Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

On the first day after abdominal surgery, a patient has a temperature of 37,9 °C and reduced breath sounds at the lung bases. Which nursing action is most helpful?

1. ARestrict oral fluids so that the lungs do not fill up with extra fluid
2. BGive a cough suppressant so that the incision is not strained
3. CKeep the patient lying flat in bed to rest the incision fully
4. DEncourage deep breathing, coughing and use of the incentive spirometer

A patient is deteriorating quickly. The nurse has called the provider twice, but the provider has not come. What is the best action?

1. AAsk the patient’s family to call the provider
2. BDocument the concern and continue routine care
3. CWait another hour and call the provider again
4. DActivate the rapid response team

A nurse cleans an IV pump with a disinfectant wipe. What must happen for the disinfectant to work?

1. AThe surface is dried with a clean towel right after wiping
2. BThe wipe is used on many pumps to save product
3. CThe surface is wiped once lightly without pressure
4. DThe surface stays wet for the contact time on the product label

A nurse finds an unknown liquid leaking from a container in the utility room, with a strong smell. What should the nurse do first?

1. AMove closer and smell it carefully to identify what the substance is
2. BMop it up with paper towels
3. CLeave the area, keep others out and alert the trained response team
4. DPour water over it to dilute it

Która wartość laboratoryjna najlepiej odzwierciedla przyczynę splątania u pacjenta z ciężką chorobą wątroby i drżeniem trzepoczącym?

1. APodwyższone stężenie amoniaku w surowicy
2. BNiska lipaza w surowicy
3. CPodwyższona troponina
4. DWyłącznie niskie stężenie potasu w surowicy

Pacjent z nową zakrzepicą żył głębokich otrzymuje wlew heparyny, a właśnie rozpoczęto warfarynę. Dlaczego heparynę kontynuuje się przez kilka dni?

1. AWarfaryna działa tylko wtedy, gdy równocześnie podaje się heparynę
2. BHeparyna zwiększa wchłanianie warfaryny z jelita
3. CWarfaryna potrzebuje kilku dni, aby osiągnąć pełne działanie przeciwzakrzepowe
4. DHeparyna zapobiega działaniom niepożądanym warfaryny

Why are patients with atrial fibrillation often given anticoagulants?

1. ATo slow the heart rate directly and prevent palpitations
2. BTo lower the blood pressure
3. CTo reduce the risk of stroke from clots in the atria
4. DTo convert the rhythm back to normal

A patient with hyperkalaemia is given IV insulin with glucose. What is the purpose, and what must be monitored?

1. ATo treat hidden diabetes; HbA1c must be checked daily
2. BTo protect the heart muscle directly; the patient must be kept nil by mouth
3. CTo remove potassium from the body; urine output must be stopped for a time
4. DTo shift potassium into cells; blood glucose must be monitored for hypoglycaemia

A patient's blood pressure is high in clinic but normal on home readings. Which step best confirms the diagnosis?

1. AA chest X-ray
2. BAmbulatory or structured home blood pressure monitoring
3. CStarting two antihypertensive drugs at once at full dose
4. DA single repeat reading in the same clinic visit

Po operacji biodra pacjent nagle zaczyna odczuwać duszność i lęk, ma tętno 124/min, SpO₂ 86% na powietrzu i ostry ból przy oddychaniu. Nad płucami szmer pęcherzykowy prawidłowy. Co powinna zrobić pielęgniarka w pierwszej kolejności?

1. APodać lek uspokajający na lęk i ponownie sprawdzić za godzinę
2. BPołożyć pacjenta płasko i unieść obie nogi na poduszkach
3. CPodać tlen, posadzić pacjenta, wezwać pilną ocenę i pozostać przy nim
4. DPrzeprowadzić pacjenta po oddziale, aby poprawić oddychanie

A patient has radioactive iodine treatment for hyperthyroidism. Which advice is correct?

1. AStart breastfeeding again the next day
2. BThere are no precautions, because the dose is tiny
3. CStay in strict isolation in hospital for several months
4. DLimit close contact with children and pregnant women for a time

A patient with diabetes insipidus after head trauma needs hourly urine output measurement. Which task can be delegated to a trained healthcare assistant (nursing assistant)?

1. AInterpreting the serum sodium results
2. BDeciding whether to give the next desmopressin dose
3. CAssessing the patient's level of consciousness
4. DMeasuring hourly urine and reporting results above a set amount

Why are accurate fluid balance charts kept after major surgery?

1. ATo check how far the patient has walked and how often they get out of bed
2. BTo detect dehydration, fluid overload or kidney problems early
3. CTo decide which meal the patient will have next
4. DTo record when visitors come and go

In recovery, an awake and anxious patient cannot lift their head, and their breaths are shallow and weak. What is the most likely cause?

1. AOpioid overdose with pinpoint pupils
2. BA simple panic attack
3. CResidual neuromuscular blockade
4. DNormal tiredness after surgery