Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient has a blood pressure of 210/120 mmHg. Which finding would make this a hypertensive emergency?

1. ANew chest pain or confusion suggesting organ damage
2. BA history of high blood pressure for ten years
3. CMild anxiety about the high reading on the monitor
4. DForgetting to take the blood pressure tablet this morning

After a head injury, a patient has clear fluid dripping from the nose. Which action should the nurse avoid?

1. AInserting a tube or suction catheter through the nose
2. BChecking the fluid for glucose or a halo sign on gauze
3. CPlacing a loose gauze under the nose
4. DInforming the provider about the drainage

A patient has orthostatic hypotension. Which teaching helps to prevent falls?

1. AGet out of bed quickly so the dizziness passes sooner
2. BAvoid drinking fluids in the morning to reduce trips to the toilet
3. CStand up straight after a hot shower to increase blood flow
4. DSit on the edge of the bed for a short time before standing up slowly

A nurse calculates a child’s prescribed dose and finds it is ten times higher than the usual dose for the child’s weight. What should the nurse do?

1. AHold the dose and verify it with the prescriber and pharmacist
2. BGive half the dose and watch the child closely
3. CGive one-tenth of the dose without telling anyone about it
4. DGive it, because the prescriber must have a reason

Which finding during a transfusion suggests transfusion-associated circulatory overload (TACO)?

1. ABack pain with dark red urine output
2. BCrackles, hypertension and a raised BNP
3. CA low temperature and slow heart rate
4. DHives and itching without other signs

A patient without symptoms has a finger-stick glucose of 340 mg/dL (18,9 mmol/L). The previous values were normal, and the patient has just peeled an orange. What should the nurse do first?

1. AReport the result as a new diagnosis of diabetes mellitus
2. BGive a correction dose of insulin for a glucose of 340 mg/dL
3. CHave the patient wash and dry their hands, then repeat the test
4. DAsk the laboratory to measure HbA1c from the same drop of blood

Which blood results are typical of Addison's disease (primary adrenal insufficiency)?

1. AHigh sodium and low potassium
2. BLow sodium and high potassium
3. CHigh glucose and high calcium
4. DLow haemoglobin and high platelets

A patient suddenly develops a painful red eye with blurred vision, haloes around lights and vomiting. What should be suspected?

1. AAcute angle-closure glaucoma
2. BSimple conjunctivitis from a viral infection
3. CA stye
4. DDry eye syndrome

Why is a higher level of HDL cholesterol considered protective?

1. AHDL lowers the blood pressure directly
2. BHDL thins the blood in the same way as an anticoagulant
3. CHDL is converted into vitamin D in the walls of the arteries
4. DHDL carries cholesterol from the tissues back to the liver

Pacjent z astmą ma szczytowy przepływ wydechowy 40% swojej najlepszej wartości, częstość oddechów 28/min i nie jest w stanie dokończyć zdań. SpO₂ wynosi 94%. Jak należy sklasyfikować ten napad?

1. AUmiarkowane zaostrzenie astmy
2. BOstra ciężka astma
3. CAstma o niemal śmiertelnym przebiegu
4. DAstma zagrażająca życiu

A routine blood test shows a potassium of 6,4 mmol/L. The lab reports that the sample was haemolysed. The patient feels well. What should the nurse do?

1. AIgnore it, because haemolysis always gives a normal result
2. BInform the doctor and arrange an urgent repeat sample
3. CStart dialysis as soon as possible
4. DGive oral potassium supplements straight away

Pacjent z ostrym udarem niedokrwiennym nie jest kandydatem do trombolizy. W pierwszej dobie ciśnienie krwi wynosi 190/100 mmHg, bez innego stanu nagłego. Co jest zasadniczo właściwe?

1. APołożyć pacjenta płasko i podać duży bolus płynów
2. BPodawać azotany w aerozolu co 5 minut, aż do spadku poniżej 120 mmHg
3. CUnikać agresywnego obniżania i stosować cele wyznaczone przez zespół udarowy
4. DSzybko obniżyć do 110/70 mmHg lekami dożylnymi

When breaking bad news, what is the first step in frameworks such as SPIKES?

1. AAsk the family to decide what the patient should be told
2. BGive all treatment options before checking understanding
3. CGive the diagnosis as quickly as possible in the corridor
4. DSet up a private setting with enough time

On day 5 after bowel resection, a patient has a fever, tachycardia and worsening abdominal pain, and the drain contains brown, faeculent fluid. What is most likely?

1. AA urinary tract infection
2. BA normal day 5 recovery
3. CPostoperative constipation
4. DAn anastomotic leak