Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient’s peripheral IV site is swollen, pale and cool, and the infusion has slowed. What should the nurse do first?

1. AStop the infusion and remove the cannula
2. BApply a tight bandage over the site to reduce swelling
3. CFlush the cannula hard to clear the blockage
4. DIncrease the infusion rate to overcome the resistance

A patient in hypovolemic shock is receiving IV fluids. Which finding best shows that the treatment is working?

1. ANew crackles at both lung bases
2. BCooler, paler skin on the arms and legs
3. CUrine output at least 0,5 mL/kg/h and clearer thinking
4. DA heart rate that keeps rising after each bag of fluid

How should a newborn be moved through hospital corridors?

1. AIn a bassinet, not carried in the arms
2. BIn the arms of any visitor who offers to help
3. COn the mother’s lap in a wheelchair, without staff
4. DCarried in the nurse’s arms for comfort

A patient with dementia is often found at the exit doors trying to leave the unit. Which measure is most appropriate?

1. AUse an electronic wander alert, supervise closely and offer meaningful activity
2. BGive a sedative each time the patient goes to the door
3. CLock the patient alone in a single room so that they cannot reach the exit doors
4. DKeep the patient in a chair with a vest restraint

Число лейкоцитов у пациента 16 × 10³/µL с высокой долей незрелых нейтрофилов (палочкоядерных). На что это, скорее всего, указывает?

1. AНа острую бактериальную инфекцию
2. BНа нормальный результат
3. CНа железодефицитную анемию
4. DТолько на хроническое вирусное заболевание

A patient on stable digoxin starts amiodarone. A week later, the patient has nausea and visual changes, and the digoxin level is above the range. What is the most likely explanation?

1. AAmiodarone has lowered potassium only
2. BDigoxin has raised the amiodarone level
3. CAmiodarone has raised the digoxin level
4. DThe patient has started a viral illness

A rising serum creatinine most often indicates:

1. AImproved liver function
2. BIncreased muscle strength
3. CReduced kidney function
4. DDehydration of the skin only

A patient with known prostate cancer reports new back pain, leg weakness and difficulty passing urine. What should be suspected?

1. AMetastatic spinal cord compression
2. BSimple mechanical back pain
3. CHypokalaemia
4. DA urinary tract infection spreading to the back

How should a patient with asthma record their peak flow at home?

1. ATake the average of ten blows after exercise
2. BBlow only during an asthma attack, never when well
3. CTake one gentle blow once a week, at any time of day
4. DTake the best of three blows, ideally morning and evening

Three hours after femoral cardiac catheterisation, a patient has new lower back and flank pain, a heart rate of 112/min and BP 92/60 mmHg. The groin looks normal. What should the nurse suspect?

1. ANormal back ache from lying flat
2. BA urinary tract infection
3. CAn allergic reaction to the contrast
4. DRetroperitoneal bleeding

Which blood gas pattern is typical of acute kidney injury?

1. AHigh pH and high bicarbonate
2. BLow pH and high carbon dioxide only
3. CLow pH and low bicarbonate
4. DHigh pH and low carbon dioxide

On day 6 after a subarachnoid haemorrhage, a patient becomes newly confused and develops weakness in one arm. The aneurysm was secured on day 1. What is the most likely cause?

1. ADelayed cerebral ischaemia from vasospasm
2. BNormal tiredness after major surgery
3. CRe-bleeding from the secured aneurysm
4. DHypoglycaemia from reduced eating

Why is the "whoosh" test no longer used to check nasogastric tube position?

1. AIt needs an X-ray machine at the bedside
2. BAir can be heard even when the tube is in the lung
3. CThe test is far too painful for most patients to tolerate
4. DThe air always makes the tube block

Six hours after surgery, a patient has not passed urine, has lower abdominal discomfort and a bladder scan shows 750 mL. What should the nurse do?

1. ARestrict fluids until the urge returns
2. BWait another twelve hours before acting
3. CGive a diuretic to increase urine flow
4. DCatheterise as per protocol or prescription