Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A nasogastric tube has just been placed for feeding. What must happen before the first feed is given?

1. APlacement is confirmed by an approved method
2. BThe feed is started slowly to see if the patient coughs
3. CThe patient is asked if the tube feels comfortable
4. DThe tube is flushed with a large volume of water

Two days after starting haloperidol, a patient suddenly develops painful neck twisting and the eyes roll upwards. What should the nurse anticipate?

1. ANo action, because the spasm is a sign of improvement
2. BPhysical restraint until the spasm passes
3. CA higher dose of haloperidol to calm the patient and stop the movements quickly
4. DAn anticholinergic drug, such as benztropine or procyclidine, as prescribed

A patient with a severe latex allergy is booked for surgery. Which measure is commonly used?

1. AWrap latex items in plastic before use
2. BUse latex-free supplies and schedule the patient as the first case of the day
3. CUse latex gloves only for short procedures
4. DGive the patient antihistamines before surgery and then use the normal supplies

A patient arrives in the operating room for knee surgery, and the site has not been marked. What should happen?

1. AStart the surgery, because the consent form shows the side
2. BMark the site after the patient is anesthetized and draped
3. CDo not start until the site is marked and verified with the patient
4. DLet the circulating nurse mark the site from memory of the surgeon’s plan

A patient without symptoms has a fasting plasma glucose of 132 mg/dL (7,3 mmol/L) on Monday and 138 mg/dL (7,7 mmol/L) on Thursday. What does this show?

1. AThe results meet the criteria for diabetes
2. BThe results show reactive hypoglycemia
3. CThe results are within the normal fasting range
4. DThe results show prediabetes only

A woman who is 34 weeks pregnant has high blood pressure, right upper abdominal pain, a platelet count of 70 × 10³/µL, raised ALT and AST, and a raised LDH. Which condition fits best?

1. AGestational diabetes
2. BPhysiologic anemia of pregnancy
3. CAcute cholecystitis
4. DHELLP syndrome

A patient is having a 12-lead ECG. Where are the chest electrodes placed?

1. AIn a straight line down the centre of the sternum from top to bottom
2. BAnywhere on the chest where the skin is clear
3. COn both shoulders and both hips only
4. DIn standard numbered positions across the front and left of the chest

Which finding suggests hypocalcaemia?

1. ASpasm of the hand when a blood pressure cuff is inflated on the arm
2. BA slow, irregular pulse with nausea and yellow-tinged vision
3. CA flapping tremor of the outstretched hands
4. DSevere thirst with a large urine output and constipation

A patient's ankle–brachial pressure index (ABPI) is 0,6. What does this suggest?

1. ANormal leg circulation
2. BStiff, calcified arteries that read falsely high
3. CA deep vein thrombosis
4. DSignificant peripheral arterial disease

After a car crash, a patient is severely breathless with absent breath sounds on the right, a deviated trachea, distended neck veins and BP 76/40 mmHg. What is the immediate management?

1. AA chest X-ray to confirm the diagnosis before any treatment
2. BLying the patient flat with the legs raised
3. CUrgent needle or finger decompression of the right chest
4. DInsertion of a urinary catheter to monitor output

A patient is starting lamotrigine. Which teaching point is most important?

1. ATake it with a glass of grapefruit juice to improve its absorption
2. BReport any skin rash promptly, especially in the first weeks
3. CDouble the dose if a seizure happens
4. DExpect an orange tint to tears and urine

Stan pacjenta z DKA się poprawia: glikemia 9 mmol/L, ketony 0,4 mmol/L, pH 7,36. Pacjent je i pije. Jak należy zakończyć dożylną insulinę?

1. APodać insulinę podskórnie z posiłkiem, a następnie zakończyć wlew dożylny po okresie nakładania się
2. BZatrzymać dożylną insulinę teraz i rozpocząć insulinę podskórną jutro
3. COdstawić całą insulinę, ponieważ kwasica ketonowa całkowicie ustąpiła
4. DPodać insulinę podskórnie tylko wtedy, gdy glikemia wzrośnie powyżej 20 mmol/L

Which change suggests that a burn wound is becoming infected?

1. AThe wound becoming pink and a little smaller at each dressing change
2. BA partial-thickness burn becoming deeper, with new discolouration
3. CLess exudate on each dressing change
4. DDry, healing skin with mild itching

A patient finds daily wound dressing changes very painful. What is the most effective nursing approach?

1. AChange the dressing less often than the plan says
2. BAvoid analgesia so the patient can report any problems during the change
3. CDo the dressing quickly and give analgesia afterwards
4. DGive analgesia timed so it works during the dressing change