Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A conscious patient with hypoglycemia drank juice 15 minutes ago. The glucose is now 62 mg/dL (3,4 mmol/L). What should the nurse do next?

1. AGive another serving of fast-acting carbohydrate and recheck in 15 minutes
2. BRecord the result and recheck the glucose at the usual time before the evening meal
3. CGive the next scheduled dose of rapid-acting insulin with the meal
4. DWait another hour, because juice can take a long time to work

A patient has a potassium of 7,0 mEq/L with peaked T waves. Several drugs are prescribed. Which one is usually given first to protect the heart?

1. AOral sodium bicarbonate
2. BOral potassium binder
3. CIV furosemide
4. DIV calcium gluconate

A patient cannot bear weight and cannot help with transfers. Which method is safest to move the patient from bed to chair?

1. AA mechanical lift used by enough trained staff
2. BTwo nurses lifting the patient under the arms
3. CAsking the patient to stand and try their best
4. DOne nurse doing a standing pivot transfer

Podczas zakładania cewnika do pęcherza moczowego techniką jałową końcówka cewnika dotyka uda pacjenta. Co powinna zrobić pielęgniarka?

1. AOpłukać końcówkę jałową wodą, a następnie kontynuować
2. BPrzetrzeć końcówkę środkiem antyseptycznym i kontynuować
3. CKontynuować, ponieważ udo zostało oczyszczone
4. DWyrzucić cewnik i użyć nowego, jałowego

A 55-year-old has a positive fecal immunochemical test (FIT) during routine screening. What is the usual next step?

1. AStart an iron supplement only
2. BNo action if there are no symptoms
3. CReferral for colonoscopy
4. DRepeat the test in 10 years

Pacjent z silnymi wymiotami ma potas 3,0 mEq/L, chlorki 88 mEq/L i wysoki wodorowęglan. Jaki obraz to przedstawia?

1. AWysoki potas z kwasicą metaboliczną wywołaną odwodnieniem
2. BKwasicę ketonową cukrzycową z wysoką luką anionową
3. CPrawidłowe wyniki niewymagające dalszej kontroli
4. DUtratę kwasu żołądkowego: niski potas i chlorki, zasadowicę metaboliczną

Long-term amiodarone treatment can affect which of the following?

1. ABlood glucose and cholesterol only
2. BHair colour and nail growth only, with no effect on organs
3. CThe sense of smell and taste only, with no other effects
4. DThyroid function, the lungs and the skin's sensitivity to sunlight

A patient due a blood transfusion is not wearing an identity band. What should the nurse do?

1. ANot start until a correct identity band is in place and identity is confirmed
2. BCheck the name on the bed and proceed
3. CAsk another patient to confirm who the patient is
4. DAsk the patient to state their name and date of birth, then start straight away

A patient with heart failure is comfortable at rest but becomes breathless walking across a room. Which NYHA class fits best?

1. AClass I
2. BClass II
3. CClass III
4. DClass IV

As the defibrillator charges, a nurse sees a colleague still holding the patient's bed rail. What should the nurse do?

1. AAsk the colleague to hold the patient's hand instead
2. BTurn off the defibrillator and start a new cycle of CPR
3. CDeliver the shock now, as the bed rail is not part of the patient
4. DCall clearly for everyone to stand clear and check before the shock

A conscious patient with a glucose of 3,1 mmol/L (56 mg/dL) can swallow safely. Which is the best first treatment?

1. AA dose of rapid-acting insulin with a sandwich
2. BGlucose tablets or a small glass of fruit juice
3. CA glass of milk and two plain biscuits
4. DA chocolate bar and a cup of tea with milk

A nurse teaches a young adult with newly diagnosed epilepsy. Which statement shows a need for further teaching?

1. A"I will tell my friends what to do if I have a seizure."
2. B"I will take a shower rather than a bath."
3. C"As long as I take my tablets, I can swim alone."
4. D"I will keep a record of any seizures I have."

What is the most important safety point about misoprostol?

1. AIt causes severe constipation in most patients
2. BIt can cause miscarriage and must not be used in pregnancy
3. CIt strongly raises blood glucose in people with diabetes
4. DIt must be given only by deep intramuscular injection

A category (stage) 4 pressure ulcer is now healing and shallower. How should it be documented according to standard guidance?

1. AAs a fully healed ulcer that can be removed from the record
2. BAs a category 1 pressure ulcer now
3. CAs a healing category 4 pressure ulcer
4. DAs a category 2 pressure ulcer now