Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient is raising his voice, pacing and clenching his fists. What should the nurse do first?

1. ASpeak calmly, keep a safe distance and invite him to talk about what is wrong
2. BApply physical restraints at once
3. CTurn away and ignore the behavior
4. DStand very close to him and tell him firmly and loudly to sit down and be quiet

Several patients on a unit develop diarrhea within two days. What should the nurse do first?

1. AMove the affected patients into shared rooms with other patients to free up beds
2. BWait to see if more patients become unwell
3. CPlace affected patients on contact precautions and inform infection control
4. DGive all patients antidiarrheal drugs without assessment

A visitor with a cold wants to see a patient who has severe neutropenia. What should the nurse advise?

1. AVisit as usual after washing the hands
2. BPostpone the visit until the visitor is well
3. CVisit only if the cold started more than a day ago
4. DVisit but avoid touching the patient’s bed

Which patient should the nurse assess first?

1. AA patient with an MRSA wound due for a routine dressing change
2. BA patient on chemotherapy with a new temperature of 38,4 °C (101,1 °F)
3. CA patient who wants more alcohol hand rub in the room
4. DA patient with tuberculosis who is asking to have visitors

Почему у пациентов с хронической болезнью почек часто бывает анемия?

1. AПовреждённые почки отфильтровывают и разрушают эритроциты
2. BВысокий калий при болезни почек разрушает эритроциты
3. CПочки вырабатывают меньше эритропоэтина, который стимулирует образование эритроцитов
4. DУремические токсины заставляют костный мозг производить лейкоциты вместо эритроцитов

A patient on high-dose dexamethasone has a white cell count of 15 × 10³/µL, mostly mature neutrophils with no bands. They have no fever and no signs of infection. What is the most likely explanation?

1. AA new leukemia that is confirmed by this result alone
2. BCertain sepsis that needs antibiotics started without delay
3. CA steroid effect that moves neutrophils into the circulating blood
4. DA laboratory error, because steroids always lower the white count

A patient with pneumonia is breathless and coughing up thick sputum. Which nursing measure helps most with breathing?

1. ADiscouraging coughing to save energy
2. BSitting the patient upright and supporting them to clear secretions
3. CLying the patient flat so that they can rest and conserve energy
4. DRestricting all oral fluids

A patient has a painful, punched-out ulcer on the toes, with a cold, pale foot and weak foot pulses. Which type of ulcer is most likely?

1. AA burn
2. BA venous ulcer
3. CA pressure ulcer from bed rest
4. DAn arterial ulcer

Which skin changes around the ankles are typical of chronic venous insufficiency?

1. AA cold, white foot with no pulse
2. BBrown staining, swelling and dry, itchy skin
3. CA sharply defined red patch with fever
4. DPale, shiny, hairless skin with weak pulses

Thirty minutes after extubation, a patient develops a high-pitched noise on breathing in and is anxious. SpO₂ is falling. What should the nurse do?

1. AEncourage the patient to sleep it off and recheck them in an hour
2. BSit the patient up, give oxygen and call for urgent airway help
3. CLay the patient flat and reassure them
4. DGive a large drink of cold water to soothe the throat and settle it

У пациента после инсульта гомонимная гемианопсия. Как медсестре следует помогать на первом этапе?

1. AПодходить со стороны, где пациент видит, и учить поворачивать голову для осмотра
2. BДержать палату тёмной, чтобы уменьшить зрительную стимуляцию
3. CПомещать кнопку вызова и напитки на сторону без зрения, чтобы её тренировать
4. DЗакрыть глаз на поражённой стороне повязкой

Состояние пациента с ДКА улучшается: глюкоза 9 mmol/L, кетоны 0,4 mmol/L, pH 7,36. Он ест и пьёт. Как следует прекратить внутривенный инсулин?

1. AПрекратить весь инсулин, так как кетоацидоз полностью разрешился
2. BВвести инсулин подкожно с едой, затем прекратить внутривенный после перекрывания
3. CПрекратить внутривенный инсулин сейчас и начать подкожный завтра
4. DВводить инсулин подкожно, только если глюкоза поднимется выше 20 mmol/L

A patient received IV morphine 20 minutes ago and the surgical consent form has not been signed. What should the nurse do?

1. AAsk a relative to sign instead of the patient
2. BTell the surgeon, as the patient may not be able to consent now
3. CSign the form on the patient's behalf as a witness
4. DAsk the patient to sign quickly before they get sleepier

A patient with a toe ulcer says the leg pain is worse at night and eases when they hang the leg over the side of the bed. What does this suggest?

1. ANeuropathic itching
2. BLymphoedema
3. CArterial insufficiency
4. DVenous insufficiency