Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient has a nasogastric tube on suction. Which task can the nurse delegate to a nursing assistant?

1. AAssessing the drainage for blood
2. BIrrigating the tube when it blocks
3. CGiving mouth care
4. DChecking the tube’s position

Two call lights go on at the same time. One patient has pain of 7/10 after surgery. The other is a confused patient at high risk of falls who is climbing out of bed alone. Who does the nurse go to first?

1. AThe confused patient climbing out of bed
2. BWhichever patient’s room is closer to the station
3. CThe patient in pain after surgery
4. DThe patient whose call light went on first

Sputum specimens are ordered to look for acid-fast bacilli (TB). How are they usually collected?

1. AOne specimen of sputum collected straight after the evening meal, when coughing is easiest
2. BThree deep-cough specimens collected 8 to 24 hours apart, at least one early in the morning
3. CThree specimens collected after an antiseptic mouthwash
4. DOne saliva sample collected at any convenient time of day

Which patient with a suspected infection meets the qSOFA criteria that signal a higher risk of a poor outcome?

1. ARespiratory rate 24/min, new confusion, systolic BP 95 mmHg
2. BRespiratory rate 16/min, alert, systolic BP 105 mmHg, WBC 13,000/mm³
3. CRespiratory rate 18/min, alert, systolic BP 130 mmHg, temperature 38,5 °C
4. DRespiratory rate 20/min, alert, systolic BP 110 mmHg, heart rate 110/min

A patient with HIV on antiretroviral therapy has an undetectable viral load. What does this mean?

1. AThe treatment can now be stopped without any risk
2. BThe treatment is suppressing the virus very well
3. CThe virus has been completely cured and removed
4. DThe CD4 count must now be dangerously low too

У истощённого пациента возобновили питание, и на 3-й день фосфат 1,2 mg/dL (0,39 mmol/L), мышечная слабость и одышка. В чём главный риск?

1. AСлабость дыхательных мышц и сердечная недостаточность из-за низкого фосфата
2. BКамни в почках из-за кальция, высвобождаемого из костей
3. CБыстрый набор массы тела, но без серьёзной опасности
4. DГиперкалиемия из-за выхода калия из клеток

A patient with DKA has an arterial blood gas showing a low pH and a low bicarbonate. Which disturbance is this?

1. ARespiratory acidosis
2. BMetabolic acidosis
3. CMetabolic alkalosis
4. DRespiratory alkalosis

Three days after bowel surgery, a patient has a distended abdomen, vomiting and absent bowel sounds, without colicky pain. What is most likely?

1. AAcute cholecystitis
2. BA urinary tract infection
3. CParalytic ileus
4. DNormal recovery after surgery

Which ECG finding is typical of atrial flutter?

1. AA chaotic baseline with no clear P waves and irregular QRS
2. BRegular sawtooth flutter waves between QRS complexes
3. CP waves with no relationship to the QRS complexes
4. DWide, bizarre QRS complexes at 180/min

The monitor shows a regular broad-complex tachycardia at 180/min. The patient is alert with BP 126/78 mmHg and no chest pain. What is the most appropriate plan?

1. ARecord a 12-lead ECG, call senior help and anticipate an antiarrhythmic
2. BDeliver an unsynchronised shock immediately, before any other assessment
3. CReassure the patient, as this is a normal rhythm
4. DStart chest compressions straight away and give a dose of IV adrenaline

Почему после тиреоидэктомии у постели часто держат инструменты для снятия швов или скоб?

1. AИми корректируют дренаж, когда он перестаёт работать
2. BГематома на шее может сдавить дыхательные пути, и её, возможно, придётся вскрыть
3. CШвы нужно снять в первый вечер после операции
4. DОни нужны для взятия крови из вен шеи

A patient with myasthenia gravis took extra pyridostigmine doses. They now have more weakness, heavy salivation, sweating, diarrhoea, small pupils and a slow pulse. What is most likely?

1. AAn allergic reaction to the drug
2. BA normal response to a higher dose
3. CA cholinergic crisis from too much medication
4. DA myasthenic crisis from too little medication

Which statement about moist wound healing is correct?

1. AA moist, not wet, wound bed helps cells move and heal faster
2. BWounds should be soaked in water for hours every day
3. CWounds heal fastest when left to dry out and form a scab
4. DA wet wound bed always prevents infection

A patient with active cancer on chemotherapy develops new swelling and pain in one calf. Why must this be reported promptly?

1. ACancer and its treatment greatly increase clot risk
2. BIt is only a muscle strain from walking
3. CThe swelling shows the cancer has gone
4. DCalf swelling is a normal effect of chemotherapy