Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A patient has a new plaster cast that is still drying. How should the nurse handle it?

1. ABy resting it directly on a hard surface
2. BBy covering it tightly with a plastic sheet
3. CWith the palms of the hands, not the fingertips
4. DWith the fingertips, pressing firmly to test it

A patient is admitted with inhalational anthrax. Which precautions are needed?

1. AFull contact and droplet precautions for all staff and visitors on the unit
2. BStandard precautions, because it does not usually spread from person to person
3. CDroplet precautions with a surgical mask for everyone who enters
4. DAirborne precautions in a negative-pressure room for the whole of the hospital stay

Które działanie na rzecz bezpieczeństwa pacjenta jest najbardziej odpowiednie u pacjenta z alergią na lateks?

1. AUżywanie rękawiczek lateksowych i dokładne umycie rąk po ich zdjęciu
2. BUżywanie wyłącznie pudrowanych rękawiczek lateksowych
3. CUżywanie sprzętu wolnego od lateksu i wyraźne udokumentowanie alergii
4. DUnikanie wszelkich rękawiczek podczas opieki nad pacjentem

A patient with pneumonia has low blood pressure and a raised serum lactate. What does the raised lactate suggest?

1. AA normal response to having a fever
2. BPoor tissue perfusion, a sign of sepsis-related shock
3. CRecovery from the infection is beginning
4. DMild dehydration from poor intake, with no further concern

A patient has had severe watery diarrhea for 4 days. Which laboratory pattern would the nurse expect?

1. AHigh sodium and high calcium
2. BLow potassium and low bicarbonate
3. CLow glucose and high magnesium
4. DHigh potassium and high bicarbonate

Four patients had a thyroidectomy earlier today. Which result should the nurse act on first?

1. ASodium 136 mEq/L on IV fluids after surgery
2. BHemoglobin 12,1 g/dL (121 g/L) after surgery
3. CCalcium 7,2 mg/dL (1,8 mmol/L) with tingling lips
4. DGlucose 145 mg/dL (8,0 mmol/L) after surgery

Which statement about storing insulin is correct?

1. AAll insulin should be stored in the freezer to keep it fresh
2. BInsulin should be kept in direct sunlight
3. CUnopened insulin is kept in the fridge and must not be frozen
4. DInsulin never expires once opened

After a head injury, a patient passes very large volumes of dilute urine and the serum sodium is rising. What is most likely?

1. ADiabetes mellitus
2. BDiabetes insipidus
3. CSyndrome of inappropriate ADH secretion
4. DAcute kidney injury

A patient takes both digoxin and furosemide. Why does the nurse watch the potassium level closely?

1. APotassium has no link with either medicine
2. BLow potassium increases the risk of digoxin toxicity
3. CHigh potassium is the main effect of furosemide
4. DLow potassium makes digoxin stop working completely

An adult inhales a peanut while laughing and now has a persistent cough and wheeze on one side. Where is the peanut most likely to have lodged?

1. AThe left main bronchus
2. BThe oesophagus
3. CThe right main bronchus
4. DThe nasal cavity

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

A patient received IV insulin and glucose for hyperkalaemia an hour ago. What must the nurse monitor over the next few hours?

1. ACapillary glucose, for hypoglycaemia
2. BPupils, for raised intracranial pressure
3. CSkin, for a drug rash
4. DUrine colour, for blood in the urine

Which change suggests that a burn wound is becoming infected?

1. ADry, healing skin with mild itching
2. BA partial-thickness burn becoming deeper, with new discolouration
3. CThe wound becoming pink and a little smaller at each dressing change
4. DLess exudate on each dressing change

After signing the consent form, a patient tells the nurse, "I don't really understand what they are going to do." What should the nurse do?

1. AExplain the surgical risks in detail without involving the surgeon
2. BInform the surgeon so that the procedure can be explained again
3. CReassure the patient that the surgeon knows best
4. DIgnore the comment because the form is already signed