Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient is receiving a blood transfusion. Which task can the nurse delegate to a nursing assistant?

1. AAssessing the patient for signs of a transfusion reaction
2. BMeasuring and reporting vital signs at the times set by the nurse
3. CDeciding whether to stop the transfusion if the patient has chills
4. DStarting the transfusion once the blood arrives

Находка у какого пациента самая срочная?

1. AПациент на инфузии гепарина с новой спутанностью и сильной головной болью
2. BПациент на варфарине с МНО 2,5, которому пора принять обычную вечернюю дозу
3. CПациент, у которого результат числа тромбоцитов ещё ожидается
4. DПациент после операции на колене с небольшим синяком в месте инъекции

Насколько туго должна быть затянута фиксация запястья?

1. AДостаточно туго, чтобы замедлить пульс на запястье
2. BДостаточно свободно, чтобы между фиксатором и кожей помещались два пальца
3. CДостаточно свободно, чтобы рука пациента могла выскользнуть
4. DКак можно туже, чтобы пациент не мог двигать рукой

In a US hospital (CMS rules), a patient keeps pulling at an endotracheal tube, and alternatives have failed. The nurse applies wrist restraints in an emergency. What must happen next?

1. AAsk the provider for a PRN restraint order to use as needed
2. BObtain a time-limited order for the restraint promptly, following policy
3. CAsk the family to sign a consent form instead of an order
4. DKeep the restraints on without an order until the patient is calm

У пациента, принимающего фуросемид, калий 2,9 mEq/L. Какую находку ожидает медсестра?

1. AДиарею и спазмы в животе из-за усиленной перистальтики
2. BВысокие остроконечные зубцы T на ЭКГ
3. CПокалывание вокруг рта с положительным симптомом Хвостека
4. DМышечную слабость и судороги в ногах

A patient has fatigue, weight gain and constipation. Results: TSH 24 mIU/L, free T₄ low, total cholesterol 285 mg/dL (7,4 mmol/L), sodium 131 mEq/L. What is the best interpretation?

1. AHyperthyroidism, with suppressed thyroid hormone production
2. BSecondary hypothyroidism from failure of the pituitary gland
3. CPrimary hypothyroidism, which can raise lipids and lower sodium
4. DFamilial hypercholesterolemia, unrelated to the thyroid results

Why is an urgent brain scan needed before thrombolysis for a suspected stroke?

1. ATo measure the size of the ventricles
2. BTo confirm the patient's age
3. CTo rule out bleeding in the brain
4. DTo check for brain tumours only

After a high spinal cord injury, a patient has low blood pressure with a slow heart rate and warm, dry skin. What is most likely?

1. AHypovolaemic shock
2. BCardiac tamponade
3. CSeptic shock
4. DNeurogenic shock

How should a patient breathe in when using a dry powder inhaler?

1. ASeveral times, breathing out into the device between breaths
2. BSlowly and gently over about ten seconds
3. CQuickly and deeply, after breathing out away from the device
4. DThrough the nose with the mouthpiece in the mouth

An older patient's varicose vein bursts at the ankle and bleeds heavily. What is the most effective first aid?

1. AStand the patient up so the blood flows away and clots faster
2. BKeep the leg hanging down over the bed
3. CLie the patient down, raise the leg and press firmly on the site
4. DApply a hot compress to the leg to help the vein close up

A conscious patient with a glucose of 3,1 mmol/L (56 mg/dL) can swallow safely. Which is the best first treatment?

1. AA dose of rapid-acting insulin with a sandwich
2. BGlucose tablets or a small glass of fruit juice
3. CA chocolate bar and a cup of tea with milk
4. DA glass of milk and two plain biscuits

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

1. AOverdrainage of CSF, so act per protocol and inform the team
2. BNo concern, because more drainage always lowers the ICP safely
3. CUnderdrainage, so the drain should be lowered further
4. DAn infected drain, so the dressing should be removed

Which is a usual benefit of laparoscopic over open abdominal surgery?

1. ALarger wounds that heal faster
2. BLess pain and a shorter hospital stay
3. CNo risk of any complications at all
4. DNo need for a general anaesthetic ever

A sacral wound has heavy exudate, and the surrounding skin is white, soft and wrinkled. What should the nurse do?

1. ALeave the same dressing in place for a week so the wound is not disturbed
2. BApply a tight plastic film directly over the wound
3. CUse a dressing that adds even more moisture
4. DProtect the skin edges and use a more absorbent dressing