Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

An older patient with dementia is restless at night and keeps trying to get out of bed. Which measure should the nurse try first?

1. ARaise all four bed rails so the patient cannot climb out
2. BCheck for pain, thirst or a full bladder, and offer toileting
3. CGive a sedative from the as-needed list without first assessing the patient
4. DApply wrist restraints for the rest of the night

A patient admitted with a stroke this morning asks for a glass of water. What should the nurse do first?

1. AAsk the family to help the patient drink while sitting upright in a chair at the bedside
2. BGive thickened fluids without checking the swallow
3. CCheck that a swallow screen has been done before giving anything by mouth
4. DGive the water through a straw so it goes down slowly

Before a blood transfusion is started, which check is required?

1. AThe nurse checks only that the bag number matches the order
2. BOne nurse checks the blood product against the order at the nurses’ station
3. CThe patient’s identity is checked against the blood product and its paperwork at the bedside
4. DThe patient signs the blood bag label to confirm their name before it is hung

Pacjentowi przepisano hydralazynę, ale apteka przysłała hydroksyzynę. Co powinna zrobić pielęgniarka?

1. ANie podać leku i skontaktować się z apteką w celu uzyskania właściwego leku
2. BPodać go teraz i poinformować lekarza później
3. CPodać połowę dawki hydroksyzyny jako kompromis
4. DPodać go, ponieważ obie nazwy leków są niemal takie same

A patient with a potassium of 2,8 mEq/L has potassium chloride prescribed IV. Which statement about giving it is correct?

1. AIt is given as an undiluted bolus into a large vein to avoid irritation
2. BIt is added to the IV bag without mixing, so it stays at the bottom
3. CIt may be given as a slow IV push over one minute if the level is very low
4. DIt is always diluted and given by infusion pump, never as an IV push

A patient on digoxin has a calcium of 12,1 mg/dL (3,0 mmol/L) and new nausea and a slow pulse. Why is the calcium result important?

1. AHigh calcium makes the kidneys clear digoxin faster
2. BHigh calcium increases the risk of digoxin toxicity
3. CHigh calcium only matters if the potassium is also high
4. DHigh calcium blocks digoxin, so the drug stops working

Które zaburzenie elektrolitowe jest najbardziej niebezpieczne dla rytmu serca?

1. AZbyt wysoki lub zbyt niski potas
2. BNiski sód
3. CNiski fosforan
4. DWysoki chlor

A patient starting a DOAC is taught about missed doses. Which statement shows a need for further teaching?

1. A"I will report any blood in my urine."
2. B"I will take it at the same time each day."
3. C"I will tell other doctors and my dentist I take an anticoagulant."
4. D"If I forget a dose, I'll take two the next day to catch up."

A patient arrives with suspected cardiac chest pain. How soon should a 12-lead ECG be recorded?

1. AWithin about 10 minutes of arrival
2. BOnly after the troponin result is available
3. CThe following morning
4. DWithin 2 hours of arrival

A heavy smoker is having surgery tomorrow and asks whether stopping smoking now is pointless. Which reply is most accurate?

1. ASmoking before surgery protects the lungs from the anaesthetic gases
2. BStopping even today lowers carbon monoxide levels before surgery
3. CStopping now will make the operation more dangerous
4. DIt is pointless unless they stopped smoking at least a year ago

Which measure best detects a decline in breathing in a patient with Guillain–Barré syndrome?

1. ARegular forced vital capacity measurements
2. BPeak flow before and after a bronchodilator
3. CDaily chest X-rays
4. DOxygen saturation alone

A patient taking an SGLT2 inhibitor is booked for major surgery. Which statement is correct?

1. AIt is usually paused in the days before surgery
2. BThe dose is usually doubled on the morning of surgery
3. CThe drug must be taken right up until the operation starts
4. DSurgery is not possible in patients taking this drug

Which initial treatment is usual for symptomatic hypercalcaemia of malignancy?

1. AIV fluids followed by an IV bisphosphonate
2. BFluid restriction and a thiazide diuretic
3. CA high-calcium diet with extra milk
4. DOral calcium tablets and vitamin D

A patient with a toe ulcer says the leg pain is worse at night and eases when they hang the leg over the side of the bed. What does this suggest?

1. ALymphoedema
2. BArterial insufficiency
3. CNeuropathic itching
4. DVenous insufficiency