Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient wants to leave the hospital against medical advice. What should the nurse do?

1. AHide the patient’s clothes and belongings until the provider arrives
2. BInform the provider, explain the risks and document the discussion
3. CLet the patient leave without telling anyone
4. DLock the door so the patient cannot leave the unit

A patient has a wrist restraint. The nurse finds the fingers on that hand pale, cool and tingling. What should the nurse do first?

1. ARaise the arm on a pillow and check again in two hours
2. BDocument the finding and continue with the medication round
3. CLoosen the restraint and assess the circulation
4. DTighten the restraint so the patient moves less

An infant has had a cleft lip repair. Why are elbow restraints often used?

1. ATo stop the infant’s hands reaching the mouth while still allowing arm movement
2. BTo prevent the infant from sucking a pacifier
3. CTo keep the infant from rolling over in the crib
4. DTo hold the IV line in place during feeds and stop it being pulled out

A patient refuses to wear an identification wristband. What should the nurse do?

1. AStop giving the patient any care until they agree to wear the band
2. BAccept the refusal and identify the patient by room number and bed space instead
3. CForce the band onto the patient’s wrist
4. DExplain why it is needed, use other ID methods per policy and document

A test has very high sensitivity for a disease. What does a negative result mean?

1. AThe disease is certain, so treatment should begin
2. BThe disease is unlikely, so it helps rule it out
3. CThe result cannot be used, because sensitivity is high
4. DThe patient must have a different disease instead

A patient with SIADH is on fluid restriction. Which task can the RN delegate to unlicensed assistive personnel (UAP), such as a nursing or healthcare assistant?

1. ADeciding when to recheck the sodium level
2. BTeaching the reasons for fluid restriction
3. CMeasuring and recording intake and output
4. DAssessing the patient for new confusion

Which ECG change is typical of hypokalaemia?

1. AFlattened T waves and prominent U waves
2. BTall, peaked T waves
3. CST elevation in leads II, III and aVF
4. DA very short PR interval with a delta wave

A catheterised postoperative patient has passed only 10 mL of urine in the last two hours. What should the nurse check first?

1. AThat the catheter and tubing are not kinked or blocked
2. BThe patient's cholesterol level from the admission bloods
3. CThe patient's weight from last year
4. DWhether the patient has eaten breakfast

A 70 kg patient has passed 20 mL of urine per hour for the last three hours. How should this be interpreted?

1. ABelow 0,5 mL/kg/h, suggesting poor kidney perfusion
2. BNormal, because any measurable urine output is reassuring
3. CHigh, suggesting fluid overload that needs a diuretic
4. DNormal, because the target is 0,1 mL/kg/h

Pacjent z astmą miał w wywiadzie świsty po przyjęciu kwasu acetylosalicylowego. Przepisano mu ibuprofen na ból pooperacyjny. Co powinna zrobić pielęgniarka?

1. APodać razem z inhalatorem doraźnym
2. BPodać tylko wtedy, gdy ból przekracza 8 w skali 10-stopniowej
3. CPodać, ponieważ ibuprofen nie jest spokrewniony z kwasem acetylosalicylowym
4. DWstrzymać podanie i poprosić o alternatywę

Why is IV calcium gluconate given in severe hyperkalaemia?

1. AIt protects the heart from arrhythmias
2. BIt moves potassium into the cells
3. CIt removes potassium through the kidneys
4. DIt binds potassium in the gut

Which statement correctly distinguishes spinal shock from neurogenic shock?

1. ASpinal shock is lost reflexes; neurogenic shock is low BP and slow pulse
2. BThey are two names for exactly the same condition
3. CSpinal shock is low blood pressure; neurogenic shock is the loss of reflexes
4. DNeurogenic shock is caused by blood loss; spinal shock is caused by infection

When is cold therapy most useful for pain?

1. AOver numb areas where sensation is lost
2. BFor long-term muscle stiffness, applied continuously for several hours
3. CDirectly on skin with poor circulation
4. DSoon after an acute soft tissue injury, to reduce swelling

While a central line is disconnected, a patient suddenly becomes breathless with chest pain and hypotension. Air embolism is suspected. What should the nurse do first?

1. AClamp the line, lie the patient left side down, head low; give oxygen
2. BSit the patient fully upright and flush the line
3. CGive the patient a drink and observe for an hour
4. DRemove the central line straight away and leave the site open to the air