Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient has a serum potassium of 2,9 mEq/L. Which finding should the nurse expect?

1. AFlushed, warm skin and a slow heart rate
2. BMuscle weakness and U waves on the ECG
3. CA rise in urine output and thirst only
4. DTall, peaked T waves and muscle twitching

A provider asks a nurse to perform a procedure that is outside the nurse’s scope of practice. What should the nurse do?

1. ADo it just this once and promise the provider not to do it again
2. BAsk a nursing assistant to do it instead
3. CDecline, explain why and suggest who can safely do it
4. DDo it, because the provider gave the instruction

Why can side rails be dangerous for a confused, restless patient?

1. AThe patient may climb over them or get trapped in gaps
2. BSide rails stop staff from reaching the patient in an emergency
3. CSide rails always cause pressure injuries
4. DSide rails make the bed move by itself

A patient’s blood splashes onto a nurse’s forearm. The skin is intact. What is the correct response?

1. AWash the area with soap and water, then follow the reporting policy
2. BScrub the area with undiluted bleach
3. CDo nothing, because intact skin cannot be contaminated
4. DStart HIV post-exposure prophylaxis right away, before any other step is taken

Dlaczego niskie stężenie wapnia całkowitego należy interpretować ostrożnie u pacjenta z niską albuminą w surowicy?

1. ANiska albumina sprawia, że każde oznaczenie wapnia jest niedokładne i bezużyteczne
2. BDużo wapnia jest związane z albuminą, więc wapń całkowity spada, nawet jeśli wapń zjonizowany jest prawidłowy
3. CAlbuminę i wapń oznacza się tą samą reakcją chemiczną, więc zawsze spadają razem
4. DNiska albumina zawsze powoduje prawdziwą, objawową hipokalcemię

A patient with long-standing rheumatoid arthritis has a hemoglobin of 10,5 g/dL (105 g/L), a low serum iron, a low total iron-binding capacity (TIBC) and a high-normal ferritin. Which condition fits best?

1. AIron-deficiency anemia
2. BAcute blood loss anemia
3. CAnemia of chronic disease (inflammation)
4. DVitamin B₁₂ deficiency anemia

Pacjent jest od niedawna splątany, ma częstość oddechów 24/min i skurczowe ciśnienie tętnicze 95 mmHg. Co należy podejrzewać w pierwszej kolejności?

1. APrawidłowy przebieg pooperacyjny
2. BLęk
3. CSepsę
4. DUpojenie alkoholowe

Which statement about oxygen in a patient with suspected acute coronary syndrome is correct?

1. AHigh-flow oxygen should always be given, whatever the SpO₂
2. BOxygen is given if the SpO₂ is below the target range
3. COxygen replaces the need for an ECG
4. DOxygen must never be given in chest pain

How can a patient reduce wound pain when coughing after abdominal surgery?

1. AAvoid coughing completely until all the stitches are removed
2. BHold a pillow firmly against the wound while coughing
3. CLie flat on the back with the legs straight
4. DHold the breath for as long as possible

A patient with a large pericardial effusion has a systolic pressure that falls by more than 10 mmHg during inspiration. What is this finding called?

1. AA pulse deficit
2. BPulsus alternans
3. CPulsus paradoxus
4. DA collapsing pulse

When the nurse squeezes the trapezius muscle, the patient brings a hand up above the collarbone towards the stimulus. Which GCS motor score is this?

1. A6, obeys commands
2. B3, abnormal flexion
3. C5, localises to pain
4. D4, withdraws from pain

A patient with Guillain–Barré syndrome has a blood pressure that swings between 80/50 and 190/100 mmHg and a heart rate that changes suddenly. What does this suggest?

1. AAnxiety that will settle with reassurance alone
2. BAutonomic dysfunction, which needs continuous cardiac monitoring
3. CA drug reaction that means all medicines must stop
4. DA faulty blood pressure cuff that should be replaced and the readings ignored

Why should metoclopramide not be used for nausea in mechanical bowel obstruction?

1. AIt always causes severe diarrhoea
2. BIt increases gut movement against the blockage
3. CIt blocks the effect of all opioids
4. DIt makes the bowel stop moving completely

A patient with a sacral pressure ulcer keeps sliding down the bed when the head is raised high. Which advice best reduces shear?

1. ARaise the head of the bed to 90° and pull the patient up the bed by the arms
2. BUse a dry sheet and drag the patient up the bed
3. CKeep the head of the bed at or below 30° if possible; use slide sheets
4. DSit the patient upright without any support for the feet