Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Straight after birth, what is the first priority for a healthy-looking newborn?

1. ADry and warm the baby while checking that it is breathing
2. BGive the vitamin K injection before anything else is done
3. CGive the first bath to remove the blood and vernix
4. DWeigh and measure the baby on the scale

A marathon runner is confused, with a temperature of 41 °C and hot skin. What is the priority?

1. AWrapping the runner in a blanket to prevent shivering
2. BGiving an antipyretic tablet and waiting for it to work
3. CRapid cooling while supporting airway and circulation
4. DAsking the runner to rest in the shade and drink slowly

A patient is on suicide precautions. Which room safety measure is appropriate?

1. ARemove items that could be used for self-harm, such as belts and cords
2. BKeep the door closed at all times so the patient has privacy
3. CAllow glass bottles if the patient seems calm
4. DLet the patient keep a personal razor for shaving, as long as staff are told

Пациенту в сознании с риском поперхнуться дают лекарства внутрь. Какая практика наиболее безопасна?

1. AИзмельчить все таблетки, не проверяя, разрешено ли это
2. BУложить пациента на спину, чтобы облегчить глотание
3. CПосадить пациента прямо и давать по одной таблетке
4. DДать все таблетки сразу, чтобы сэкономить время

A patient taking spironolactone asks about using a salt substitute. What should the nurse explain?

1. AMost salt substitutes contain potassium and can raise the level too high
2. BSalt substitutes protect against the potassium loss caused by this drug
3. CSalt substitutes are safe because they contain only sodium chloride
4. DSalt substitutes are fine as long as the patient drinks more water

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

Why is an ankle–brachial pressure index (ABPI) measured before applying compression bandages to a leg ulcer?

1. ATo check for a urinary tract infection that could delay ulcer healing
2. BTo measure how deep the ulcer is and how much exudate it produces
3. CTo exclude significant arterial disease, as compression could cut off blood flow
4. DTo work out the patient's fluid needs

A patient's hypoglycaemia was caused by a sulfonylurea such as gliclazide or glipizide. Why might they need monitoring for longer than usual?

1. AThe drug makes glucose tablets and drinks ineffective
2. BSulfonylureas act for a long time, so hypoglycaemia can recur
3. CThe drug causes rebound hyperglycaemia later the same day
4. DSulfonylureas only work at night

A patient on home oxygen has dry, sore lips. Which product is safest to use?

1. AAn alcohol-based gel
2. BAn oil-based balm
3. CPetroleum jelly
4. DA water-based lubricant

An 84-year-old with heart failure becomes breathless with new crackles and a rising blood pressure during a blood transfusion. What should the nurse suspect?

1. AAn acute haemolytic reaction from wrong blood
2. BTransfusion-associated circulatory overload
3. CNormal effects of the transfusion
4. DA mild febrile reaction

Which nursing care is most important for a patient with diabetes insipidus?

1. AGiving a loop diuretic to clear extra fluid
2. BStrict fluid balance, daily weight and free access to water
3. CA strict fluid restriction to reduce the amount of urine passed
4. DWeighing the patient once a month

Which patient on a stroke unit is most at risk of falling?

1. AA patient with mild dysarthria who walks steadily with a frame
2. BA patient with a TIA whose symptoms resolved completely yesterday
3. CA patient with a right-hemisphere stroke who is impulsive and denies having weakness
4. DA patient with a left-hemisphere stroke who has expressive aphasia and waits for help

Which treatment often relieves pain from a bone metastasis?

1. AA diet low in calcium and vitamin D
2. BIron supplements by mouth for several months
3. CComplete bed rest for a month
4. DPalliative radiotherapy to the area

A nurse teaches a patient with a new ileostomy. Which statement shows a need for further teaching?

1. A"I'll watch for dizziness and dark urine."
2. B"I'll drink less so my bag fills more slowly."
3. C"I'll report if my output becomes very watery and high."
4. D"I'll chew my food well to avoid blockages."