Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient reports pain of 8/10. Before giving the prescribed as-needed analgesic, what does the nurse do first?

1. AAsk the nursing assistant to reposition the patient
2. BTell the patient to wait until the next scheduled dose is due in two hours
3. CGive the strongest analgesic on the chart straight away
4. DAssess the location, character and onset of the pain and the vital signs

Podczas triażu START dorosły nie oddycha. Po zmianie ułożenia dróg oddechowych poszkodowany nadal nie oddycha. Jaka jest prawidłowa kategoria?

1. ACzerwona, ponieważ brak oddechu jest najpilniejszym objawem
2. BŻółta, a wrócić później
3. CCzarna (zmarły lub oczekujący)
4. DCzerwona i natychmiastowe rozpoczęcie resuscytacji

How should a newborn be moved through hospital corridors?

1. AIn a bassinet, not carried in the arms
2. BCarried in the nurse’s arms for comfort
3. CIn the arms of any visitor who offers to help
4. DOn the mother’s lap in a wheelchair, without staff

A patient’s cardiac monitor alarms often because of artifact, and a colleague suggests turning the alarm off. What is the best response?

1. ATurn the alarm volume down as low as it will go
2. BKeep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy
3. CDisconnect the monitor overnight so the patient can sleep
4. DTurn the alarm off and check the monitor screen at the nurses’ station every hour instead

How does the nurse start a 24-hour urine collection at 08:00?

1. AHave the patient void and discard that urine, then save all urine until 08:00 the next day
2. BCollect only the first urine passed on waking, and repeat this the next morning
3. CSave the 08:00 urine as the first sample, then collect until 08:00 the next day
4. DSave three samples spread across the day and discard all of the urine passed at night

The nurse teaches a patient with thrombocytopenia (platelets 25 × 10³/µL) about home safety. Which statement shows a need for further teaching?

1. A"I'll use an electric razor to shave"
2. B"I'll use a soft-bristled toothbrush"
3. C"I'll take aspirin if I get a headache"
4. D"I'll blow my nose gently, not forcefully"

Which advice is important for a patient on long-term oral corticosteroids?

1. ATake them on an empty stomach at night
2. BDo not stop them suddenly
3. CDouble the dose if a dose is missed
4. DTake them only when symptoms flare

A few hours after cardiac surgery, a patient has low blood pressure, a raised jugular venous pressure and quiet, muffled heart sounds. What should be suspected?

1. AHypovolaemia from dehydration
2. BHyperkalaemia
3. CPneumonia
4. DCardiac tamponade

A patient on nasal cannula oxygen breathes mainly through the mouth. What is the most accurate statement?

1. AThe flow must be increased to 15 L/min to make it work at all
2. BThe cannula should be placed in the mouth
3. CIt has no effect at all in mouth breathers and must be stopped
4. DIt can still work, because oxygen collects in the nasopharynx

A patient has sudden severe chest pain spreading to the back between the shoulder blades. Which finding most supports aortic dissection rather than myocardial infarction?

1. APain that started at rest
2. BSweating, nausea and pallor that started with the pain
3. CA heart rate of 104/min and a respiratory rate of 22/min
4. DA large difference in blood pressure between the arms

Why is pyridostigmine often taken about 30–60 minutes before meals by patients with myasthenia gravis?

1. ATo reduce stomach acid so the food is digested better
2. BTo lower the blood glucose rise after eating a meal
3. CTo stop the drug from irritating an empty stomach later on
4. DTo improve the strength of chewing and swallowing at mealtimes

A patient with stable epilepsy on phenytoin started a new medicine last week. They now have nystagmus, an unsteady gait and slurred speech. What should the nurse do?

1. ASuspect phenytoin toxicity, hold the next dose and ask for a drug level
2. BSuspect a new stroke and give aspirin straight away before any scan
3. CGive the next phenytoin dose early to prevent a seizure
4. DEncourage the patient to walk more to improve their balance

Który obszar służy do szybkiego oszacowania 1% powierzchni ciała przy małych lub rozproszonych oparzeniach?

1. ADłoń pacjenta wraz z palcami
2. BDłoń i przedramię pacjenta
3. CPaznokieć kciuka pacjenta
4. DDłoń badającego wraz z palcami

U pacjenta z niedrożnością jelit rozwija się stały silny ból (już nie kurczowy), gorączka, częstość serca 120/min i sztywny, tkliwy brzuch. Co to sugeruje?

1. ANiedrożność ustępuje, ponieważ jelito zaczyna się poruszać
2. BZadzierzgnięcie lub perforację wymagającą pilnej oceny chirurgicznej
3. CPrawidłowy przebieg wymagający jedynie regularnej prostej analgezji
4. DZaparcie, które należy leczyć pobudzającym środkiem przeczyszczającym