Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A nurse sees a nursing assistant leave a confused patient’s bed in the highest position after care. What should the nurse do?

1. AAsk the family to lower the bed when they next visit
2. BLower the bed now and remind the assistant why it matters
3. CLeave it because the patient is asleep
4. DWrite it in the assistant’s yearly review only

An adult has burns over 40% of the body with no signs of airway injury. Which treatment is the priority during the first hours?

1. AStarting physiotherapy to prevent contractures straight away
2. BApplying antibiotic cream to all the burns before anything else
3. CLarge-volume IV fluids with close monitoring of urine output
4. DGiving a high-protein meal to support healing

Hair must be removed from a planned surgical site. Which method reduces the risk of surgical site infection?

1. AShaving with a razor just before the incision
2. BUsing wax strips on the morning of surgery
3. CShaving with a disposable razor the night before surgery
4. DClipping with electric clippers just before surgery

A nurse teaches parents about firearm safety at home. Which statement shows a need for further teaching?

1. A“We keep all the ammunition locked away separately from the gun.”
2. B“We will ask other parents about guns before play dates.”
3. C“We keep the gun loaded in the nightstand, and the children know not to touch it.”
4. D“We store the gun unloaded in a locked safe in the bedroom.”

How should a blood sample for serum ammonia be handled?

1. APlaced on ice and sent to the laboratory at once
2. BShaken firmly to mix it before it is sent away
3. CKept warm and sent with the next routine batch
4. DLeft at room temperature for several hours first

A 68-year-old man has fatigue, a hemoglobin of 9,8 g/dL (98 g/L), an MCV of 72 fL and a low ferritin. He eats a normal diet. What is the most important next step?

1. AGive iron and do no further tests at all
2. BLook for a source of blood loss in the gut
3. CStart vitamin B₁₂ injections
4. DRepeat the blood count in one year

Karta bilansu płynów pacjenta wykazuje w ciągu 24 godzin przyjęcie 1,200 mL i wydalenie 2,300 mL. Co to oznacza?

1. ADodatni bilans płynów 3,500 mL
2. BDodatni bilans płynów 1,100 mL
3. CUjemny bilans płynów 1,100 mL
4. DWyrównany bilans płynów

A patient with myasthenia gravis develops increasing difficulty swallowing and weak, shallow breathing. What is the main danger?

1. ARespiratory failure from a myasthenic crisis
2. BA urinary tract infection
3. CA sudden rise in blood glucose from the stress
4. DSevere hypertension from anxiety

After thrombolysis for a myocardial infarction, which complication is the nurse most concerned to detect?

1. AConstipation from bed rest
2. BA skin rash appearing at the sites of the ECG electrodes
3. CA high blood glucose caused by the thrombolytic drug itself
4. DBleeding, including a sudden change in neurological status

A patient receiving noradrenaline (norepinephrine) through a peripheral cannula has pale, cold skin around the site. What should the nurse do?

1. AIncrease the rate so the drug enters the vein faster and leaks less
2. BContinue the infusion, as this is expected
3. CMassage the area firmly to spread the drug out into the surrounding tissue
4. DStop it at that site, inform the team and follow the extravasation policy

Które stwierdzenie dotyczące zespołu hiperglikemiczno-hiperosmolarnego (HHS) jest prawidłowe?

1. ARozwija się w ciągu minut i jest mniej niebezpieczny niż DKA
2. BDotyczy głównie osób starszych z cukrzycą typu 2 i rozwija się w ciągu dni
3. CZawsze powoduje wysokie stężenie ketonów we krwi i ciężką kwasicę metaboliczną
4. DWystępuje głównie u małych dzieci z cukrzycą typu 1

Podczas hemodializy ciśnienie pacjenta spada do 80/50 mmHg, a pacjent ma zawroty głowy i nudności. Jakie jest najodpowiedniejsze pierwsze działanie pielęgniarskie?

1. AOd razu podać zwykłą dawkę leku hipotensyjnego pacjenta
2. BPosadzić pacjenta w pozycji wyprostowanej i zachęcić do krótkiego spaceru
3. CZwiększyć szybkość usuwania płynu, aby sesja skończyła się szybciej
4. DPołożyć pacjenta płasko, zmniejszyć usuwanie płynu i wezwać pomoc

Why is the time a surgical limb tourniquet is inflated carefully recorded?

1. AThe surgeon is paid per minute of use
2. BIt shows how long the anaesthetic gas was used
3. CThe tourniquet slowly loses all its air after one minute
4. DLong inflation can cause nerve and muscle damage

A patient with diabetes has rapidly spreading redness around a small wound, severe pain out of proportion, fever and crackling under the skin. What should the nurse suspect?

1. AA simple insect bite
2. BNecrotising fasciitis
3. CMild contact dermatitis
4. DA healing venous ulcer