Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient’s peripheral IV site is swollen, pale and cool, and the infusion has slowed. What should the nurse do first?

1. AIncrease the infusion rate to overcome the resistance
2. BStop the infusion and remove the cannula
3. CFlush the cannula hard to clear the blockage
4. DApply a tight bandage over the site to reduce swelling

Podczas triażu START dorosły, który nie chodzi, oddycha 28 razy na minutę, nie ma tętna na tętnicy promieniowej i ma nawrót włośniczkowy 4 sekundy. Do jakiej kategorii zostaje zakwalifikowany?

1. ACzerwonej (natychmiastowa pomoc)
2. BŻółtej (odroczona), ponieważ częstość oddechów jest poniżej 30/min
3. CZielonej (drobne obrażenia)
4. DCzarnej (oczekujący)

A patient with delirium is at risk of falls and of pulling out lines. Which option is less restrictive than restraints?

1. AA trained sitter or video monitoring with staff nearby
2. BFour side rails raised and the door closed so the patient stays in bed
3. CA vest restraint applied for the whole night
4. DA sedative given every few hours as needed

During bedside handoff, the patient says, “I’m allergic to sulfa drugs,” but no allergy is recorded. What should the nurse do?

1. AClarify the reaction, update the allergy record and tell the prescriber
2. BIgnore it, because the electronic record is more reliable than the patient’s memory
3. CTell the patient that sulfa drugs are always safe
4. DWait until the patient is discharged to update the record

A patient has macrocytic anemia with numbness and tingling of the feet and poor balance. Which deficiency is most likely?

1. AVitamin C (ascorbic acid)
2. BIron (low ferritin)
3. CFolate (folic acid)
4. DVitamin B₁₂

A patient without diabetes in the ICU with sepsis has a glucose of 260 mg/dL (14,4 mmol/L) and an HbA1c of 5,2%. What is the best interpretation?

1. AType 1 diabetes from autoimmune damage
2. BA meter error, because HbA1c is normal
3. CLong-standing undiagnosed type 2 diabetes
4. DStress hyperglycemia from acute illness

Which blood result often rises in an upper GI bleed because blood is digested in the gut?

1. ACalcium
2. BSodium
3. CGlucose
4. DUrea (blood urea nitrogen)

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

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

Why is a higher level of HDL cholesterol considered protective?

1. AHDL thins the blood in the same way as an anticoagulant
2. BHDL lowers the blood pressure directly
3. CHDL carries cholesterol from the tissues back to the liver
4. DHDL is converted into vitamin D in the walls of the arteries

Three hours after femoral cardiac catheterisation, a patient has new lower back and flank pain, a heart rate of 112/min and BP 92/60 mmHg. The groin looks normal. What should the nurse suspect?

1. ARetroperitoneal bleeding
2. BNormal back ache from lying flat
3. CA urinary tract infection
4. DAn allergic reaction to the contrast

The day after a thyroidectomy, a patient reports tingling around the mouth and in the fingers. Why might this happen?

1. AThe parathyroid glands may have been damaged, lowering calcium
2. BThe thyroid hormone level has risen too high after surgery
3. CThe patient is breathing too slowly after the operation
4. DThe anaesthetic has caused an allergic reaction

A patient has fever, confusion, odd behaviour and a new seizure. Herpes simplex encephalitis is suspected. Which drug is usually started straight away?

1. AIV aciclovir
2. BOral amoxicillin
3. CIV insulin
4. DOral prednisolone

Why do patients usually have a dental review before radiotherapy to the head and neck?

1. AThe dentist gives the radiotherapy
2. BIt causes dry mouth and raises the risk of decay and jaw damage
3. CTeeth block the radiation beam completely
4. DRadiotherapy can only be given once all the teeth have been removed

On day 5 after a major burn, a patient is confused, with a temperature of 39,2 °C, tachycardia, and an offensive, discoloured wound. What should the nurse suspect?

1. AAn allergy to the dressing only
2. BDelirium from boredom on the ward
3. CBurn wound infection with sepsis
4. DThe normal hypermetabolic response alone