Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient with asthma uses a peak flow meter. A reading below 50% of personal best is in the red zone. Which statement shows correct understanding?

1. A“I will stop all my inhalers until the reading is back up.”
2. B“I will use my reliever inhaler and get emergency help straight away.”
3. C“I will wait until tomorrow morning to see if the reading gets better on its own.”
4. D“I will go for a short run to open up my lungs.”

A patient admitted with suspected appendicitis says the pain suddenly got better, but now the abdomen is rigid and the heart rate is rising. What does this suggest?

1. AThe pain has moved to a different, harmless place
2. BThe appendicitis is getting better without surgery
3. CThe appendix may have ruptured, causing peritonitis
4. DThe patient’s analgesic has finally started to work

An infant has had a cleft lip repair. Why are elbow restraints often used?

1. ATo prevent the infant from sucking a pacifier
2. BTo hold the IV line in place during feeds and stop it being pulled out
3. CTo stop the infant’s hands reaching the mouth while still allowing arm movement
4. DTo keep the infant from rolling over in the crib

In START triage at a mass-casualty incident, a casualty cannot walk, breathes 20 times a minute, has a radial pulse and follows simple commands. Which category applies?

1. AGreen (minor)
2. BRed (immediate)
3. CYellow (delayed)
4. DBlack (expectant or dead)

When is a peak level for an IV aminoglycoside such as gentamicin usually drawn?

1. AJust before the next dose is started
2. BAbout 30 minutes after the infusion ends
3. CExactly 24 hours after the first dose
4. DAt any time convenient for the patient

У пациента с кальцием 6,8 mg/dL (1,7 mmol/L) внезапно появляется шумное дыхание и охриплый голос. О чём это говорит?

1. AО нормальной реакции, которая пройдёт без лечения
2. BО ларингоспазме — неотложном состоянии, требующем срочной помощи и внутривенного кальция
3. CО тревоге из-за результатов анализов, требующей спокойного успокоения
4. DОб обычной простуде, начавшейся этим утром

У пациента с циррозом печени появились спутанность сознания и сонливость, а также хлопающий тремор рук. Какое осложнение вероятно?

1. AГипогликемия, вызванная инсулином
2. BТолько алкогольное опьянение
3. CПечёночная энцефалопатия
4. DИнсульт

Which route and site are recommended for the first dose of adrenaline (epinephrine) in anaphylaxis on a ward?

1. AOral tablet dissolved under the tongue
2. BIntramuscular injection into the anterolateral thigh
3. CSubcutaneous injection into the upper arm
4. DIntravenous bolus given by the nurse without monitoring

Почему трубку плеврального дренажа, как правило, нельзя пережимать?

1. AПережатие навсегда ослабляет трубку и вызывает трещины
2. BПережатие вызывает испарение воды в затворе
3. CПережатие приводит к слишком быстрому оттоку жидкости из грудной клетки
4. DНакопившийся воздух может вызвать напряжённый пневмоторакс

A patient with asthma needs their reliever every three hours and their peak flow is falling well below their personal best. What does their action plan most likely advise?

1. AFollow the worsening-asthma steps and get a same-day review
2. BWait two weeks to see whether it improves without any change
3. CDo extra exercise to open the airways
4. DStop the preventer inhaler for a few days to rest the lungs

A patient taking warfarin is diagnosed with an intracerebral haemorrhage. What is the priority treatment?

1. AIV thrombolysis within 4,5 hours
2. BUrgent reversal of the anticoagulant effect
3. CDoubling the warfarin dose to stabilise the INR
4. DStarting aspirin to prevent further clots

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

1. AOverdrainage of CSF, so act per protocol and inform the team
2. BNo concern, because more drainage always lowers the ICP safely
3. CAn infected drain, so the dressing should be removed
4. DUnderdrainage, so the drain should be lowered further

Which description fits a category (stage) 4 pressure ulcer?

1. AFull-thickness loss with exposed bone, tendon or muscle
2. BIntact skin with redness that does not blanch
3. CA blister filled with clear fluid over the heel or sacrum
4. DA shallow wound into the dermis only

У пациента с известным варикозным расширением вен пищевода обильная рвота свежей кровью. Какого лечения должна ожидать медсестра до эндоскопии?

1. AНПВП внутрь для обезболивания и богатой белком еды
2. BБыстрой инфузии физиологического раствора до высокого давления
3. CОктреотида или терлипрессина, а также антибиотиков внутривенно во время реанимации
4. DСрочного исследования с глотанием бария до начала любой лекарственной терапии