Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Pielęgniarka, która zwykle pracuje na oddziale położniczym, zostaje oddelegowana na oddział chorób wewnętrznych dla dorosłych. Którego pacjenta najodpowiedniej jej przydzielić?

1. APacjenta z czynnym krwawieniem z górnego odcinka przewodu pokarmowego
2. BPacjenta z zapaleniem płuc, stabilnego na doustnych antybiotykach
3. CPacjenta z ciągłym wlewem insuliny z powodu kwasicy ketonowej
4. DPacjenta ze świeżą tracheostomią

A 2-month-old infant has a spiral fracture of the femur. The parents say the baby rolled off the sofa. What should the nurse recognize?

1. ANo further action is needed once the fracture is treated
2. BThe injury does not fit the infant’s development, so possible abuse must be reported
3. CA spiral fracture in an infant is always caused by birth trauma
4. DInfants of this age often roll off furniture and break bones in this way

Why are blood cultures usually taken from two separate venipuncture sites?

1. ABecause each site tests a different antibiotic
2. BTo reduce the total amount of blood taken
3. CTo help tell a true infection from skin contamination
4. DTo make the results come back faster from the laboratory

Patients contaminated with radioactive dust arrive at the hospital. Which step removes most of the external contamination?

1. AWrapping the patient in a blanket
2. BScrubbing the skin until it is red
3. CGiving the patient potassium iodide
4. DRemoving the patient’s clothing

A patient with a low clinical probability of deep vein thrombosis has a normal (negative) D-dimer. What is the best interpretation?

1. AThe test is useless and should always be ignored
2. BA DVT is unlikely and can usually be ruled out
3. CA pulmonary embolism is now certain to be present
4. DA DVT is confirmed and anticoagulation is needed

A patient has fatigue, weight gain and constipation. Results: TSH 24 mIU/L, free T₄ low, total cholesterol 285 mg/dL (7,4 mmol/L), sodium 131 mEq/L. What is the best interpretation?

1. APrimary hypothyroidism, which can raise lipids and lower sodium
2. BSecondary hypothyroidism from failure of the pituitary gland
3. CFamilial hypercholesterolemia, unrelated to the thyroid results
4. DHyperthyroidism, with suppressed thyroid hormone production

W trakcie wlewu dożylnego okolica kaniuli staje się obrzęknięta, chłodna i blada, a wlew zwalnia. Co jest prawdopodobne?

1. AZapalenie żyły spowodowane bakteryjnym zakażeniem ściany żyły
2. BPrzeciążenie krążenia płynami
3. CNacieczenie płynem otaczającej tkanki
4. DZator powietrzny

A nurse notices that a wrong dose of a drug was prepared but was caught before it was given. What should be done?

1. ATell only the patient's family
2. BSay nothing, because no harm reached the patient
3. CDiscipline the nurse who prepared it on the spot in front of colleagues
4. DReport it as a near miss through the incident reporting system

When should an adult with cystic fibrosis take pancreatic enzyme capsules?

1. AOnly when they have diarrhoea
2. BOnce a day on waking, at least an hour before any food
3. COnly at bedtime
4. DWith all meals and snacks that contain fat

The monitor of a patient with a permanent pacemaker shows pacing spikes, but none of them is followed by a QRS complex. What does this mean?

1. AFailure to capture
2. BAtrial fibrillation
3. CNormal pacemaker function
4. DFailure to sense

Który wynik badania moczu najlepiej odróżnia moczówkę prostą od SIADH?

1. AMoczówka prosta daje mocz rozcieńczony; SIADH daje mocz stężony
2. BMoczówka prosta daje mocz stężony; SIADH daje mocz rozcieńczony
3. COba schorzenia dają bardzo stężony mocz
4. DMoczówka prosta daje glukozę w moczu; SIADH daje białko

A patient with an acute stroke has a glucose of 15 mmol/L (270 mg/dL). They do not have known diabetes. What is appropriate?

1. AReport it and monitor glucose, as it can worsen outcome
2. BIgnore it, because stress always raises glucose
3. CStop all IV fluids to lower the glucose
4. DGive glucose gel to stabilise the level

Which advice has good evidence for reducing cancer-related fatigue?

1. ARegular light to moderate activity, such as walking
2. BAvoiding all daily activities
3. CDrinking several strong coffees every evening
4. DComplete bed rest for the whole course of treatment

A patient with a PICC line develops swelling and aching of the same arm and prominent veins on the chest. What should the nurse suspect?

1. ANormal swelling after line insertion
2. BLymphoedema from a previous operation
3. CAn allergy to the dressing
4. DA catheter-related deep vein thrombosis