Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Które zadanie asystenta pielęgniarskiego jest odpowiednie u pacjenta dwa dni po endoprotezoplastyce biodra?

1. ASprawdzenie rany pod kątem zaczerwienienia, ocieplenia i wycieku
2. BNauczenie pacjenta zasad ochrony biodra przed wypisem
3. CPomoc pacjentowi w przejściu na krzesło z zachowaniem zasad ochrony biodra
4. DOcena, czy ostatnia dawka leku przeciwbólowego skutecznie zniosła ból

Podczas triażu START dorosły, który nie chodzi, oddycha 24 razy na minutę, ma tętno na tętnicy promieniowej, ale nie wykonuje prostych poleceń. Do jakiej kategorii zostaje zakwalifikowany?

1. ACzerwonej (natychmiastowa pomoc)
2. BZielonej (drobne obrażenia)
3. CCzarnej (oczekujący)
4. DŻółtej (odroczona)

When is it appropriate to use the override function on an automated dispensing cabinet to take a drug before pharmacist review?

1. AWhenever the nurse is sure of the dose
2. BOnly in an urgent situation where delay would harm the patient, per policy
3. CAt the start of each shift to save time later
4. DWhenever the pharmacist is slow to review new orders and the patient is waiting

A visitor becomes very agitated and starts shouting at the nurse in a patient’s room. What should the nurse do first?

1. AKeep a safe distance and a clear exit, speak calmly and call security if needed
2. BTouch the visitor’s arm to help them calm down
3. CTurn away from the visitor and continue with the patient’s care as normal
4. DRaise the voice to show who is in charge

When should a blood specimen tube be labeled?

1. AIn the laboratory, by the staff who receive the unlabeled sample
2. BBefore entering the room, so tubes are ready for the next patients
3. CAt the bedside, in the patient's presence, using two identifiers
4. DAt the nurses' station, after all samples for the shift are drawn

A patient has a sodium of 150 mEq/L, a glucose of 180 mg/dL and a BUN of 28 mg/dL. Using the formula 2 × Na + glucose/18 + BUN/2,8, what is the calculated serum osmolality?

1. AAbout 300 mOsm/kg, which is normal
2. BAbout 358 mOsm/kg, which is high
3. CAbout 285 mOsm/kg, which is normal
4. DAbout 320 mOsm/kg, which is high

What is the recommended first aid for a thermal burn?

1. ACool it under cool running water for about 20 minutes
2. BSpread butter or oil over the burn
3. CBurst any blisters to release the fluid
4. DApply ice directly to the burn until the pain stops completely

Why must blood samples for a cross-match be labelled at the bedside immediately after they are taken?

1. ATo keep the sample warm so the cells do not break down in transit
2. BTo prevent "wrong blood in tube" errors that can cause fatal reactions
3. CTo let the patient sign the label
4. DTo speed up the laboratory's computer system and reduce the waiting time

How is a patient usually positioned for a thoracentesis?

1. ALying on the affected side with the head down
2. BSitting upright and leaning forward over a table
3. CProne with the arms by the sides
4. DFlat on the back with the legs raised

A patient who has had a total laryngectomy becomes breathless and needs oxygen. How should it be given?

1. AVia a mask or humidified device over the neck stoma
2. BVia nasal cannula at 2 L/min
3. CVia a non-rebreather mask over the mouth only
4. DVia a standard face mask over the nose and mouth

Tydzień po operacji tarczycy głos pacjenta nadal jest ochrypły i słaby. Które powikłanie jest najbardziej prawdopodobne?

1. APrzełom tarczycowy wywołany operacją
2. BNiskie stężenie wapnia z powodu uszkodzenia przytarczyc
3. CReakcja alergiczna na przylepiec opatrunku
4. DUszkodzenie nerwu krtaniowego wstecznego

During haemodialysis, a patient suddenly becomes breathless with chest pain, and air is seen in the line. What should the nurse do first?

1. AContinue the session and recheck in 30 minutes
2. BSpeed up the pump to clear the air into the patient
3. CSit the patient upright and give a drink of water
4. DClamp the lines and lay the patient left side down, head low

A patient received IV morphine 20 minutes ago and the surgical consent form has not been signed. What should the nurse do?

1. ATell the surgeon, as the patient may not be able to consent now
2. BAsk a relative to sign instead of the patient
3. CSign the form on the patient's behalf as a witness
4. DAsk the patient to sign quickly before they get sleepier

Podczas znieczulenia ogólnego u pacjenta rozwija się sztywność szczęk, rosnące CO₂ końcowowydechowe i tachykardia, a następnie szybko rosnąca temperatura. Który lek jest leczeniem swoistym?

1. ASuksametonium
2. BNalokson
3. CParacetamol
4. DDantrolen