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

A patient is admitted with suspected meningococcal meningitis. Which precautions are needed until treatment has been given for long enough?

1. AStandard precautions only
2. BContact precautions only
3. CAirborne precautions
4. DDroplet precautions

A patient wants to use their own electric hair dryer in the hospital. What is correct?

1. AIt can be plugged into an extension lead under the bed
2. BIt is checked for electrical safety according to hospital policy before use
3. CIt can be used straight away if it looks new
4. DIt can be used in the bathroom near the sink if the patient is careful

A nurse asks a colleague to “just glance” at an insulin infusion before starting it. What makes a check truly independent?

1. AThe second nurse looks at the bag label from the doorway
2. BThe first nurse reads the details aloud and the second agrees
3. CThe second nurse signs the record after the infusion has already been started by the first
4. DThe second nurse checks the order, drug, dose and pump settings separately without being told the answer

A patient with chronic kidney disease has a potassium of 5,6 mEq/L. Which food should the nurse advise the patient to limit?

1. ABananas
2. BApples
3. CWhite rice
4. DCabbage

Пациент с новым тромбозом глубоких вен получает инфузию гепарина, и только что начат варфарин. Почему гепарин продолжают несколько дней?

1. AВарфарин действует, только если одновременно вводят гепарин
2. BВарфарину требуется несколько дней для полного антикоагулянтного эффекта
3. CГепарин усиливает всасывание варфарина из кишечника
4. DГепарин предотвращает побочные эффекты варфарина

Каково медикаментозное лечение первой линии при анафилаксии?

1. AПероральный антигистаминный препарат, например цетиризин
2. BПарацетамол внутривенно
3. CАдреналин внутримышечно
4. DИнгаляционный кортикостероид

Пациент с трахеостомой внезапно не может дышать, трубка кажется закупоренной. Каково первое действие?

1. AИзвлечь внутреннюю канюлю и проверить, не закупорена ли она
2. BСдуть манжету и оставить пациента
3. CДавать кислород только через рот
4. DЖдать врача, прежде чем что-либо делать

A patient with an implantable cardioverter-defibrillator asks what to do if it fires. Which teaching is correct?

1. AOne shock and well: contact the device clinic; repeated shocks or unwell: call emergency services
2. BRemove the device battery at home if it fires more than once
3. CDrive straight to hospital alone after any shock so the device can be checked by the team
4. DIgnore any shock at all, because the device is designed to fire every day and needs no follow-up

Four hours after abdominal surgery, a patient's heart rate has risen from 84 to 122/min and they are restless and pale. BP is still 118/76 mmHg, and the surgical drain is filling with blood. What should the nurse conclude?

1. AEarly haemorrhagic shock is likely, so escalate urgently
2. BThe drain is working well, so no action is needed
3. CThe patient is stable because the blood pressure is normal
4. DThe tachycardia is from pain and needs only analgesia

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

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

An 84-year-old man became more confused a week after starting oxybutynin. Infection has been ruled out. What should the nurse suspect?

1. ANormal ageing that needs no review
2. BAnticholinergic side effects of the drug
3. CA sign that the drug dose is too low
4. DA symptom of a high potassium from the drug

Why do patients usually have a dental review before radiotherapy to the head and neck?

1. AIt causes dry mouth and raises the risk of decay and jaw damage
2. BRadiotherapy can only be given once all the teeth have been removed
3. CThe dentist gives the radiotherapy
4. DTeeth block the radiation beam completely

A patient has had a large terminal ileum resection for Crohn's disease. Which long-term problems should the nurse anticipate?

1. AVitamin B₁₂ deficiency and bile-acid diarrhoea
2. BInsulin deficiency and high blood glucose from loss of the islets
3. CIron overload and constipation
4. DExcess vitamin D and calcium kidney stones in the first year