Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

An older patient with dementia is restless at night and keeps trying to get out of bed. Which measure should the nurse try first?

1. ACheck for pain, thirst or a full bladder, and offer toileting
2. BApply wrist restraints for the rest of the night
3. CRaise all four bed rails so the patient cannot climb out
4. DGive a sedative from the as-needed list without first assessing the patient

A patient is going home on a new oral anticoagulant. There is only a short time for teaching. Which topic is most important?

1. AHow to choose comfortable walking shoes
2. BSigns of bleeding and when to seek help
3. CHow to cook low-fat meals
4. DWhich television programs help with relaxation

A nurse’s hands are dry and cracked from frequent hand hygiene. What is the best approach?

1. AWear gloves all day instead of cleaning the hands between patients
2. BUse any lotion from home, whatever its contents
3. CUse the hand lotion approved by the facility to keep the skin intact
4. DStop hand hygiene until the skin heals

A patient with pulmonary tuberculosis has been on treatment. Which findings usually allow airborne isolation to end?

1. AThree negative sputum smears, clinical improvement and continued therapy
2. BThe patient has been in hospital for one week and has taken every dose of medicine
3. COne negative chest x-ray after starting treatment
4. DThe cough has stopped, even with no sputum tests

A patient starts high-dose prednisone. Which laboratory change should the nurse expect?

1. AA fall in serum sodium
2. BA rise in serum potassium
3. CA rise in blood glucose
4. DA fall in the white cell count

У пациента на внутривенной инфузии инсулина глюкоза крови 65 mg/dL (3,6 mmol/L). Какое действие лучшее?

1. AПродолжить с той же скоростью и перепроверить через четыре часа
2. BОстановить инфузию и отложить повторную проверку глюкозы до утра
3. CДать калий внутрь для защиты сердца
4. DДействовать по протоколу при низкой глюкозе и уведомить врача

A very anxious patient breathes rapidly for a long period. Which change is expected?

1. ARespiratory acidosis from a high PaCO₂
2. BRespiratory alkalosis from a low PaCO₂
3. CMetabolic acidosis from a low bicarbonate
4. DMetabolic alkalosis from vomiting

A patient with hyperkalaemia is given IV insulin with glucose. What is the purpose, and what must be monitored?

1. ATo treat hidden diabetes; HbA1c must be checked daily
2. BTo protect the heart muscle directly; the patient must be kept nil by mouth
3. CTo remove potassium from the body; urine output must be stopped for a time
4. DTo shift potassium into cells; blood glucose must be monitored for hypoglycaemia

Why must intravenous potassium chloride never be given as a rapid push or undiluted?

1. AIt immediately lowers the blood glucose to dangerous levels
2. BIt works only when given by mouth
3. CIt turns into solid crystals inside the vein and blocks it
4. DA sudden high potassium level can cause cardiac arrest

A patient receiving weeks of IV antibiotics through a PICC line in the left arm develops swelling and aching of that arm and neck veins that look fuller on the left. What should the nurse suspect?

1. AA local skin allergy to the dressing
2. BAn expected effect of the antibiotic
3. CLymphoedema from lying in bed
4. DA catheter-related deep vein thrombosis

A patient has just started levetiracetam. Which side effect should the nurse teach them to report?

1. ASwelling and overgrowth of the gums around the teeth
2. BChanges in mood, such as irritability, low mood or anger
3. COrange discoloration of the urine
4. DA persistent dry cough at night

A patient with a cervical spinal cord injury is helped to sit up for the first time. They become dizzy and pale, and the BP falls from 110/70 to 78/46 mmHg. What should the nurse do?

1. ALower the patient back towards lying, then raise them gradually later
2. BContinue sitting them upright, because it will pass in an hour
3. CStand the patient up to improve the blood flow to the legs
4. DGive a large meal and a strong coffee to raise the blood pressure

Какие признаки указывают на тяжёлый острый панкреатит с кровотечением в ткани?

1. AОтёк губ, языка и лица
2. BПурпурная сыпь на ладонях и подошвах
3. CЖёлтая окраска ногтей на пальцах рук
4. DКровоподтёки вокруг пупка или на боках

Four hours after surgery, a catheterised patient's urine output has been 10 mL/h for two hours. Vital signs are stable. What should the nurse check first?

1. AYesterday's chest X-ray and blood gas results
2. BThat the catheter and tubing are not kinked or blocked
3. CWhether the patient wants a cup of tea
4. DThe time the patient last ate