Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

В смешанном терапевтическом отделении какого пациента медсестре следует осмотреть первым?

1. AПациента с гипертонией, у которого давление 136/84 mmHg
2. BПациента с лёгкой головной болью напряжения, просящего ацетаминофен
3. CПациента, просящего письменную информацию о завтрашней выписке
4. DПациента с депрессией, раздавшего свои вещи и имеющего план самоубийства

A child is admitted with a suspected Wilms tumor (nephroblastoma). Which instruction is most important for all staff?

1. AGive a warm bath with abdominal massage
2. BEncourage the child to play contact sports
3. CMeasure abdominal girth by pressing firmly
4. DDo not palpate the abdomen

A patient with delirium is at risk of falls and of pulling out lines. Which option is less restrictive than restraints?

1. AA vest restraint applied for the whole night
2. BFour side rails raised and the door closed so the patient stays in bed
3. CA sedative given every few hours as needed
4. DA trained sitter or video monitoring with staff nearby

A patient’s white cell differential shows a raised eosinophil count. Which cause is most consistent with this finding?

1. ABone marrow suppression from chemotherapy
2. BAn allergic reaction or a parasitic infection
3. CA viral infection such as a cold
4. DAn acute bacterial infection

A patient receiving chemotherapy has an ANC of 300/µL and a new temperature of 38,3 °C (100,9 °F). What should the nurse do first?

1. AReport it at once so cultures and antibiotics start quickly
2. BEncourage oral fluids and record the fever in the chart
3. CRemove extra blankets and offer a tepid sponge bath
4. DGive acetaminophen (paracetamol) and recheck the temperature in 4 hours

Which patient's result should the nurse act on first?

1. AHemoglobin 6,4 g/dL (64 g/L) with new chest pain and a pulse of 124/min
2. BFerritin 15 ng/mL in a well patient with known iron-deficiency anemia on oral iron
3. CPlatelets 140 × 10³/µL in a patient with mild chronic liver disease
4. DHemoglobin 9,6 g/dL (96 g/L) in a patient with stable chronic kidney disease

В каком временном окне обычно проводят внутривенный тромболизис при остром ишемическом инсульте?

1. AВ течение 4,5 часов от начала симптомов
2. BТолько через 24 часа
3. CВ любое время в течение недели
4. DВ течение 48 часов от появления симптомов

Вскоре после начала трансфузии у пациента появились одышка, свистящее дыхание, гипотензия и отёк лица. Что медсестра должна сделать в первую очередь?

1. AДать парацетамол и антигистаминный препарат и продолжить трансфузию
2. BОстановить трансфузию, сохранить внутривенный доступ и срочно вызвать помощь
3. CБыстро перелить дозу до конца, чтобы как можно сильнее сократить время воздействия
4. DЗамедлить скорость трансфузии и перепроверить показатели через час

A patient with heart failure is comfortable at rest but becomes breathless walking across a room. Which NYHA class fits best?

1. AClass I
2. BClass II
3. CClass IV
4. DClass III

A patient on a morphine PCA after surgery is very drowsy, with a respiratory rate of 7/min and pinpoint pupils. SpO₂ is 89%. What should the nurse do first?

1. ALeave the patient to sleep and recheck the observations in an hour
2. BEncourage the patient to keep pressing the PCA button for comfort
3. CGive a sedative to keep the patient comfortable
4. DStop the PCA, support breathing, give oxygen and get naloxone

Why does a patient with untreated hypothyroidism need extra care when given opioids or sedatives?

1. AThey break the drugs down slowly and are more sensitive to them
2. BThere is no difference compared with other patients
3. CThey clear the drugs too fast, so higher doses are needed
4. DThese drugs make the thyroid gland overactive

Two days after a spinal cord injury, a patient has a swollen abdomen, no bowel sounds and is vomiting. What is most likely, and what is the nursing action?

1. AA full bladder, so encourage oral fluids
2. BNormal constipation, so give a large meal to stimulate the bowel
3. CAn allergic reaction to food, so give an antihistamine
4. DParalytic ileus, so keep nil by mouth and prepare for an NG tube

A patient takes co-codamol at home (a combination tablet sold under different names in different countries). Why should the nurse check this before giving regular paracetamol (acetaminophen)?

1. AParacetamol and codeine cause a severe allergic reaction when combined
2. BIt already contains paracetamol, so overdose could occur
3. CCo-codamol stops paracetamol from working
4. DCo-codamol must be stopped a week before any paracetamol

A patient with bone metastases is starting regular zoledronic acid. Which advice is important?

1. ATake extra calcium only on the day of infusion
2. BAvoid all physical activity for six months
3. CStop drinking all fluids on the day of each infusion
4. DHave a dental check and report jaw pain or loose teeth