Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient is in skeletal traction. Which finding needs the nurse to act?

1. AThe patient’s body is in line with the traction
2. BThe ropes are in the pulleys
3. CThe weights are resting on the floor
4. DThe weights are hanging freely

Four patients arrive at the emergency department at the same time. Who should be seen first?

1. AA child with a temperature of 39 °C who is alert and drinking
2. BAn older adult with weakness on one side that began 40 minutes ago
3. CA young adult with a swollen, painful ankle after a fall on the stairs
4. DAn adult with kidney stone pain of 9/10 and stable vital signs

A parent calls because a toddler has swallowed some household cleaner. The child is awake and breathing normally. What should the nurse advise first?

1. AGive syrup of ipecac from the medicine cabinet
2. BMake the child vomit, using a finger at the back of the throat
3. CContact the local poison advice service now for specific advice
4. DWait to see whether any symptoms develop over the next day

Ten minutes into a red blood cell transfusion, the patient reports chills and low back pain and has a new fever. What should the nurse do first?

1. AStop the transfusion
2. BSlow the transfusion and recheck vital signs in 15 minutes
3. CGive an antipyretic and continue the transfusion
4. DCall the blood bank and let the transfusion continue

A patient taking spironolactone asks about using a salt substitute. What should the nurse explain?

1. ASalt substitutes protect against the potassium loss caused by this drug
2. BSalt substitutes are safe because they contain only sodium chloride
3. CSalt substitutes are fine as long as the patient drinks more water
4. DMost salt substitutes contain potassium and can raise the level too high

Wynik którego pacjenta pielęgniarka powinna zgłosić najpierw?

1. AKreatynina 1,6 mg/dL (141 µmol/L) u pacjenta ze znaną, stabilną PChN
2. BCholesterol całkowity nieco powyżej celu
3. CHbA1c 7,4% (57 mmol/mol) u pacjenta z cukrzycą typu 2
4. DGlukoza 42 mg/dL (2,3 mmol/L) u pacjenta, który się poci i jest splątany

Which side effect of regular opioids usually needs preventive treatment from the start?

1. ADiarrhoea
2. BHigh blood pressure
3. CExcessive hunger
4. DConstipation

During CPR for asystole, when should adrenaline (epinephrine) be given according to standard adult guidelines?

1. ANever, because asystole is not treated with drugs
2. BAs soon as IV or IO access is obtained, then every 3–5 minutes
3. COnly once the patient has a pulse again
4. DOnly after three shocks have been delivered by the defibrillator

How big should a suction catheter be compared with the tracheostomy or endotracheal tube?

1. ALarger than the tube, so that it clears it completely
2. BExactly the same diameter as the tube, for a tight fit
3. CAny size, as the diameter does not matter
4. DNo more than half the internal diameter of the tube

A patient is listed for coronary angiography in the morning. Which pre-procedure result should the nurse report to the team?

1. AA normal platelet count
2. BA haemoglobin in the normal range
3. CA blood glucose of 5,4 mmol/L (97 mg/dL)
4. DA markedly reduced eGFR

A patient taking sodium valproate becomes tired and is vomiting, and the nurse notices yellowing of the eyes. What is the main concern?

1. AA normal adjustment reaction to the drug
2. BDehydration from drinking too little
3. CA sign that the dose is too low
4. DLiver toxicity from valproate

Which patient on a stroke unit is most at risk of falling?

1. AA patient with a left-hemisphere stroke who has expressive aphasia and waits for help
2. BA patient with a TIA whose symptoms resolved completely yesterday
3. CA patient with a right-hemisphere stroke who is impulsive and denies having weakness
4. DA patient with mild dysarthria who walks steadily with a frame

Why are patients with large burns at risk of hypothermia?

1. ALoss of skin reduces their ability to keep in heat
2. BBurns always cause a low thyroid hormone level in the blood
3. CThe fluids given are always chilled
4. DTheir metabolism stops after the injury

A nurse teaches a patient about a fentanyl skin patch. Which statement shows a need for further teaching?

1. A"I can cut the patch in half if I need less."
2. B"I'll put the new patch on a different area of skin."
3. C"I won't put a hot water bottle over the patch."
4. D"I'll fold used patches sticky sides together before disposal."