Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A nursing assistant tells the RN that a patient’s IV pump is alarming. What is the best response?

1. A“I will come and check the pump and the IV site now.”
2. B“Turn the pump off and on again until it stops.”
3. C“Increase the rate a little so the alarm clears.”
4. D“Silence the alarm and I will check it at the end of the shift.”

A nurse has a needlestick injury from a used needle. What should the nurse do first?

1. AWash the area with soap and water
2. BSqueeze the wound hard and suck it
3. CScrub the area with bleach
4. DFinish the shift and report it tomorrow

When should blood specimen tubes be labeled?

1. ABack at the station after all the samples are collected
2. BAt the bedside, in front of the patient, right after collection
3. CAt the nurses’ station before going to the patient, to save time
4. DBy the laboratory staff after the tubes arrive

While preparing a chemotherapy infusion, the drug splashes onto a nurse’s forearm. What should the nurse do first?

1. AFinish hanging the infusion and then wash the skin
2. BRemove contaminated PPE and wash the skin with soap and water at once
3. CWipe the skin with an alcohol swab and continue preparing the infusion
4. DCover the area with a dressing and report later

A patient has had severe watery diarrhea for 4 days. Which laboratory pattern would the nurse expect?

1. ALow glucose and high magnesium
2. BHigh potassium and high bicarbonate
3. CHigh sodium and high calcium
4. DLow potassium and low bicarbonate

Ten minutes into a red cell transfusion, a patient develops fever, chills, low back pain and dark urine. After stopping the transfusion, what should the nurse do next?

1. AFlush the remaining blood through the line with the IV fluid to finish it
2. BKeep the IV open with normal saline using new tubing and call the provider
3. CRestart the transfusion more slowly after giving an antipyretic drug
4. DDiscard the blood bag and tubing in the clinical waste to stop exposure

Why is blood pressure monitored closely in a patient with an epidural infusion?

1. ABlood pressure readings show whether the catheter is infected
2. BThe local anaesthetic can block sympathetic nerves and cause hypotension
3. CEpidurals always cause severe hypertension that needs regular treatment
4. DThe epidural pump uses the blood pressure to set the rate

Why must a unit of red cells be transfused within the set time limit (commonly four hours) after it leaves controlled cold storage?

1. AThe blood group of the cells changes after a few hours
2. BThe bag stops dripping after four hours
3. CBacteria can grow in the blood at room temperature
4. DThe red cells break down and turn into plasma

Why are IV fluids given cautiously to a patient with heart failure?

1. AIV fluids directly damage the heart valves
2. BIV fluids lower the blood pressure dangerously
3. CIV fluids stop diuretics from being absorbed
4. DExtra volume can quickly cause pulmonary oedema

A nurse teaches a patient how to measure blood pressure at home. Which statement shows a need for further teaching?

1. A"I will sit with my back supported and my arm at heart level."
2. B"I will take two readings and write them both down."
3. C"I will measure it straight after my morning jog."
4. D"I will rest quietly for five minutes before measuring."

Jaki wynik w skali Glasgow (GCS) zwykle sugeruje, że pacjent może nie być w stanie chronić własnych dróg oddechowych?

1. A15
2. B11 lub więcej
3. C13 lub mniej
4. D8 lub mniej

Przewlekłą hiponatremię pacjenta skorygowano z 115 do 132 mmol/L w ciągu 24 godzin. Dwa dni później pojawia się bełkotliwa mowa, trudności w połykaniu i osłabienie kończyn. Jaka jest najbardziej prawdopodobna przyczyna?

1. AZespół demielinizacji osmotycznej
2. BHipoglikemia z powodu słabego przyjmowania pokarmów
3. CNowy udar niezwiązany z sodem
4. DPrawidłowy powrót do zdrowia po hiponatremii

Which patient is at highest risk of refeeding syndrome?

1. AA healthy adult after an overnight fast for minor surgery
2. BA patient with a normal BMI eating three meals a day
3. CA patient who missed one lunch because of a scan
4. DAn underweight patient who has eaten very little for 10 days

U pacjenta z rakiem płuca pojawia się obrzęk twarzy, poszerzone żyły szyjne i duszność nasilająca się w pozycji leżącej. Jaki stan nagły jest prawdopodobny?

1. AUcisk rdzenia kręgowego
2. BMasywna zatorowość płucna
3. CZespół żyły głównej górnej
4. DHiperkalcemia w przebiegu nowotworu