Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Какого пациента медсестре следует осмотреть первым после передачи смены?

1. AПациента на диуретике, выделившего 400 mL мочи с 08:00
2. BПациента с остеоартритом, сообщающего об утренней скованности
3. CПациента с новой гипсовой повязкой, который говорит, что стопа онемела, а пальцы холодные
4. DПациента, который хочет помощи принять душ до прихода посетителей

Which patient needs airborne precautions rather than droplet precautions?

1. AA teenager with mumps
2. BAn adult with influenza
3. CA child with pertussis (whooping cough)
4. DA child with chickenpox (varicella)

Стерильный физиологический раствор пролился на стерильную простыню, лежащую на нестерильном столе. Что это означает?

1. AЗагрязнена только мокрая часть, поэтому предметы можно переложить на сухую часть
2. BПоле загрязнено, потому что влага может переносить микроорганизмы через простыню
3. CПоле остаётся стерильным, потому что физиологический раствор стерилен
4. DПоле снова становится стерильным, когда высыхает

A visitor becomes very agitated and starts shouting at the nurse in a patient’s room. What should the nurse do first?

1. ATurn away from the visitor and continue with the patient’s care as normal
2. BKeep a safe distance and a clear exit, speak calmly and call security if needed
3. CTouch the visitor’s arm to help them calm down
4. DRaise the voice to show who is in charge

Which IV fluid can be given through the same line as a red cell transfusion?

1. A0,45% sodium chloride
2. B0,9% sodium chloride
3. CLactated Ringer's (Hartmann's) solution
4. D5% dextrose in water

У пациентки с метастатическим раком молочной железы кальций 13,2 mg/dL (3,3 mmol/L), она спутана и страдает запором. Какое назначенное лечение медсестра ожидает начать первым?

1. AВнутривенный 0,9% хлорид натрия
2. BСтрогий постельный режим
3. CПероральные добавки кальция
4. DТиазидный диуретик

A pressure ulcer shows full-thickness tissue loss with exposed bone. Which category (stage) is this?

1. ACategory 4
2. BCategory 3
3. CCategory 1
4. DCategory 2

A patient faints during cannulation, with a slow pulse and pallor, and recovers quickly when laid flat. There is no rash, wheeze or swelling. What is most likely?

1. AA stroke
2. BA hypoglycaemic coma
3. CAnaphylaxis
4. DVasovagal syncope

How does intermittent pneumatic compression help prevent DVT?

1. AIt warms the legs gently so the blood becomes thinner and flows faster
2. BIt keeps the legs completely still to protect the veins
3. CIt squeezes the legs in cycles to push venous blood towards the heart
4. DIt breaks up and dissolves clots that have already formed in the veins

A patient who has had a total laryngectomy becomes breathless and needs oxygen. How should it be given?

1. AVia a mask or humidified device over the neck stoma
2. BVia nasal cannula at 2 L/min
3. CVia a non-rebreather mask over the mouth only
4. DVia a standard face mask over the nose and mouth

A patient has just started haemodialysis. What usually happens to their protein needs?

1. AThey increase, because dialysis removes amino acids
2. BThey stay exactly the same as they were before dialysis
3. CProtein must be replaced only by IV infusion
4. DThey fall to almost zero to rest the kidneys

A patient with a subarachnoid haemorrhage develops a low sodium. Why is fluid restriction usually avoided in this patient?

1. AFluid restriction would cause the aneurysm to re-bleed
2. BLow sodium in this condition always corrects itself
3. CLow blood volume can worsen vasospasm and brain ischaemia
4. DFluid restriction raises the risk of seizures

Why are many patients screened for MRSA before planned surgery?

1. ATo decide which anaesthetic drug to use
2. BSo that surgery can be cancelled for all positive patients
3. CSo that carriers can be decolonised to reduce infection
4. DTo check whether the patient has had a flu vaccine

Four patients are on a gastroenterology ward. Which should the nurse see first?

1. AA patient with GORD who wants an antacid
2. BA patient with an ileostomy waiting to change the pouch
3. CA patient with cirrhosis who is newly confused and drowsy
4. DA patient with stable ulcerative colitis asking about diet