Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Pacjent, któremu właśnie powiedziano, że ma nowotwór, płacze, ale także kilkakrotnie wymiotował i nie może utrzymać płynów. Czym najpierw zajmuje się pielęgniarka?

1. AKontaktem z kapelanem szpitalnym
2. BEdukacją na temat chemioterapii
3. CWsparciem emocjonalnym w związku z rozpoznaniem
4. DWymiotami i utratą płynów

Pacjent uratowany z pożaru domu ma oparzenia twarzy, osmalone włosy w nosie i chrypkę. Co jest priorytetem?

1. ARozpoczęcie przetaczania płynów dożylnych obliczonych na podstawie rozległości oparzenia
2. BPodanie leczenia przeciwbólowego
3. CZabezpieczenie dróg oddechowych, przygotowanie do wczesnego wsparcia dróg oddechowych
4. DOczyszczenie i opatrzenie oparzeń twarzy

A patient receiving continuous nasogastric feeding has pulled the tube partly out. What should the nurse do first?

1. AStop the feeding until the tube position is checked
2. BTape the tube in its new position and continue
3. CPush the tube back in and restart the feed
4. DIncrease the feed rate to make up for the lost time

A patient with suspected sepsis has orders for blood cultures and an IV antibiotic. What is the correct order of actions?

1. ADraw the blood cultures first, then give the antibiotic without delay
2. BWait for the culture results before starting the antibiotic
3. CGive the antibiotic and take the cultures an hour later
4. DGive the antibiotic first so that treatment starts, and take the cultures the next day

When blood is drawn from a central venous catheter, why is a small volume of blood usually discarded first, according to policy?

1. ATo remove blood clots that form in all central lines
2. BTo lower the patient's hemoglobin for a blood transfusion
3. CTo check that the catheter tip is still in the right vein
4. DTo avoid diluting the sample with flush or infusion fluid

A patient's creatinine was 0,9 mg/dL (80 µmol/L) on admission and is 1,3 mg/dL (115 µmol/L) 36 hours later. Using the common KDIGO criteria, what does this show?

1. AChronic kidney disease, because creatinine has risen above baseline
2. BNo kidney injury, because the creatinine is still within the normal range
3. CAcute kidney injury, because it rose by at least 0,3 mg/dL within 48 hours
4. DA laboratory error, because creatinine cannot change within 2 days

During a red cell transfusion, when are serious acute reactions most likely to start?

1. AAbout 24 hours later
2. BIn the first 15 minutes
3. CAfter the third unit only
4. DOnly after the unit has finished

A nurse teaches a patient with heart failure about self-care. Which statement shows a need for further teaching?

1. A"I will report it if I need more pillows to sleep."
2. B"I will take my water tablet in the morning."
3. C"I only need to weigh myself once a month."
4. D"I will weigh myself each morning after passing urine."

A pulse oximeter on a patient's finger gives an unreliable, flickering reading. Which factor is the most likely cause?

1. AA regular heart rate of 75 beats per minute
2. BThe patient sitting upright in a chair
3. CCold hands with poor peripheral circulation
4. DThe patient having eaten recently

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, ponieważ ibuprofen nie jest spokrewniony z kwasem acetylosalicylowym
3. CWstrzymać podanie i poprosić o alternatywę
4. DPodać tylko wtedy, gdy ból przekracza 8 w skali 10-stopniowej

A patient has radioactive iodine treatment for hyperthyroidism. Which advice is correct?

1. AStart breastfeeding again the next day
2. BThere are no precautions, because the dose is tiny
3. CStay in strict isolation in hospital for several months
4. DLimit close contact with children and pregnant women for a time

A nurse teaches a woman with recurrent UTIs. Which statement shows a need for further teaching?

1. A"I will wipe from front to back."
2. B"I will hold my urine for as long as I can."
3. C"I will drink enough fluids during the day."
4. D"I will pass urine soon after sex."

During the first infusion of a monoclonal antibody such as rituximab, which problem is most important to watch for?

1. ASevere constipation within the first hour of starting the infusion
2. BSudden hair loss during the infusion
3. CA rise in platelet count above normal
4. DAn infusion reaction, such as fever, rigors or breathlessness

A patient took a large paracetamol (acetaminophen) overdose 6 hours ago and says they feel completely well. Which statement is correct?

1. AFeeling well means the dose was too small to cause harm
2. BLiver damage after paracetamol occurs only within the first hour or so
3. CLiver damage may still develop, and appears only days later
4. DTreatment is not needed if the patient has not vomited