Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A nurse takes a telephone order from a provider. What must the nurse do?

1. ARemember the order and write it in the chart at the end of the shift
2. BWrite the order down and read it back to the provider to confirm it
3. CCarry out the order first and ask the provider to confirm it later
4. DAsk the ward clerk to take the order on the nurse’s behalf instead

A medical-unit nurse is floated to intensive care and given a patient on a ventilator, which the nurse has never managed. What is the best response?

1. ARefuse to work and go home, because the assignment is unsafe
2. BLeave the intensive care unit and go back to the medical unit without telling anyone
3. CAccept the full assignment without comment to avoid conflict
4. DTell the charge nurse about the gap, accept tasks within competence and ask for support

A confused patient keeps pulling at an IV line. Which is a less restrictive option to consider before wrist restraints?

1. AUsing a vest restraint in the chair so that the patient’s hands stay down
2. BCovering the site with a sleeve or using hand mitts with supervision
3. CTying both arms to the bed frame
4. DGiving a sedative every few hours

A patient on contact precautions for MRSA has become withdrawn and says, “Everyone avoids me.” What is the best nursing action?

1. AAsk the provider for a sedative to help the patient cope
2. BKeep visits short to limit the risk of spreading MRSA
3. CStop the precautions for a few days so the patient feels less isolated and alone
4. DExplain why the precautions are needed and plan regular, unhurried time in the room

In countries that screen all pregnant women (such as the US), a vaginal-rectal swab is taken at about 36–37 weeks. Which organism is it screening for?

1. AGroup B Streptococcus
2. BHepatitis B virus
3. CCandida albicans
4. DStaphylococcus aureus

The nurse teaches a patient about the HbA1c test. Which statement shows a need for further teaching?

1. A"I must not eat anything for 12 hours before the HbA1c test"
2. B"A lower result means less risk of damage to my eyes and kidneys"
3. C"The test shows my average glucose over the past few months"
4. D"My daily finger-stick readings still matter between the tests"

A patient with sickle cell disease is admitted with a painful crisis. What is a key early nursing priority?

1. ADelaying pain relief until a diagnosis is confirmed
2. BRestricting oral fluids
3. CApplying cold packs to the painful areas
4. DGiving prompt, effective analgesia

In a patient with a head injury, which is usually the earliest sign of rising intracranial pressure?

1. AIrregular breathing pauses
2. BA slow pulse with high blood pressure
3. CA fixed, dilated pupil on both sides
4. DA change in level of consciousness

A patient has episodes of severe headache, sweating and palpitations with very high blood pressure. Which rare cause should be considered?

1. AStable angina
2. BAortic stenosis
3. CAsthma
4. DPhaeochromocytoma

An older patient's varicose vein bursts at the ankle and bleeds heavily. What is the most effective first aid?

1. ALie the patient down, raise the leg and press firmly on the site
2. BStand the patient up so the blood flows away and clots faster
3. CApply a hot compress to the leg to help the vein close up
4. DKeep the leg hanging down over the bed

After a lumbar discectomy, which finding should the nurse report promptly?

1. ANew weakness or numbness in the legs
2. BA dry, intact wound dressing
3. CMild pain at the wound site
4. DStiffness when getting out of bed

A nurse teaches a patient about peritoneal dialysis. Which statement shows a need for further teaching?

1. A"If the fluid is cloudy, I'll see if it clears next time."
2. B"I will weigh myself daily and record my fluid balance."
3. C"I will wash my hands carefully before each exchange."
4. D"I will check my exit site every day."

Które podejście do przetaczania krwinek czerwonych u stabilnego pacjenta z krwawieniem z przewodu pokarmowego zgadza się z aktualnymi dowodami?

1. APrzetaczanie wszystkim, aby hemoglobina zawsze była powyżej 150 g/L
2. BRutynowe przetoczenie dwóch jednostek przed każdą endoskopią
3. CNigdy nie przetaczać, niezależnie od hemoglobiny i objawów
4. DRestrykcyjny próg, często około 70 g/L, u większości stabilnych pacjentów

Na oddziale chirurgicznym leży czterech pacjentów. Którego pacjenta pielęgniarka powinna ocenić w pierwszej kolejności?

1. A3. doba po operacji: prosi o środek przeczyszczający na zaparcie
2. BZ neutropenią: temperatura godzinę temu prawidłowa, czuje się dobrze
3. CCztery godziny po operacji jelita: tętno 118/min, ciśnienie 90/55 mmHg
4. DStabilna ileostomia: prosi o pomoc w zmianie worka