Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient wants to leave the hospital against medical advice. What should the nurse do?

1. AHide the patient’s clothes and belongings until the provider arrives
2. BLock the door so the patient cannot leave the unit
3. CInform the provider, explain the risks and document the discussion
4. DLet the patient leave without telling anyone

A patient with Guillain-Barré syndrome has weakness that is spreading up from the legs. Which assessment has the highest priority?

1. ABreathing strength, such as vital capacity and the ability to cough
2. BMuscle strength in the feet and ankles at the start of each morning
3. CThe patient’s mood and coping
4. DSkin condition over the heels

Sputum specimens are ordered to look for acid-fast bacilli (TB). How are they usually collected?

1. AThree deep-cough specimens collected 8 to 24 hours apart, at least one early in the morning
2. BThree specimens collected after an antiseptic mouthwash
3. COne specimen of sputum collected straight after the evening meal, when coughing is easiest
4. DOne saliva sample collected at any convenient time of day

A nurse has raised a safety concern about an order with the prescriber, who dismissed it without addressing it. What should the nurse do next?

1. ARefuse to care for the patient for the rest of the shift until the prescriber apologizes
2. BState the concern clearly a second time and, if still unresolved, use the chain of command
3. CCarry out the order as written, because the prescriber has heard the concern
4. DDiscuss the concern with the patient and let them decide

A patient has a calcium of 7,0 mg/dL (1,75 mmol/L) and tingling around the mouth. Which nursing measure is most appropriate?

1. APromote walking to move calcium back into the bone
2. BPut seizure precautions in place and report the result
3. CLimit dairy products until the level falls again
4. DEncourage 3 L of fluid per day to dilute the calcium

Which patient should the nurse assess first?

1. AHypertension with a potassium of 3,6 mEq/L on a thiazide
2. BStable angina with a total cholesterol of 245 mg/dL (6,3 mmol/L)
3. CHeart failure with a BNP lower than the result on admission
4. DChest pain with troponin rising from the first to the second sample

A patient without diabetes is started on high-dose prednisolone. Why might capillary blood glucose be monitored?

1. ASteroids always cause hypoglycaemia
2. BSteroids destroy the pancreas
3. CSteroids make glucose meters inaccurate
4. DSteroids can raise the blood glucose

Why must severe chronic hyponatraemia be corrected slowly?

1. AToo-rapid correction can cause osmotic demyelination in the brain
2. BFast correction causes severe hypoglycaemia and seizures in most patients
3. CFast correction makes the kidneys stop producing urine
4. DSodium given quickly causes immediate cardiac arrest

After varicose vein surgery, which advice is usually given?

1. AStand still for long periods to help the veins heal
2. BStay in bed for two weeks with the legs hanging down
3. CAvoid all walking until the bruising has gone
4. DWear the compression stockings as advised and walk regularly

A nurse looked after a patient for a shift before smear-positive pulmonary TB was diagnosed, without wearing a respirator. What should happen?

1. AStay off work for six months in case symptoms develop
2. BTake no action, as healthcare workers are immune to TB
3. CReport it so occupational health can arrange follow-up screening
4. DStart a full six-month course of TB drugs at once without any tests

Po dożylnej trombolizie w udarze, które obserwacje są najważniejsze w pierwszych 24 godzinach?

1. ACzęste kontrole neurologiczne i ciśnienia krwi
2. BCogodzinne szmery jelitowe i obwód brzucha
3. CCogodzinny szczytowy przepływ wydechowy i wysycenie tlenem
4. DCodzienne ważenie i wyłącznie bilans płynów

Pacjent na ciągłym nocnym żywieniu dojelitowym otrzymuje insulinę dostosowaną do żywienia. O 2:00 sonda się zatyka i żywienie ustaje. Jakie jest główne ryzyko i co powinna zrobić pielęgniarka?

1. ABrak ryzyka; insulina po prostu zostanie zmagazynowana do wznowienia żywienia
2. BHiperglikemia; od razu podać dodatkową dawkę insuliny
3. CKwasica ketonowa; odstawić całą insulinę do rana
4. DHipoglikemia; często kontrolować glikemię i postępować zgodnie z planem zabezpieczenia glukozą

Które zaburzenie elektrolitowe może przyczyniać się do pooperacyjnej niedrożności porażennej?

1. AHiperkaliemia
2. BHiperfosfatemia
3. CHipernatremia
4. DHipokaliemia

A patient with a platelet count of 8 × 10⁹/L (8,000/µL) develops a sudden severe headache and confusion. What should the nurse suspect?

1. ANormal effects of chemotherapy
2. BDehydration from poor intake
3. CA tension headache from stress
4. DIntracranial bleeding