Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient with a spinal cord injury at T4 suddenly has a severe headache, flushing above the injury and a blood pressure of 200/110 mmHg. What does the nurse do first?

1. AApply extra blankets to keep the patient warm and calm
2. BSit the patient upright with the legs lowered
3. CGive a warm drink and recheck the blood pressure in an hour
4. DLay the patient flat with the legs raised

A day after a femur fracture, a young patient becomes confused and breathless, with small red spots on the chest. What should the nurse suspect?

1. AFat embolism syndrome
2. BAlcohol withdrawal
3. CNormal pain after a fracture
4. DAn allergic reaction to the cast

Before helping a patient from bed into a wheelchair, what should the nurse do with the wheelchair?

1. ALock the brakes and place it close to the bed on the patient’s stronger side
2. BPlace it at the foot of the bed, facing away
3. CLeave the brakes off so the chair can move along with the patient during the pivot
4. DPlace it on the patient’s weaker side so that side is supported

During flu season, a nurse wakes up with fever, cough and muscle aches. What is the best action?

1. ATake an antipyretic so the fever does not show at work
2. BStay home and inform the employer according to the illness policy
3. CGo to work but wear a surgical mask for the whole shift
4. DGo to work but avoid caring for patients who have weak immune systems

A patient with hepatic encephalopathy is receiving lactulose. Which finding best shows that the treatment is effective?

1. ASix to eight watery stools a day with dizziness
2. BNo bowel movement for 2 days and calm sleep
3. CTwo to three soft stools a day and clearer thinking
4. DA rising serum ammonia with a slower flapping tremor

A patient has fever, chills, flank pain and costovertebral angle tenderness. Urinalysis shows many white cells and white cell casts. Which condition is most likely?

1. AGlomerulonephritis
2. BNephrotic syndrome
3. CSimple cystitis
4. DAcute pyelonephritis

Pacjent z marskością wątroby staje się splątany i senny, z drżeniem trzepoczącym rąk. Jakie powikłanie jest prawdopodobne?

1. AHipoglikemia wywołana insuliną
2. BUdar
3. CEncefalopatia wątrobowa
4. DWyłącznie upojenie alkoholowe

U pacjenta z wlewem heparyny pięć dni po rozpoczęciu nagle spada liczba płytek krwi. Co należy podejrzewać?

1. AMałopłytkowość wywołaną heparyną
2. BNiedokrwistość z niedoboru żelaza
3. CPrawidłową reakcję na heparynę
4. DNiedobór witaminy K spowodowany niedostatecznym spożyciem

After an above-knee amputation, which measure helps prevent a hip flexion contracture?

1. ALying prone for periods and avoiding pillows under the stump
2. BSitting in a chair for most of the day with the hips bent
3. CKeeping the hip bent to reduce stump swelling
4. DKeeping a pillow under the stump at all times, day and night

Ten days after cardiac surgery, a patient has a fever, a red sternal wound with discharge and a clicking feeling in the chest when coughing. What should the nurse suspect?

1. ACostochondritis caused by forceful coughing
2. BPericarditis from the operation
3. CNormal wound healing with some expected discharge
4. DSternal wound infection with an unstable sternum

A patient's potassium stays low despite replacement. Which other level should be checked?

1. ABilirubin
2. BAmylase
3. CFerritin
4. DMagnesium

Weeks after starting insulin, a patient with newly diagnosed type 1 diabetes needs much less insulin and has frequent mild hypos. What is the most likely explanation?

1. AThe diabetes has been cured, so insulin can stop
2. BA honeymoon phase, but insulin is still needed
3. CThe insulin has gone off and should be replaced
4. DThe patient actually has type 2 diabetes

Patients on immune checkpoint inhibitors may develop immune-related side effects. Which symptom should they report promptly?

1. ANew diarrhoea or abdominal pain
2. BA small bruise after a knock
3. CMild tiredness after a busy day
4. DSlight hair thinning over months

A nurse teaches a patient going home between chemotherapy cycles. Which statement shows a need for further teaching?

1. A"I'll check my temperature whenever I feel hot, shivery or unwell."
2. B"If I get a fever, I'll take paracetamol and see if it settles."
3. C"I'll wash my hands often and avoid people with infections."
4. D"I'll keep the emergency number and call if I feel shivery."