Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A nurse teaches a patient who uses home oxygen. Which statement shows a need for further teaching?

1. A“I will not use oil-based creams on my face.”
2. B“I will put up no-smoking signs at the front door and in my room.”
3. C“I will keep the oxygen away from the gas stove.”
4. D“My husband can smoke in my room if the window is open.”

A toddler with tetralogy of Fallot becomes very blue and breathless while crying. What should the nurse do first?

1. APlace the child in a knee-to-chest position
2. BEncourage the child to keep crying to open the lungs
3. CLay the child flat on their back
4. DGive a large drink of water to calm the child

A nurse who never had BCG vaccine has a positive tuberculin skin test for the first time. The chest x-ray is clear and there are no symptoms. What does this most likely mean?

1. AA failed test that must be repeated next year
2. BActive TB, which needs airborne isolation
3. CLatent TB infection, which is not contagious
4. DImmunity to TB from a past exposure

A patient with dementia is often found at the exit doors trying to leave the unit. Which measure is most appropriate?

1. AUse an electronic wander alert, supervise closely and offer meaningful activity
2. BLock the patient alone in a single room so that they cannot reach the exit doors
3. CKeep the patient in a chair with a vest restraint
4. DGive a sedative each time the patient goes to the door

A patient taking empagliflozin (an SGLT2 inhibitor) has glucose in the urine but a normal blood glucose. What is the best interpretation?

1. AAn expected effect of the drug
2. BA sign of kidney failure
3. CA urinary tract infection
4. DUncontrolled diabetes needing insulin

Four patients had a thyroidectomy earlier today. Which result should the nurse act on first?

1. AGlucose 145 mg/dL (8,0 mmol/L) after surgery
2. BSodium 136 mEq/L on IV fluids after surgery
3. CHemoglobin 12,1 g/dL (121 g/L) after surgery
4. DCalcium 7,2 mg/dL (1,8 mmol/L) with tingling lips

Which oxygen device delivers a precise, fixed concentration of oxygen?

1. ANon-rebreathe mask
2. BNasal cannula
3. CVenturi mask
4. DSimple face mask

Przyjęto pacjenta z oparzeniem obejmującym 30% powierzchni ciała. Które wczesne powikłanie budzi największe obawy w pierwszych 24 godzinach?

1. AZaparcie
2. BBlizny i przykurcze
3. COdleżyny wynikające z długotrwałego unieruchomienia
4. DWstrząs hipowolemiczny z powodu utraty płynów

Virchow's triad describes three factors that promote venous thrombosis. Which patient factor represents venous stasis?

1. AAn inherited clotting disorder
2. BDamage to a vein during hip surgery
3. CTaking an oestrogen-containing pill
4. DImmobility after major surgery

Pacjent wentylowany mechanicznie na oddziale intensywnej terapii jest zagrożony zapaleniem płuc związanym z respiratorem. Które działanie pielęgniarskie pomaga zmniejszyć to ryzyko?

1. AWymiana układu oddechowego respiratora co kilka godzin
2. BUtrzymywanie wezgłowia łóżka uniesionego do 30–45°
3. CUtrzymywanie pacjenta w pozycji płaskiej, aby chronić rurkę intubacyjną
4. DUnikanie higieny jamy ustnej, aby zapobiec krwawieniu z dziąseł

An 85-year-old care home resident becomes newly confused and is falling more often. A UTI is one possibility. Why?

1. AConfusion is the only symptom of a UTI at any age
2. BUrinary infections always cause a high fever in older adults
3. COlder adults often show infection as confusion
4. DA UTI cannot occur in people over 80

During a TURP, a patient becomes confused and nauseated, with a slow pulse and a raised BP. The sodium is 121 mmol/L. What is most likely?

1. ATURP syndrome from absorbed irrigation fluid
2. BA normal reaction to the spinal anaesthetic
3. CAn allergic reaction to the catheter
4. DHypoglycaemia from fasting for many hours before surgery

Która faza gojenia rany obejmuje tworzenie tkanki ziarninowej i nowych naczyń krwionośnych?

1. AFaza zapalna
2. BFaza proliferacyjna
3. CFaza dojrzewania
4. DFaza hemostazy (krzepnięcia)

Which history should most alert the nurse to a possible latex allergy before surgery?

1. AHay fever every spring since childhood
2. BItching with bananas, avocado and kiwi, and many operations
3. CA rash after taking amoxicillin as a child, with a family history of asthma
4. DFeeling sick after eating shellfish once