Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Which patient with diabetes should the nurse see first?

1. AGlucose 48 mg/dL (2,7 mmol/L), sweating and confused
2. BNeeds foot care teaching before discharge tomorrow
3. CGlucose 210 mg/dL (11,7 mmol/L) after a large lunch, feels well
4. DHbA1c result of 8,2%, asking about diet

A patient with a head injury has a pupil on one side that is now large and does not react to light. What should the nurse do?

1. ARecheck it at the next routine observation in four hours
2. BDim the room lights so the pupil can get smaller
3. CDocument it, because pupils often differ slightly after a head injury
4. DReport it at once, as it may mean the brain is being compressed

Which technique is used for suctioning a tracheostomy in hospital?

1. ASterile technique, with a sterile catheter and sterile glove
2. BClean technique, with the catheter rinsed in tap water
3. CClean technique, reusing the catheter during the shift
4. DNo gloves at all, because the airway already contains bacteria

A chemical cloud has been released near the hospital, and authorities order “shelter in place”. What should staff do?

1. AKeep everyone inside, close windows and doors and shut off outside air intake
2. BOpen the windows to let fresh air into the wards and dilute the chemical
3. CEvacuate all patients into the car park at once
4. DSend all visitors home through the main entrance

Which blood collection practice helps prevent hemolysis of the sample?

1. AUsing the smallest needle available for every patient
2. BGently inverting the tubes instead of shaking them
3. CForcing blood quickly through a needle into the tube
4. DLeaving the tourniquet on for at least 3 minutes

A patient receiving IV magnesium sulfate has a respiratory rate of 9/min and absent patellar reflexes. After stopping the infusion, which medication should the nurse expect to give?

1. ACalcium gluconate
2. BPotassium chloride
3. CProtamine sulfate
4. DSodium bicarbonate

A nurse finds a patient lying on the floor beside the bed. What should be done first?

1. APhone the patient's family
2. BComplete the incident report form
3. CCheck the patient for injuries before moving them
4. DLift the patient straight back into bed so they are comfortable

U pacjenta z urazem głowy GCS spada z 14 do 10, a jedna źrenica się poszerza i wolno reaguje. Co powinna zrobić pielęgniarka?

1. AZachęcić pacjenta do snu
2. BSkontrolować GCS przy następnym rutynowym pomiarze
3. CNatychmiast eskalować jako stan nagły neurologiczny
4. DPodać lek uspokajający, by pacjent się uspokoił

Which exercise advice is recommended for intermittent claudication?

1. AComplete bed rest until the leg pain has gone for at least a month
2. BSupervised walking until pain is near maximal, then rest and repeat
3. CStopping walking at the very first twinge of pain each time
4. DWalking only on days when the legs feel warm and painless

A patient with small-cell lung cancer becomes confused. Sodium is 122 mmol/L (122 mEq/L) with concentrated urine, and there are no signs of dehydration. What is the most likely cause?

1. ASyndrome of inappropriate ADH secretion
2. BExcess salt in the diet over several weeks
3. CCranial diabetes insipidus from brain metastases
4. DSevere dehydration from poor oral intake

A patient has a nephrostomy tube. Which finding needs urgent action?

1. ADrainage that stops suddenly with new loin pain
2. BA dry, intact dressing at the site
3. CLight pink urine on the first day after insertion
4. DSteady urine drainage into the bag

During haemodialysis, a patient suddenly becomes breathless with chest pain, and air is seen in the line. What should the nurse do first?

1. AClamp the lines and lay the patient left side down, head low
2. BSit the patient upright and give a drink of water
3. CContinue the session and recheck in 30 minutes
4. DSpeed up the pump to clear the air into the patient

Dlaczego w pierwszych dniach po dużej operacji często woli się regularną (zaplanowaną) analgezję niż dawki „w razie potrzeby”?

1. AEliminuje potrzebę oceniania bólu pacjenta w ciągu dnia
2. BPozwala podawać dawki wyższe niż maksymalna dawka dobowa
3. CCałkowicie zapobiega wszystkim działaniom niepożądanym opioidów
4. DUtrzymuje stałe stężenia leku i zapobiega silnym szczytom bólu

A patient with gallstones has a temperature of 39 °C with rigors, jaundice and right upper abdominal pain. What should the nurse suspect?

1. AAcute hepatitis A
2. BUncomplicated reflux
3. CSimple biliary colic
4. DAscending cholangitis