Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient taking lithium has vomiting, diarrhea and a new coarse tremor. What should the nurse do?

1. AEncourage the patient to cut down on salt and fluids
2. BReassure the patient that a coarse tremor is expected at first
3. CGive the dose with food to reduce the stomach upset
4. DHold the next dose and report for an urgent lithium level

Four laboratory results come back at once. Which one should the nurse report first?

1. AHemoglobin 6,5 g/dL (65 g/L) in a patient with a GI bleed
2. BPotassium 3,4 mEq/L in a patient on a diuretic
3. CCreatinine 1,3 mg/dL in an older adult, unchanged from last week
4. DGlucose 180 mg/dL after a meal in a patient with diabetes

A patient is on suicide precautions. Which room safety measure is appropriate?

1. ALet the patient keep a personal razor for shaving, as long as staff are told
2. BKeep the door closed at all times so the patient has privacy
3. CAllow glass bottles if the patient seems calm
4. DRemove items that could be used for self-harm, such as belts and cords

A nurse discovers that an insulin infusion was programmed using the wrong drug concentration in the pump library. What should the nurse do first?

1. AStop the infusion and check the patient’s blood glucose
2. BDouble the rate to correct for the error
3. CReprogram the pump and finish the shift before reporting
4. DLeave it running and check the glucose at the next routine time

A trauma patient receives 2 L of IV crystalloid. The hemoglobin falls from 13,0 to 11,4 g/dL (130 to 114 g/L), and the vital signs are now stable. Which explanation is most likely?

1. AA sudden failure of the bone marrow
2. BIncreased red cell production
3. CA laboratory error in the first sample
4. DDilution of the blood by the IV fluid

A trauma patient receives many units of blood quickly and then develops muscle twitching and low blood pressure. Which laboratory value is most likely to explain this?

1. AA high serum sodium
2. BA high serum magnesium
3. CA low ionized calcium
4. DA low serum glucose

A spontaneously breathing patient is critically ill and hypoxic. Which oxygen delivery gives the highest concentration?

1. ANon-rebreathe mask with reservoir bag at 15 L/min
2. BNasal cannula at 2 L/min
3. CVenturi mask set to 24%
4. DSimple face mask at 5 L/min with the patient sitting up

A catheterised postoperative patient has passed only 10 mL of urine in the last two hours. What should the nurse check first?

1. AThat the catheter and tubing are not kinked or blocked
2. BWhether the patient has eaten breakfast
3. CThe patient's weight from last year
4. DThe patient's cholesterol level from the admission bloods

A patient on home oxygen has dry, sore lips. Which product is safest to use?

1. APetroleum jelly
2. BAn alcohol-based gel
3. CA water-based lubricant
4. DAn oil-based balm

У пациента с фибрилляцией предсердий ЧСС 165/мин, АД 78/45 mmHg, боль в груди и новая спутанность. Какого лечения должна ожидать медсестра?

1. AСрочной синхронизированной электрической кардиоверсии
2. BБисопролола внутрь и осмотра утром
3. CНесинхронизированной дефибрилляции, как при остановке сердца
4. DАтропина внутривенно для улучшения артериального давления

After a lumbar discectomy, which finding should the nurse report promptly?

1. AA dry, intact wound dressing
2. BStiffness when getting out of bed
3. CMild pain at the wound site
4. DNew weakness or numbness in the legs

A patient taking amiodarone has gained weight and feels tired and cold. Which blood test is most relevant?

1. ASerum amylase and lipase levels
2. BThyroid function tests
3. CBlood alcohol level
4. DSerum ferritin

What is achalasia?

1. AFailure of the lower oesophageal sphincter to relax on swallowing
2. BInflammation of the oesophagus caused by a fungal infection
3. CA tear at the junction of the oesophagus and the stomach
4. DWeakness of the lower oesophageal sphincter that allows reflux

У пациента с циррозом и асцитом новая лихорадка, болезненность живота и нарастающая спутанность. Какое осложнение следует заподозрить?

1. AОстрый панкреатит
2. BПростой запор
3. CСпонтанный бактериальный перитонит
4. DНормальное прогрессирование асцита