Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient had a colostomy formed yesterday. Which stoma appearance should be reported straight away?

1. AA little bleeding when cleaned
2. BMoist and pink-red
3. CSlightly swollen
4. DDark purple or black

A severely malnourished patient started nutrition two days ago and now has weakness and confusion. Which laboratory result should the nurse check first?

1. ASerum phosphate
2. BSerum amylase
3. CSerum cholesterol
4. DThyroid hormone

A nurse wants to set up a sterile field in the morning for a procedure that will take place after lunch. What is correct?

1. ASet it up just before the procedure, because a waiting field may become contaminated
2. BSet it up in the morning and ask a colleague to check it once
3. CSet it up in the morning and cover it with a clean towel until the procedure starts
4. DSet it up in the morning and leave it uncovered in an empty room

A nurse has a needlestick from a patient known to have hepatitis C. Which statement about management is correct?

1. AThere is no preventive drug, so baseline and follow-up testing are done to detect infection early
2. BHepatitis C immune globulin is given within 24 hours, followed by a booster dose
3. CThe hepatitis C vaccine series is started at once, with a booster dose six months later
4. DNo follow-up is needed because hepatitis C does not spread by needles

A patient on warfarin for atrial fibrillation has a target INR of 2,0–3,0. How does the usual target for a patient with a mechanical mitral valve compare?

1. AThe same, 2,0–3,0
2. BHigher, about 2,5–3,5
3. CLower, about 1,0–1,5
4. DMuch higher, about 5,0–6,0

A patient's potassium is 7,2 mEq/L, and the monitor shows wide QRS complexes. Several treatments are prescribed. Which should be given first?

1. AUrgent hemodialysis session
2. BIV calcium gluconate (or chloride)
3. CIV furosemide (a loop diuretic)
4. DAn oral potassium binder dose

A nurse suspects that an older patient is being financially abused by a relative. What should the nurse do?

1. AWait until the patient has been discharged
2. BRaise the concern through the local safeguarding (adult protection) procedure
3. CKeep it secret because it is a family matter
4. DConfront the relative directly at the bedside about it

A nurse phones a doctor about a deteriorating patient using SBAR. Which statement belongs in the "R" section?

1. A"He was admitted three days ago with pneumonia."
2. B"I am calling about Mr Smith, who is breathless."
3. C"Please review him within the next 15 minutes."
4. D"His blood pressure is 85/50 and he is confused."

A patient with stable angina is afraid nicotine patches will harm their heart. Which reply is most accurate?

1. ANicotine replacement is much safer than smoking and is recommended
2. BNicotine replacement only works if smoking continues
3. CNicotine patches are much more harmful to the heart than cigarettes
4. DPeople with angina must stop smoking without any help

Pacjent, który wczoraj zaczął przyjmować inhibitor ACE, ma obrzęk warg i języka oraz ochrypły głos. Co pielęgniarka powinna zrobić w pierwszej kolejności?

1. APrzyłożyć lód do warg i ponownie ocenić rano
2. BPodać następną dawkę wcześniej, ponieważ to szybko zmniejszy obrzęk
3. COcenić drożność dróg oddechowych, wezwać pilną pomoc i wstrzymać kolejne dawki
4. DWyjaśnić, że to spodziewane, nieszkodliwe działanie niepożądane

Which side effects are common with oxybutynin for an overactive bladder?

1. ADiarrhoea and heavy sweating
2. BA cough and a raised potassium
3. CWeight loss and a fast tremor
4. DDry mouth and constipation

The night after hip surgery, an 84-year-old becomes suddenly confused and tries to pull out their IV line. What is the most appropriate first step?

1. ALook for causes such as low oxygen, pain, retention or infection
2. BAsk for a strong sedative so that the patient can sleep
3. CTell the family that this is the start of dementia
4. DApply wrist restraints to protect the IV line

Why might a patient's platelet count be monitored while they receive heparin?

1. ATo measure the heparin dose in the blood exactly
2. BTo see whether the patient has an infection
3. CTo detect heparin-induced thrombocytopenia
4. DTo check whether the heparin is causing anaemia

A bag of parenteral nutrition runs out and the next one will not arrive for several hours. Which risk should the nurse anticipate?

1. ASevere hyperkalaemia
2. BRaised intracranial pressure
3. CRebound hypoglycaemia
4. DAcute urinary retention