Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

A nurse teaches a patient with heart failure. Which statement shows a need for further teaching?

1. A“I will call if my weight goes up quickly over a day or two.”
2. B“I will take my water tablet in the morning.”
3. C“I will weigh myself every morning after I use the toilet.”
4. D“I add extra salt to my food so it tastes better.”

Które przydzielenie pacjenta LPN/LVN jest najodpowiedniejsze?

1. APacjenta przeniesionego z oddziału intensywnej terapii godzinę temu
2. BPacjenta ze stabilną POChP, który wymaga zaplanowanych nebulizacji leków rozszerzających oskrzela i leków doustnych
3. CPacjenta z nowym migotaniem przedsionków, który właśnie rozpoczął dożylny wlew diltiazemu
4. DPacjenta, który wymaga edukacji przed wypisem w związku z nowo rozpoczętą warfaryną

Which patient has the highest risk of a burn from a heating pad?

1. AA healthy young adult with a strained muscle
2. BA patient with diabetic peripheral neuropathy
3. CA patient recovering from a cold
4. DA patient with a sprained wrist who is fully alert

A nurse teaches a patient going home with an MRSA wound infection. Which statement shows a need for further teaching?

1. A“I will wash my hands after touching my dressing.”
2. B“I will keep the wound covered with a clean, dry dressing.”
3. C“I will put used dressings in a sealed bag before throwing them out.”
4. D“I can share towels with my family if I wash them every week.”

Which IV fluid can be given through the same line as a red cell transfusion?

1. A5% dextrose in water
2. B0,45% sodium chloride
3. CLactated Ringer's (Hartmann's) solution
4. D0,9% sodium chloride

A patient started methimazole for hyperthyroidism 6 weeks ago and now has a fever and a severe sore throat. Which action is most important?

1. AHold the drug and arrange an urgent white cell and neutrophil count
2. BGive the next dose and suggest warm salt-water gargles for comfort
3. CCheck the TSH and double the dose if it is still low
4. DAdvise the patient to continue the drug and drink more fluid

Why is it important to prevent hypothermia during and after surgery?

1. AIt makes the patient's pain disappear
2. BIt causes high blood glucose only
3. CIt makes the patient wake up too quickly and become agitated in recovery
4. DIt increases the risk of wound infection, bleeding and cardiac complications

During a general anaesthetic, a patient develops a rapidly rising temperature, muscle rigidity and rising carbon dioxide levels. What should be suspected?

1. AA normal response to surgery
2. BNeuroleptic malignant syndrome from antipsychotics
3. CMalignant hyperthermia
4. DPostoperative infection

Why is a raised serum lactate concerning in a patient with shock?

1. AIt confirms a bacterial infection is present
2. BIt shows only that the patient has eaten a large meal in the past hour
3. CIt suggests tissues are short of oxygen and using anaerobic metabolism
4. DIt means the kidneys are working harder than normal to clear fluid

Pacjent wentylowany mechanicznie na oddziale intensywnej terapii jest zagrożony zapaleniem płuc związanym z respiratorem. Które działanie pielęgniarskie pomaga zmniejszyć to ryzyko?

1. AUtrzymywanie pacjenta w pozycji płaskiej, aby chronić rurkę intubacyjną
2. BUnikanie higieny jamy ustnej, aby zapobiec krwawieniu z dziąseł
3. CUtrzymywanie wezgłowia łóżka uniesionego do 30–45°
4. DWymiana układu oddechowego respiratora co kilka godzin

What is the main purpose of continuous bladder irrigation after a transurethral resection of the prostate (TURP)?

1. ATo stop blood clots from blocking the catheter
2. BTo treat a urinary infection after the operation
3. CTo give the patient extra fluids
4. DTo measure the size of the bladder

A 66-year-old smoker has had two episodes of painless red urine. Urine cultures are negative. Which plan is most appropriate?

1. AReassure him, because the blood has stopped
2. BAnother course of antibiotics for a UTI
3. CUrgent referral for cystoscopy and imaging
4. DAdvise more fluids and review in a year

A patient is starting regular oral morphine. Which bowel advice is most appropriate?

1. AWait until there has been no stool for a week
2. BStop eating fibre completely
3. CStart a regular laxative at the same time
4. DTake a bulk-forming laxative only with very little water

A patient with recurrent diverticulitis reports passing air and faecal matter in the urine. What is the most likely cause?

1. AA kidney stone blocking the ureter
2. BA fistula between the colon and the bladder
3. CBowel preparation that was taken too quickly
4. DA simple lower urinary tract infection