Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient’s urinary catheter has drained no urine for two hours, and the lower abdomen is swollen. What should the nurse do first?

1. ACheck the tubing for kinks or obstruction
2. BRemove the catheter and wait for the patient to void
3. CEncourage the patient to drink more water
4. DGive a prescribed diuretic straight away

A charge nurse notices that a nurse smells of alcohol and is slurring words at the start of the shift. What is the priority?

1. AWait until the end of the shift and then discuss the concern with the nurse privately
2. BAsk the nurse to drink coffee and then start work
3. CLet the nurse work, but only with stable patients
4. DRemove the nurse from patient care and report it according to policy

W sali pacjenta wybucha mały pożar w koszu na odpady, a pacjent leży w łóżku. Co robi najpierw pielęgniarka?

1. ASzuka najbliższej gaśnicy
2. BOtwiera okna, aby usunąć dym
3. CDzwoni do przełożonej, aby zgłosić pożar
4. DUsuwa pacjenta z bezpośredniego niebezpieczeństwa

A toddler has bruises of different ages and a burn, and the parent’s explanation does not fit the injuries. What should the nurse do?

1. AWait until there is clear proof of abuse before reporting anything at all
2. BReport the concern following child-protection (safeguarding) procedures
3. CConfront the parent and ask them to admit to abuse
4. DDocument only and say nothing to anyone

A healthy patient's result is slightly outside the laboratory reference range, and all other results are normal. Which statement best explains why this can happen?

1. AAny result outside the range always means disease is present
2. BRanges cover about 95% of healthy people, so some fall outside
3. CReference ranges are the same in every laboratory worldwide
4. DReference ranges include every healthy person without exception

A patient has taken metformin for 8 years and now has numbness in the feet, a hemoglobin of 10,2 g/dL (102 g/L) and an MCV of 108 fL. Which deficiency is most likely?

1. AVitamin D (calciferol) deficiency
2. BVitamin B₁₂ deficiency
3. CIron deficiency from gut loss
4. DVitamin K deficiency

Why is an ankle–brachial pressure index (ABPI) measured before applying compression bandages to a leg ulcer?

1. ATo check for a urinary tract infection that could delay ulcer healing
2. BTo measure how deep the ulcer is and how much exudate it produces
3. CTo work out the patient's fluid needs
4. DTo exclude significant arterial disease, as compression could cut off blood flow

A hypotensive postoperative patient is given a fluid bolus. Which findings suggest a good response?

1. AThe heart rate falls, blood pressure rises and urine output improves
2. BThe respiratory rate rises and new lung crackles appear
3. CThe heart rate rises further and the patient becomes more confused
4. DThe capillary refill time becomes longer

Płyn w drenie klatki piersiowej przestał się wahać. Co to może oznaczać?

1. APo drugiej stronie rozwinęła się nowa odma opłucnowa
2. BPoziom wody w komorze jest teraz zbyt wysoki, by się poruszać
3. CZestaw drenażowy zaczął drenować jamę brzuszną
4. DPłuco się rozprężyło albo dren jest załamany lub zatkany

Seconds after an intramuscular injection, a patient becomes pale, sweaty and faint, with a heart rate of 48/min. There is no rash, wheeze or swelling, and they recover quickly when laid flat. What is the most likely cause?

1. AA tension pneumothorax
2. BAnaphylaxis
3. CA vasovagal reaction
4. DA myocardial infarction

Why can a patient with an insulin pump develop DKA within hours if the pump stops working?

1. AThe body becomes allergic to insulin when the pump stops
2. BThe pump gives long-acting insulin, which builds up and stops working all at once
3. CThe pump gives only rapid-acting insulin, so there is no long-acting reserve
4. DThe battery in the pump releases chemicals into the blood

A patient with suspected meningitis has a GCS of 9 and pupils that have become unequal. A doctor plans an immediate lumbar puncture. What is the main concern?

1. AA lumbar puncture would spread the infection to the blood
2. BRaised pressure in the skull, so the procedure could cause herniation
3. CThere is no concern, because the lumbar puncture lowers pressure safely
4. DThe patient is too confused to stay still, so it is not needed

Jaka skala służy do oceny ryzyka w krwawieniu z górnego odcinka przewodu pokarmowego przed endoskopią?

1. ASkala Wellsa dla zakrzepicy żył głębokich
2. BSkala ryzyka odleżyn Waterlow
3. CSkala Glasgow-Blatchford
4. DSkala śpiączki Glasgow

W 6. dobie po operacji jamy brzusznej pacjent mówi, że podczas kaszlu coś „puściło”, a przez ranę widać jelito. Co pielęgniarka powinna zrobić natychmiast?

1. AZostawić ranę odkrytą i posadzić pacjenta całkiem pionowo w łóżku
2. BDelikatnie wsunąć jelito z powrotem i mocno zakleić brzegi rany plastrem
3. CPodać pacjentowi lekki posiłek, aby go uspokoić w oczekiwaniu na zespół
4. DPrzykryć jałowymi opatrunkami nasączonymi solą fizjologiczną, zgiąć kolana, wezwać chirurga