Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A drowsy patient who has just returned from surgery starts to vomit. What should the nurse do first?

1. AGive an oral anti-sickness tablet
2. BRaise the legs above the heart
3. CGive a drink of water
4. DTurn the patient onto their side

A patient has a heart rate of 38/min, feels dizzy and has a blood pressure of 80/50 mmHg. Which drug is usually given first, as prescribed?

1. ADigoxin
2. BMetoprolol
3. CDiltiazem
4. DAtropine

A portable x-ray is taken at the bedside. Which action protects the nurse?

1. ALook directly at the x-ray tube during the exposure to check its position
2. BStep away from the patient or wear a lead apron during the exposure
3. CStand next to the patient and hold the film without protection
4. DStay close to the patient to keep them still without protection

Pacjenta przyjęto z ostrą biegunką i podejrzewa się C. difficile. Wynik badania jest w toku. Kiedy należy rozpocząć środki ostrożności przeciwko transmisji przez kontakt?

1. APo trzech dniach biegunki
2. BNatychmiast, bez czekania na wynik badania
3. CDopiero gdy wynik badania będzie dodatni
4. DTylko jeśli u pacjenta pojawi się gorączka

A patient taking phenazopyridine for bladder pain has bright orange urine. What should the nurse know about urine tests?

1. AThe color proves blood is present in the urine
2. BThe color shows severe liver failure is present
3. CThe dye can interfere with dipstick color readings
4. DThe drug improves the accuracy of all dipsticks

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

A patient with leukaemia has a very low platelet count. Which nursing precaution is appropriate?

1. AGive medicines by intramuscular injection
2. BEncourage contact sports to keep fit
3. CUse a soft toothbrush and an electric razor
4. DTake temperatures rectally

Why must a unit of red cells be transfused within the set time limit (commonly four hours) after it leaves controlled cold storage?

1. AThe red cells break down and turn into plasma
2. BBacteria can grow in the blood at room temperature
3. CThe blood group of the cells changes after a few hours
4. DThe bag stops dripping after four hours

A patient has pneumonia in the right lung only. In which side-lying position will oxygenation usually be best?

1. AFlat on the back with no pillows
2. BLying on the left side, with the healthy lung down
3. CLying on the right side, with the affected lung down
4. DProne with the head down

Two days after coronary artery bypass surgery, a patient feels palpitations. The pulse is irregularly irregular at 140/min and BP is 112/70 mmHg. Which rhythm is most likely?

1. AVentricular fibrillation
2. BComplete heart block
3. CAtrial fibrillation
4. DSinus tachycardia

Which action is part of an effective bowel programme after a spinal cord injury?

1. ARestricting fluids to reduce the volume of stool
2. BAvoiding fibre to prevent bloating
3. CUsing strong laxatives only when the bowel has not opened for a week
4. DA routine at the same time each day, often after a meal

A patient received IV insulin and glucose for hyperkalaemia an hour ago. What must the nurse monitor over the next few hours?

1. AUrine colour, for blood in the urine
2. BPupils, for raised intracranial pressure
3. CCapillary glucose, for hypoglycaemia
4. DSkin, for a drug rash

Which intervention most reduces pressure ulcer risk in an immobile patient?

1. AMassaging red areas firmly at each turn to bring back the circulation
2. BKeeping the head of the bed raised at 90° all day
3. CUsing a doughnut-shaped ring cushion
4. DRegular repositioning and a pressure-redistributing mattress

After two days of large volumes of IV 5% glucose, a postoperative patient becomes confused with a headache. Sodium is 124 mmol/L. What is the likely cause?

1. AHypernatraemia from too much salt
2. BHyponatraemia from hypotonic fluids
3. CHypoglycaemia from the glucose
4. DNormal confusion after any anaesthetic