Priorytetyzacja i delegowanie w stylu NCLEX: zestaw na powtórkę

Asystent pielęgniarski zgłasza, że ciśnienie tętnicze pacjenta wynosi 168/98 mmHg (wcześniej 130/80), a pacjent ma ból głowy. Co powinna zrobić RN?

1. AOcenić pacjenta, ponownie zmierzyć ciśnienie tętnicze i poszukać objawów
2. BPoprosić asystenta o ponowny pomiar ciśnienia za godzinę
3. CPoprosić asystenta o podanie teraz doraźnego leku hipotensyjnego
4. DUdokumentować wartość i kontynuować rozdawanie leków

A patient opens their eyes only to pain, uses inappropriate words and withdraws from pain. What is the Glasgow Coma Scale score?

1. A13
2. B9
3. C7
4. D11

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

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

Before the wound is closed, the sponge count does not match the starting count. What should happen?

1. AChange the count on the record so that it matches, then close the wound as planned
2. BTell the surgeon and team, search for the item, and image the patient per policy if it is not found
3. CAssume that the first count was wrong and continue
4. DClose the wound to avoid a long anesthetic and recount the sponges after surgery

A patient with pneumonia had a CRP of 180 mg/L on admission and 40 mg/L after 4 days of antibiotics. What does this most likely show?

1. AThe inflammation is settling with treatment
2. BThe antibiotic is causing liver damage
3. CThe patient has developed a new infection
4. DThe infection has spread to another organ

A patient with long-standing rheumatoid arthritis has a hemoglobin of 10,5 g/dL (105 g/L), a low serum iron, a low total iron-binding capacity (TIBC) and a high-normal ferritin. Which condition fits best?

1. AVitamin B₁₂ deficiency anemia
2. BIron-deficiency anemia
3. CAcute blood loss anemia
4. DAnemia of chronic disease (inflammation)

A spontaneously breathing patient is critically ill and hypoxic. Which oxygen delivery gives the highest concentration?

1. ANon-rebreathe mask with reservoir bag at 15 L/min
2. BNasal cannula at 2 L/min
3. CSimple face mask at 5 L/min with the patient sitting up
4. DVenturi mask set to 24%

A patient has sudden, severe "tearing" chest pain going through to the back and a large difference in blood pressure between the arms. What should be suspected?

1. AGastro-oesophageal reflux
2. BPericarditis
3. CAortic dissection
4. DStable angina

A patient who had a stroke has a weak swallow. Which measure most reduces the risk of aspiration pneumonia?

1. ALying flat for 30 minutes after eating to aid digestion
2. BA swallowing assessment and sitting upright for meals
3. CGiving thin fluids quickly through a straw between meals
4. DGiving meals while the patient is drowsy

On the first day after abdominal surgery, a patient has a temperature of 37,8 °C, SpO₂ 93% on air and reduced breath sounds at both bases. They have stayed in bed because of pain. What is the most likely cause and response?

1. APulmonary oedema: restrict all oral fluids and give a diuretic
2. BNormal recovery; no action is needed
3. CAtelectasis: give analgesia, deep breathing and mobilisation
4. DWound infection: open the wound fully and swab it for culture

Which nursing action helps most to prevent and manage delirium in an older inpatient?

1. AKeep the lights on all night so the patient can see clearly
2. BUse glasses and hearing aids and reorient the patient often
3. CRestrain the patient so that they do not wander off the ward
4. DMove the patient to a different room each day for variety

Why might a frail 88-year-old with type 2 diabetes have a less strict HbA1c target?

1. ABecause older people cannot use any glucose medicines
2. BBecause diabetes cannot damage older people
3. CTo save money on blood tests and drugs
4. DTo reduce the risk of hypos, falls and confusion

For which stoma can colostomy irrigation be considered?

1. AAn ileal conduit draining urine
2. BAn established descending or sigmoid colostomy
3. CA new ileostomy in the first week
4. DAny stoma that has liquid or very loose output

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. BIgnore the comment because the form is already signed
3. CInform the surgeon so that the procedure can be explained again
4. DReassure the patient that the surgeon knows best