Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Które zadanie pielęgniarka powinna delegować asystentowi pielęgniarskiemu u pacjenta objętego profilaktyką upadków?

1. APodjęcie decyzji, czy alarm łóżkowy jest nadal potrzebny
2. BOcenę i zapisywanie wyniku ryzyka upadku pacjenta każdego ranka
3. CNauczenie rodziny, jak zapobiegać upadkom w domu
4. DPomoc pacjentowi w dojściu do toalety co 2 godziny zgodnie z planem

A patient with known abdominal aortic aneurysm suddenly has severe back pain, a pulsing mass in the abdomen and a falling blood pressure. What should the nurse do?

1. AEncourage the patient to walk to ease the back pain
2. BPalpate the mass firmly to check its size and spread
3. CCall for emergency help at once and prepare for urgent surgery
4. DGive an oral analgesic and reassess the patient in about one hour

Jaką metodę higieny rąk powinien stosować personel po opiece nad pacjentem podczas ogniska norowirusa na oddziale?

1. AWyłącznie wycieranie rąk ręcznikiem papierowym
2. BBrak higieny rąk, jeśli noszono rękawiczki
3. CMycie wodą z mydłem
4. DWyłącznie preparat alkoholowy do rąk

A patient weighs 180 kg and needs to be moved from bed to chair. The standard ceiling lift on the unit has a lower weight limit. What should the nurse do?

1. AAsk the patient to stand and pivot without help
2. BHave two staff lift the patient by hand
3. CUse the standard lift, because limits include a safety margin
4. DUse bariatric-rated equipment and enough trained staff

A patient has taken a proton pump inhibitor (such as omeprazole) for many years and now has muscle cramps and tremor. Which electrolyte is most likely to be low?

1. AMagnesium
2. BChloride
3. CPhosphate
4. DSodium

Two sets of blood cultures were taken from separate sites. Only one bottle in one set grows coagulase-negative staphylococci, and the patient has no line or implant. What is the most likely interpretation?

1. AProof that the patient has infective endocarditis
2. BProbable skin contamination of the sample
3. CCertain bloodstream infection needing treatment
4. DInfection with a resistant organism such as MRSA

For a patient in skin traction on the leg, which is correct?

1. AThe weights rest on the floor overnight
2. BThe rope is tied to the bed frame to keep it still
3. CThe weights hang freely and do not rest on the bed or floor
4. DThe weights are removed whenever the patient feels uncomfortable

A hypotensive postoperative patient is given a fluid bolus. Which findings suggest a good response?

1. AThe respiratory rate rises and new lung crackles appear
2. BThe heart rate falls, blood pressure rises and urine output improves
3. CThe heart rate rises further and the patient becomes more confused
4. DThe capillary refill time becomes longer

A patient has exercise-induced asthma. Which advice is most appropriate?

1. AAvoid all forms of exercise permanently to prevent attacks
2. BExercise only in cold, dry air to toughen the airways
3. CTake a beta-blocker before exercise
4. DUse the reliever inhaler shortly before exercise and warm up

A patient with end-stage COPD has severe breathlessness at rest despite optimal treatment and wants comfort-focused care. Which measure is recognised to help?

1. AHigh-flow oxygen at 15 L/min whatever the oxygen saturation is
2. BA low-dose opioid with a hand-held fan and calm positioning
3. CStopping all medicines, including inhalers
4. DEncouraging long walks to build fitness

How does the nurse test the facial nerve (VII)?

1. AShine a light in each eye and check the pupil response
2. BAsk them to raise the eyebrows, shut the eyes tightly and smile
3. CAsk the patient to stick out the tongue and move it from side to side
4. DTouch the forehead, cheek and chin with cotton wool

A patient has fever, confusion, odd behaviour and a new seizure. Herpes simplex encephalitis is suspected. Which drug is usually started straight away?

1. AOral amoxicillin
2. BOral prednisolone
3. CIV aciclovir
4. DIV insulin

Which pain pattern classically suggests a duodenal rather than a gastric ulcer?

1. APain in the right lower abdomen with fever and vomiting
2. BPain straight after eating that is worsened by food
3. CPain 2–3 hours after meals and at night, eased by eating
4. DPain only on deep breathing that eases when sitting forwards

A patient on modified-release morphine for cancer pain has needed four breakthrough doses every day for several days. What should the nurse do?

1. AReport it, as the regular background dose may need review
2. BTell the patient to put up with the pain between doses
3. CGive all breakthrough doses at the same time
4. DStop the breakthrough doses to reduce opioid use