacjenta z wieloletnim nadciśnieniem, którego ciśnienie tętnicze wynosi 158/94 mmHg i który nie ma objawów

Why is keeping a patient warm (normothermia) during surgery part of infection prevention?

1. AWarm patients do not need antibiotic prophylaxis
2. BCold makes bacteria grow faster in the operating room air and on the drapes
3. CLow body temperature reduces blood flow and immune function in the wound
4. DWarmth sterilizes the surgical site

Shortly after a patient falls, the team holds a brief “post-fall huddle”. What is its main purpose?

1. ATo agree on what the team will tell the patient’s lawyer and the family
2. BTo find out quickly why the fall happened and change the care plan to prevent another
3. CTo decide which staff member was to blame for the fall
4. DTo complete the patient’s discharge paperwork

A patient with pneumonia had a CRP of 180 mg/L on admission and 40 mg/L after 4 days of antibiotics. What does this most likely show?

1. AThe inflammation is settling with treatment
2. BThe infection has spread to another organ
3. CThe antibiotic is causing liver damage
4. DThe patient has developed a new infection

A patient has a positive hepatitis C antibody (anti-HCV) test. What is the most appropriate next step?

1. ATell the patient they definitely have chronic hepatitis C
2. BGive hepatitis C vaccine to prevent further infection
3. CTest for HCV RNA to find out whether infection is current
4. DRepeat the antibody test, as a positive test is always false

A patient without diabetes is started on high-dose prednisolone. Why might capillary blood glucose be monitored?

1. ASteroids always cause hypoglycaemia
2. BSteroids destroy the pancreas
3. CSteroids make glucose meters inaccurate
4. DSteroids can raise the blood glucose

A patient who speaks little English needs to give consent for a procedure. Their 14-year-old child offers to interpret. What is the best action?

1. AUse gestures and proceed
2. BAsk the patient to sign the form without explanation
3. CLet the child interpret to save time
4. DArrange a professional interpreter

Why must intravenous potassium chloride never be given as a rapid push or undiluted?

1. AIt works only when given by mouth
2. BIt turns into solid crystals inside the vein and blocks it
3. CIt immediately lowers the blood glucose to dangerous levels
4. DA sudden high potassium level can cause cardiac arrest

A patient on a morphine PCA after surgery is very drowsy, with a respiratory rate of 7/min and pinpoint pupils. SpO₂ is 89%. What should the nurse do first?

1. AEncourage the patient to keep pressing the PCA button for comfort
2. BGive a sedative to keep the patient comfortable
3. CLeave the patient to sleep and recheck the observations in an hour
4. DStop the PCA, support breathing, give oxygen and get naloxone

How does bladder training help urge incontinence?

1. AA catheter is used every night
2. BThe patient goes to the toilet every 15 minutes
3. CThe patient drinks as little as possible
4. DThe time between voids is slowly increased

A patient with diabetic neuropathy has a hot, red, swollen foot that is barely painful. The skin is intact, and there is no fever. What should the nurse suspect?

1. ANormal swelling from standing too long
2. BAn acute Charcot foot, needing urgent offloading
3. CA sprained ankle that will settle with walking
4. DGout, which only needs pain relief

Jaki opatrunek zasadniczo nadaje się do suchej rany z martwicą rozpadową, która wymaga wilgoci?

1. AHydrożel
2. BSucha gaza
3. CPianka
4. DAlginian

Pacjent z cewnikiem zewnątrzoponowym po operacji jamy brzusznej ma ciśnienie 82/48 mmHg, tętno 70/min i ciepłe stopy. Krwawienie wykluczono. Jaka jest najbardziej prawdopodobna przyczyna?

1. ABlokada współczulna z powodu znieczulenia zewnątrzoponowego
2. BAnafilaksja na środek znieczulenia miejscowego
3. CWstrząs hipowolemiczny z utraty krwi
4. DWstrząs kardiogenny po operacji