Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Через четыре часа после операции на щитовидной железе какую находку у пациента медсестре следует обработать первой?

1. AБоль в разрезе 4/10
2. BПросьба сесть, чтобы попить
3. CНебольшое количество серозного отделяемого на повязке на шее
4. DГолос, становящийся всё более охриплым, с новым шумным дыханием

A victim heavily contaminated with an industrial chemical arrives at the emergency department with stable vital signs. What should happen first?

1. ADecontamination before the victim enters the treatment area
2. BFull assessment inside the main department straight away
3. CPlacing the victim in the waiting room until a doctor is free
4. DTaking the victim straight to the X-ray department

A patient has a non-violent restraint. In most nursing policies, how often at minimum is it released for range of motion, toileting and skin care?

1. AOnce every 12-hour shift
2. BOnly when the patient asks for it
3. COnce a day, during the bath
4. DAt least every 2 hours

A child with fever, cough, red eyes and a spreading rash is in a clinic waiting room. Measles is suspected. What should the nurse do first?

1. AGive the child an antipyretic and continue triage
2. BAsk the family to wait in the main waiting room until the child is called in
3. CSend the child home to rest without an assessment
4. DPut a mask on the child and move them into an airborne isolation room

A patient with type 2 diabetes has a target HbA1c below 7% (53 mmol/mol). Today's result is 7,8% (62 mmol/mol). What is the best interpretation?

1. AThe result shows today's fasting glucose is above the target
2. BThe patient has had frequent episodes of severe hypoglycemia
3. CGlucose control has been excellent for the past several months
4. DAverage glucose over the past months has been above the target

A patient in DKA is receiving IV fluids and insulin. The glucose has fallen to about 220 mg/dL (12,2 mmol/L), but the anion gap is still high. What change would the nurse expect?

1. AGive an IV bolus of sodium bicarbonate at once
2. BStop the IV fluids and start oral fluids only
3. CAdd dextrose to the IV fluids and continue the insulin
4. DStop the insulin infusion because the glucose is near normal

Which pattern is typical of relapsing–remitting multiple sclerosis?

1. AA single stroke that leaves permanent weakness
2. BConstant weakness that starts in the feet and spreads upwards after a viral illness
3. CAttacks of symptoms, such as visual loss or numbness, that improve between relapses
4. DSudden severe headache with neck stiffness

У пациента с острым панкреатитом сильная боль в эпигастрии, иррадиирующая в спину. Какой сестринский уход важнее всего?

1. AОграничение всех жидкостей
2. BАдекватное обезболивание, внутривенные жидкости и тщательный контроль водного баланса
3. CОбильная жирная еда для стимуляции поджелудочной железы
4. DСтрогий постельный режим без контроля показателей

After thrombolysis for a myocardial infarction, which complication is the nurse most concerned to detect?

1. AA skin rash appearing at the sites of the ECG electrodes
2. BConstipation from bed rest
3. CBleeding, including a sudden change in neurological status
4. DA high blood glucose caused by the thrombolytic drug itself

During a cardiac arrest, the monitor shows an organised rhythm, but there is no pulse. What should the team do?

1. ADeliver an unsynchronised shock at once and then check the pulse
2. BContinue CPR and give adrenaline (epinephrine), as the rhythm is non-shockable
3. CGive adenosine to slow the rhythm down
4. DStop CPR, because an organised rhythm on the monitor means recovery

A patient on ciclosporin or tacrolimus asks about grapefruit juice. Which advice is correct?

1. ADrink it with each dose to improve the absorption
2. BAvoid it, because it can raise the drug levels
3. CDrink it daily to protect the kidney
4. DIt has no effect on these drugs

A patient with type 1 diabetes has a seizure on the ward. Their capillary glucose is 1,9 mmol/L (34 mg/dL). They cannot swallow. What is the most appropriate treatment?

1. AGlucose gel squeezed into the mouth during the seizure
2. BA rapid-acting insulin dose to stabilise the glucose
3. CAn antiepileptic drug only, because seizures need seizure treatment
4. DIV glucose or IM glucagon, then recheck the glucose

What are anticipatory ("just in case") medicines at the end of life usually prescribed for?

1. APain, nausea, agitation and respiratory secretions
2. BWeight gain and appetite stimulation
3. CHigh blood pressure, high cholesterol and diabetes
4. DInfection prevention and vaccination

A patient with bone metastases is starting regular zoledronic acid. Which advice is important?

1. AStop drinking all fluids on the day of each infusion
2. BAvoid all physical activity for six months
3. CTake extra calcium only on the day of infusion
4. DHave a dental check and report jaw pain or loose teeth