Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient has a blood pressure of 210/120 mmHg. Which finding would make this a hypertensive emergency?

1. AForgetting to take the blood pressure tablet this morning
2. BNew chest pain or confusion suggesting organ damage
3. CMild anxiety about the high reading on the monitor
4. DA history of high blood pressure for ten years

A patient on peritoneal dialysis has cloudy fluid draining out and abdominal pain. What does this most likely mean?

1. AToo much fluid left in the abdomen after the drain
2. BConstipation that will settle with a laxative later today or tomorrow
3. CPeritonitis, which needs prompt reporting and a fluid sample
4. DA normal finding at the end of each exchange

The laboratory calls with a critical lab result by phone. What should the nurse do?

1. AWrite it down, read it back to confirm and report it to the provider promptly
2. BTell the patient the result first and then call the provider
3. CRemember the value and enter it in the chart at the end of the shift
4. DWait for the printed report to arrive before telling the provider about it

A patient with fever and a spreading rash is suspected of having smallpox. Which precautions are needed?

1. AContact precautions only
2. BAirborne and contact precautions
3. CStandard precautions only
4. DDroplet precautions with a surgical mask

Перед введением назначенного внутривенного хлорида калия какая оценка наиболее важна?

1. AДиурез и функция почек
2. BРазмер зрачков и реакция на свет
3. CТургор кожи на предплечье
4. DСлух в обоих ушах

У пациента с хронической болезнью почек фосфат 7,2 mg/dL (2,3 mmol/L). Какое диетическое обучение наиболее уместно?

1. AПить больше газированных напитков типа колы, чтобы не обезвоживаться
2. BУвеличить молоко и сыр, чтобы защитить кости от потери кальция
3. CПринимать добавки кальция натощак вместо связывающего препарата
4. DОграничить продукты, богатые фосфатами, такие как переработанные продукты и колу

A patient's low potassium does not improve despite potassium replacement. Which other electrolyte should be checked?

1. AChloride
2. BMagnesium
3. CSodium
4. DPhosphate

A patient has a swollen, warm, tender calf on one side. Which action should the nurse avoid?

1. AMeasuring and comparing calf circumference
2. BChecking whether VTE prophylaxis was given
3. CMassaging the calf
4. DReporting the findings to the doctor

Which side effect is particularly common with verapamil?

1. ADry cough
2. BHair loss
3. CDiarrhoea
4. DConstipation

After a car crash, a patient is severely breathless with absent breath sounds on the right, a deviated trachea, distended neck veins and BP 76/40 mmHg. What is the immediate management?

1. AA chest X-ray to confirm the diagnosis before any treatment
2. BInsertion of a urinary catheter to monitor output
3. CLying the patient flat with the legs raised
4. DUrgent needle or finger decompression of the right chest

После операции на гипофизе у пациента в течение трёх часов выделяется по 400 mL мочи в час с низким удельным весом. Что должна заподозрить медсестра?

1. AНормальный диурез
2. BСНАДГ
3. CНесахарный диабет
4. DОстрое повреждение почек

A patient's glucose is 6,2 mmol/L (112 mg/dL) at 03:00 and 12 mmol/L (216 mg/dL) before breakfast. No hypoglycaemia occurred overnight. What is the most likely explanation?

1. AThe meter is faulty and should be replaced
2. BThe dawn phenomenon from early-morning hormones
3. CThe Somogyi effect from a night-time hypo
4. DA large snack eaten in the night by mistake

Which is a recognised risk of long-term proton pump inhibitor use?

1. AHypercalcaemia
2. BHyperkalaemia
3. CHypernatraemia
4. DHypomagnesaemia

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. BAdvise hot soaks for the hands and feet
3. CReassure that it is a sign of an unrelated allergy to washing powder
4. DTell the patient to take a double dose next time