Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

При триаже START на месте происшествия с массовыми жертвами пострадавший может дойти до указанной зоны по просьбе. В какую категорию он попадает?

1. AЧёрная (безнадёжные)
2. BЖёлтая (отсроченная помощь)
3. CКрасная (немедленная помощь)
4. DЗелёная (лёгкие)

Two patients on the unit have the same surname. What should the nurse do before giving a medication?

1. ACheck two identifiers against the wristband and the medication record
2. BAsk the patient, “Are you Mr Smith?” and give the drug once he says yes
3. CUse the room number as the main identifier
4. DAsk a nursing assistant which patient is which

Where is a gait belt placed when helping a patient to walk?

1. AAround the patient’s waist, over clothing
2. BAround both thighs, just above the knees
3. CAround the hips, directly on bare skin
4. DAround the chest, under the arms

Which patient should the nurse assess first?

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

У пациента абсолютное число нейтрофилов 0,4 × 10³/µL. Какая мера уместна?

1. AРазместить в одной палате с другим пациентом, которого лечат от пневмонии
2. BИзмерять температуру ректально, так как показания точнее
3. CПринести свежие цветы в палату, чтобы поднять настроение пациента
4. DСтрогая гигиена рук, контроль температуры и отсутствие посетителей с инфекциями

Ten days after chemotherapy, a patient has a platelet count of 9 × 10³/µL and reports a sudden severe headache and blurred vision. What is the priority?

1. AGive acetaminophen (paracetamol) for the headache and reassess in 1 hour
2. BEncourage the patient to drink more fluids and check the blood pressure later
3. CAssess neurological status and report it at once as possible brain bleeding
4. DDim the lights and encourage rest, as headaches are common after chemotherapy

A patient is having a 12-lead ECG. Where are the chest electrodes placed?

1. AIn standard numbered positions across the front and left of the chest
2. BIn a straight line down the centre of the sternum from top to bottom
3. COn both shoulders and both hips only
4. DAnywhere on the chest where the skin is clear

A nurse teaches a patient with diabetes about foot care. Which statement shows a need for further teaching?

1. A"I will check my feet every day for cuts or blisters."
2. B"I will see the podiatrist about hard skin."
3. C"I will wear well-fitting shoes."
4. D"I will walk barefoot at home to toughen my feet."

A patient on nasal cannula oxygen breathes mainly through the mouth. What is the most accurate statement?

1. AIt has no effect at all in mouth breathers and must be stopped
2. BThe cannula should be placed in the mouth
3. CThe flow must be increased to 15 L/min to make it work at all
4. DIt can still work, because oxygen collects in the nasopharynx

An older inpatient develops sudden fever, muscle aches and a dry cough during the winter influenza season. Which plan is most appropriate?

1. ALeave them in the open bay and give a course of antibiotics only
2. BWait a week to see whether the symptoms settle before testing
3. CIsolate with droplet precautions, test and expect early antivirals
4. DIsolate only if they develop a rash

A patient with type 1 diabetes has gastroenteritis and cannot eat. Which sick-day advice is correct?

1. AStop all insulin until normal eating restarts
2. BCheck glucose once a day only and rest in bed until better
3. CAvoid drinking fluids to reduce the vomiting
4. DKeep taking basal insulin and check glucose and ketones more often

A patient with a cervical spinal cord injury is helped to sit up for the first time. They become dizzy and pale, and the BP falls from 110/70 to 78/46 mmHg. What should the nurse do?

1. AStand the patient up to improve the blood flow to the legs
2. BGive a large meal and a strong coffee to raise the blood pressure
3. CContinue sitting them upright, because it will pass in an hour
4. DLower the patient back towards lying, then raise them gradually later

A routine wound swab grows bacteria, but the wound shows no signs of infection. What does this usually mean?

1. AThe patient needs IV antibiotics straight away, whatever the wound looks like
2. BThe wound is colonised; antibiotics are not usually needed
3. CThe wound must be closed with sutures again
4. DThe swab result means the wound is infected

After a fall, a patient with advanced dementia is agitated, grimacing and guarding the hip, and cannot rate the pain. What should the nurse do?

1. AAssume there is no pain because none is reported
2. BUse an observational pain tool, give analgesia and reassess
3. CWait until a relative can confirm the pain
4. DGive a sedative to treat the agitation and avoid giving any analgesia