Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient has a nasogastric tube on suction. Which task can the nurse delegate to a nursing assistant?

1. AAssessing the drainage for blood
2. BIrrigating the tube when it blocks
3. CChecking the tube’s position
4. DGiving mouth care

A patient who is 7 weeks pregnant has one-sided lower abdominal pain, pain in the shoulder tip, a heart rate of 120/min and a blood pressure of 88/54 mmHg. What is most likely?

1. AA urinary tract infection
2. BA ruptured ectopic pregnancy
3. CA normal early pregnancy
4. DSevere morning sickness

How should a newborn be moved through hospital corridors?

1. ACarried in the nurse’s arms for comfort
2. BIn a bassinet, not carried in the arms
3. CIn the arms of any visitor who offers to help
4. DOn the mother’s lap in a wheelchair, without staff

A nurse teaches the daughter of a patient with moderate Alzheimer’s disease about home safety. Which statement shows a need for further teaching?

1. A“I keep her medicines locked away and give each dose to her myself.”
2. B“We put locks high up on the outside doors.”
3. C“She wears an ID bracelet in case she gets lost.”
4. D“I let Mom cook alone on the gas stove because she enjoys it.”

Glikemia na czczo pacjenta dziś wynosi 98 mg/dL (5,4 mmol/L), ale HbA1c wynosi 8,9% (74 mmol/mol). Jaka jest najlepsza interpretacja?

1. ADzisiejszy dobry wynik dowodzi, że cukrzyca jest dobrze kontrolowana
2. BHbA1c odzwierciedla tylko ostatnie 24 godziny
3. CKontrola glikemii w ostatnich 2–3 miesiącach była słaba
4. DPacjent nie ma cukrzycy

After a crush injury, a patient's urine dipstick is strongly positive for blood, but microscopy shows almost no red cells. CK is very high. What best explains this?

1. ABleeding is coming from the bladder lining
2. BA kidney stone is scraping the ureter lining
3. CMyoglobin from damaged muscle is in the urine
4. DThe sample was contaminated with menstrual blood

Pacjent przyjmujący warfarynę ma INR znacznie powyżej zakresu docelowego i siniaki. Jaki lek może zostać zlecony w celu odwrócenia działania?

1. ANalokson
2. BWitamina K
3. CKwas acetylosalicylowy
4. DSiarczan protaminy

A patient taking dapagliflozin is vomiting and unwell, with high blood ketones and a blood glucose of only 11 mmol/L (198 mg/dL). What should be suspected?

1. AHypoglycaemia
2. BSimple gastroenteritis with no further concern
3. CHyperosmolar hyperglycaemic state
4. DEuglycaemic diabetic ketoacidosis

How is the jugular venous pressure usually assessed?

1. APatient sitting upright with the arms raised above the head
2. BPatient standing with the neck flexed forward
3. CPatient lying completely flat with the head turned to the right
4. DPatient reclined at 45° with the head turned slightly to the left

A patient has been on continuous NIV via a full-face mask for two days. Which nursing measure helps prevent the most common complication?

1. ARemove the mask for an hour each time the alarm sounds
2. BCheck mask fit and protect the bridge of the nose
3. CTighten the straps as far as they will go to stop any leak
4. DUse the same mask size for every patient

Which statement about giving IV potassium is correct?

1. AIt needs no monitoring at all once the infusion is running
2. BIt is diluted and given through an infusion pump, never as a bolus
3. CIt can be given quickly as a push to correct the level fast
4. DIt is safest given through a small vein in the hand at a fast rate

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

1. AAn infected drain, so the dressing should be removed
2. BNo concern, because more drainage always lowers the ICP safely
3. COverdrainage of CSF, so act per protocol and inform the team
4. DUnderdrainage, so the drain should be lowered further

Jakie oceny przyłóżkowe służą do śledzenia wodobrzusza?

1. AGlikemia włośniczkowa przed każdym posiłkiem
2. BSzczytowy przepływ wydechowy i wysycenie tlenem
3. CWielkość źrenic i reakcja dwa razy dziennie
4. DCodzienna masa ciała i obwód brzucha

Just after extubation in recovery, a patient develops a high-pitched noise on breathing in, with falling SpO₂. What should the nurse do first?

1. AGive an opioid to calm the patient's breathing and reduce anxiety
2. BSit the patient up and give a drink of water
3. CWait a few minutes to see if it passes
4. DCall for help, give 100% oxygen and use a jaw thrust