Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Pielęgniarka dyplomowana mówi do asystenta pielęgniarskiego: „Proszę zajrzeć do pacjenta w sali 12”. Którego „właściwego” elementu delegowania brakuje?

1. AWłaściwej osoby do zadania
2. BWłaściwych wskazówek i komunikacji
3. CWłaściwego zadania dla danego miejsca
4. DWłaściwych okoliczności

A marathon runner is confused, with a temperature of 41 °C and hot skin. What is the priority?

1. AGiving an antipyretic tablet and waiting for it to work
2. BRapid cooling while supporting airway and circulation
3. CWrapping the runner in a blanket to prevent shivering
4. DAsking the runner to rest in the shade and drink slowly

When walking with axillary crutches, where should the patient’s weight be taken?

1. AOn the shoulders, with the crutches pressed upward
2. BOn the armpits, resting on the crutch tops
3. COn the hands, with the crutch tops a few finger widths below the armpits
4. DOn the elbows, kept bent at a right angle with the crutch tops tucked under the arms

A nurse has weeping dermatitis on both hands. What is the most appropriate action?

1. AAvoid direct patient care and handling of equipment until it heals, and see occupational health
2. BCover the lesions with a waterproof bandage and keep working with patients as usual
3. CContinue care as usual and wear one pair of gloves
4. DUse extra alcohol hand rub on the lesions

Why must a blue-top (citrate) coagulation tube be filled to the correct level?

1. AThe laboratory charges extra when a tube is not filled correctly
2. BAn overfull tube is needed to measure the potassium level
3. CUnderfilled tubes always give a falsely low hemoglobin and hematocrit
4. DThe blood-to-anticoagulant ratio must be right for accurate clotting times

A patient on high-dose dexamethasone has a white cell count of 15 × 10³/µL, mostly mature neutrophils with no bands. They have no fever and no signs of infection. What is the most likely explanation?

1. ACertain sepsis that needs antibiotics started without delay
2. BA new leukemia that is confirmed by this result alone
3. CA steroid effect that moves neutrophils into the circulating blood
4. DA laboratory error, because steroids always lower the white count

What is the best way to protect the heels of a bed-bound patient from pressure damage?

1. AApply a tight bandage to the heels
2. BRest the heels on a rolled-up towel
3. CMassage the heels firmly several times a day to help circulation
4. DOffload the heels so they do not touch the mattress

A patient going home with a leg cast is taught about cast care. Which statement shows a need for further teaching?

1. A"I can push a knitting needle down the cast to scratch an itch."
2. B"I will keep my leg raised on pillows for the first few days."
3. C"I will come back if my toes go numb or turn blue."
4. D"I will keep the cast dry."

Why must inspired air be humidified for a patient with a tracheostomy?

1. ADry air is needed to stop secretions forming in the trachea
2. BThe nose and upper airway, which warm and moisten air, are bypassed
3. CHumidification prevents the cuff from deflating
4. DHumidified air contains more oxygen than dry air at the same flow

After a pneumonectomy, how is the patient usually positioned?

1. AHead down with the legs raised, to drain secretions from the lung
2. BOn the back or the operated side, not fully on the remaining lung
3. CFully on the non-operated side, to help drain the empty space
4. DFlat and prone for the whole of the first day after surgery

Which approach helps most when talking to a patient with expressive aphasia?

1. AFinish their sentences quickly to save them effort
2. BAsk questions that can be answered with yes, no or a gesture
3. CSpeak louder, because the patient cannot hear well
4. DAvoid talking to them until their speech has recovered

A patient has frothy urine and marked leg swelling. Serum albumin is 18 g/L (1,8 g/dL), and BP is normal. The urine shows heavy protein but little blood. What is most likely?

1. AAcute pyelonephritis
2. BNephritic syndrome
3. CA urethral stricture
4. DNephrotic syndrome

What is a Curling's ulcer?

1. AA stress ulcer of the stomach or duodenum after a major burn
2. BA leg ulcer caused by venous disease after long bed rest
3. CA pressure ulcer under a splint that has been left on too long
4. DA burn on the sole of the foot

On day 3 after surgery, a patient has a temperature of 38,6 °C, respiratory rate 24/min, pulse 118/min, BP 92/58 mmHg and new confusion. What should the nurse do?

1. AEscalate urgently and start the sepsis pathway
2. BEncourage oral fluids and wait for the doctor's round
3. CGive paracetamol and recheck in four hours
4. DRecord the observations and continue routine care