Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Which patient with diabetes should the nurse see first?

1. AGlucose 210 mg/dL (11,7 mmol/L) after a large lunch, feels well
2. BHbA1c result of 8,2%, asking about diet
3. CGlucose 48 mg/dL (2,7 mmol/L), sweating and confused
4. DNeeds foot care teaching before discharge tomorrow

A patient has a new spinal cord injury at C4. Which assessment is the priority?

1. ASkin over the sacrum and heels
2. BBowel sounds in all four abdominal quadrants
3. CAbility to feed themselves
4. DBreathing effort and ability to cough

An order reads “Give potassium chloride by IV push.” What should the nurse do?

1. AGive it slowly by IV push over two minutes while watching the cardiac monitor
2. BGive half by IV push and the rest later
3. CNot give it, and contact the prescriber, because it is never given by IV push
4. DDilute it in a small syringe and push it

A handwritten order is hard to read, and the nurse is not sure of the drug name. What should the nurse do?

1. AChoose the drug that seems most likely from the diagnosis
2. BAsk a colleague to guess what it says
3. CHold the drug until the next day without telling anyone
4. DContact the prescriber to clarify before giving anything

A patient starts high-dose prednisone. Which laboratory change should the nurse expect?

1. AA fall in the white cell count
2. BA fall in serum sodium
3. CA rise in blood glucose
4. DA rise in serum potassium

Pacjentowi z liczbą płytek 35 × 10³/µL zlecono wstrzyknięcie domięśniowe. Co powinna zrobić pielęgniarka?

1. APodać wstrzyknięcie zgodnie ze zleceniem i mocno masować miejsce
2. BZapytać lekarza zlecającego, czy można użyć innej drogi podania
3. CPodać wstrzyknięcie dłuższą igłą
4. DPodać wstrzyknięcie i przyłożyć ciepły okład

A patient taking a statin reports unexplained muscle pain and weakness. What should the nurse do?

1. AReassure them that this is a sign the drug is working
2. BReport it, as statins can cause muscle damage
3. CAdvise more vigorous exercise to work through it
4. DTell them to double the dose

A patient with stress incontinence is taught self-care. Which statement shows a need for further teaching?

1. A"I'll drink as little as possible so I don't leak."
2. B"I'll cut down on caffeine."
3. C"I'll try to lose some weight if I can."
4. D"I'll do my pelvic floor exercises every day."

Where is the V1 electrode placed for a 12-lead ECG?

1. AOver the left nipple
2. BJust below the left collarbone
3. CThe fifth intercostal space in the mid-axillary line
4. DThe fourth intercostal space just right of the sternum

Ten days after cardiac surgery, a patient has a fever, a red sternal wound with discharge and a clicking feeling in the chest when coughing. What should the nurse suspect?

1. APericarditis from the operation
2. BSternal wound infection with an unstable sternum
3. CNormal wound healing with some expected discharge
4. DCostochondritis caused by forceful coughing

Which nursing action helps most to prevent and manage delirium in an older inpatient?

1. AUse glasses and hearing aids and reorient the patient often
2. BRestrain the patient so that they do not wander off the ward
3. CKeep the lights on all night so the patient can see clearly
4. DMove the patient to a different room each day for variety

During a water deprivation test for suspected diabetes insipidus, the patient loses more than 3% of body weight and becomes hypotensive. What should the nurse do?

1. AGive the patient a large drink and then restart the test
2. BGive desmopressin without a prescription
3. CContinue the test, because this result is expected
4. DStop the test and inform the doctor

Które objawy sugerują ciężkie ostre zapalenie trzustki z krwawieniem do tkanek?

1. AZasinienie wokół pępka lub w okolicach bocznych brzucha
2. BŻółte przebarwienie paznokci
3. CObrzęk warg, języka i twarzy
4. DFioletowa wysypka na dłoniach i podeszwach

After a fall, a patient with advanced dementia is agitated, grimacing and guarding the hip, and cannot rate the pain. What should the nurse do?

1. AWait until a relative can confirm the pain
2. BAssume there is no pain because none is reported
3. CGive a sedative to treat the agitation and avoid giving any analgesia
4. DUse an observational pain tool, give analgesia and reassess