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. AЖёлтая (отсроченная помощь)
2. BЗелёная (лёгкие)
3. CЧёрная (безнадёжные)
4. DКрасная (немедленная помощь)

A patient with diabetic ketoacidosis is about to start an IV insulin infusion. The serum potassium is 3,0 mEq/L. What should the nurse do?

1. AGive the insulin as a fast bolus to bring the potassium up
2. BReport the result before starting, because insulin will push potassium even lower
3. CIgnore the result, since potassium is always high in this condition and will correct itself
4. DStart the insulin at once, because the glucose is the bigger problem

A parent will give a liquid antibiotic to a child at home. Which teaching is best?

1. AUse a tablespoon for doses over 5 mL
2. BUse the oral syringe or dosing cup that comes with the medicine
3. CUse any teaspoon or tablespoon from the kitchen drawer at home
4. DEstimate the dose by pouring into a cup

A patient weighs 180 kg and needs to be moved from bed to chair. The standard ceiling lift on the unit has a lower weight limit. What should the nurse do?

1. AUse bariatric-rated equipment and enough trained staff
2. BHave two staff lift the patient by hand
3. CUse the standard lift, because limits include a safety margin
4. DAsk the patient to stand and pivot without help

During a red cell transfusion, when are serious acute reactions most likely, so the nurse stays with the patient?

1. AIn the first 15 minutes
2. BAfter about 2 hours
3. CAfter the last drop is given
4. DThe next morning

Which patient should the nurse assess first?

1. AStable angina with a total cholesterol of 245 mg/dL (6,3 mmol/L)
2. BHeart failure with a BNP lower than the result on admission
3. CChest pain with troponin rising from the first to the second sample
4. DHypertension with a potassium of 3,6 mEq/L on a thiazide

A patient with renal colic is asked to pass urine through a strainer. Why?

1. ATo catch any stone so that it can be analysed
2. BTo measure the urine's pH and specific gravity
3. CTo make passing urine less painful
4. DTo remove bacteria from the urine

A day after surgery, a patient's haemoglobin has fallen from 125 g/L to 85 g/L (12,5 to 8,5 g/dL) and their heart rate has risen to 118/min. What is the priority?

1. ADocument the result and take no further action
2. BEncourage the patient to eat iron-rich foods
3. CRecheck the haemoglobin next week
4. DEscalate urgently, as the patient may be bleeding

Virchow's triad describes three factors that promote venous thrombosis. Which patient factor represents venous stasis?

1. AImmobility after major surgery
2. BAn inherited clotting disorder
3. CTaking an oestrogen-containing pill
4. DDamage to a vein during hip surgery

After an anaphylactic reaction to a bee sting that responded to adrenaline (epinephrine), a patient asks to go home immediately. Which advice is most appropriate?

1. AGo home straight away, because anaphylaxis never recurs once adrenaline has worked
2. BGo home and take antihistamines only if the throat swells
3. CStay for observation, then go home with an adrenaline auto-injector and teaching
4. DStay in hospital for at least two weeks on daily intravenous antihistamines

Which action is part of an effective bowel programme after a spinal cord injury?

1. ARestricting fluids to reduce the volume of stool
2. BAvoiding fibre to prevent bloating
3. CA routine at the same time each day, often after a meal
4. DUsing strong laxatives only when the bowel has not opened for a week

A patient with gastroparesis has hypos soon after their meal-time insulin, then high glucose several hours later. What is the best explanation?

1. AThe meter gives false results for several hours after every meal
2. BFood is absorbed slowly, so the insulin peaks before the glucose rises
3. CThe patient is secretly eating sweets between meals
4. DThe insulin has gone off and needs replacing

How can low-dose opioids help a patient with breathlessness from advanced cancer?

1. AThey open the airways like an inhaler
2. BThey reduce the feeling of breathlessness
3. CThey increase the oxygen level in the blood
4. DThey cure the underlying lung disease

A patient taking oral capecitabine reports red, painful, peeling palms and soles. What should the nurse do?

1. AReport it; this is hand-foot syndrome and treatment may need changing
2. BTell the patient to take a double dose next time
3. CReassure that it is a sign of an unrelated allergy to washing powder
4. DAdvise hot soaks for the hands and feet