Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Пациент, которому только что сообщили о раке, плачет, но у него также несколько раз была рвота, и он не удерживает жидкость. Чем медсестра занимается первым?

1. AВызовом больничного капеллана
2. BОбучением по химиотерапии
3. CРвотой и потерей жидкости
4. DЭмоциональной поддержкой по поводу диагноза

A patient taking an MAO inhibitor antidepressant is taught about diet. Which statement shows a need for further teaching?

1. A“A sudden severe headache is a warning sign.”
2. B“I will avoid tap beer and red wine.”
3. C“I can still eat aged cheese and cured salami.”
4. D“I will check with the pharmacist before cold remedies.”

How should a nurse handle soiled bed linen?

1. AShake it out first to check for lost items
2. BHold it away from the uniform and place it straight into a linen bag
3. CCarry it bundled against the body to the soiled utility room down the hall
4. DPut it on the floor until the bed is made

A nurse has a needlestick from a patient with hepatitis B. The nurse finished the vaccine series and has a documented protective antibody level. Which statement is correct?

1. ANo hepatitis B treatment is needed, but the injury is still reported and followed up
2. BThe nurse must stop all patient care for six months
3. CNo reporting is needed because the nurse is immune
4. DHepatitis B immune globulin and a complete new vaccine series are both needed at once

A patient had a total gastrectomy. Which long-term therapy is needed to prevent anemia?

1. ALifelong vitamin B₁₂ replacement
2. BMonthly transfusions of red blood cells
3. CWeekly doses of oral vitamin K tablets
4. DLifelong oral folic acid tablets only

A nursing student has a positive interferon-gamma release assay (IGRA) for tuberculosis, no symptoms and a normal chest X-ray. What does this most likely mean?

1. AActive pulmonary TB, which is contagious
2. BA false result, as the test does not detect TB
3. CPast BCG vaccination only, with no infection
4. DLatent TB infection, which is not contagious

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

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

Which task is most appropriate for a registered nurse to delegate to a trained healthcare assistant (unlicensed assistive personnel)?

1. AGiving a dose of intravenous antibiotic
2. BMeasuring and recording vital signs on a stable patient
3. CTeaching a patient to inject insulin for the first time
4. DAssessing a patient who has just reported new chest pain

How does varenicline help people stop smoking?

1. AIt partly stimulates and partly blocks nicotine receptors
2. BIt speeds the clearance of nicotine by the liver
3. CIt makes cigarettes taste of metal so smoking feels unpleasant
4. DIt replaces nicotine through the skin, like a nicotine patch

После катетеризации сердца через лучевую артерию какая оценка важнее всего?

1. AУдельный вес мочи каждые четыре часа
2. BКровообращение, чувствительность и движения кисти, а также место пункции
3. CКишечные шумы и окружность живота каждый час после исследования
4. DРазмер зрачков и реакция на свет каждые 15 минут

Какая картина электролитов типична для болезни Аддисона?

1. AВысокий кальций и низкий фосфат
2. BВысокий натрий и низкий калий
3. CНизкий калий и низкая глюкоза
4. DНизкий натрий и высокий калий

Two days after a spinal cord injury, a patient has a swollen abdomen, no bowel sounds and is vomiting. What is most likely, and what is the nursing action?

1. AParalytic ileus, so keep nil by mouth and prepare for an NG tube
2. BA full bladder, so encourage oral fluids
3. CAn allergic reaction to food, so give an antihistamine
4. DNormal constipation, so give a large meal to stimulate the bowel

Why are patients with large burns at risk of hypothermia?

1. AThe fluids given are always chilled
2. BBurns always cause a low thyroid hormone level in the blood
3. CTheir metabolism stops after the injury
4. DLoss of skin reduces their ability to keep in heat

A nurse teaches a patient after a laparoscopic fundoplication for reflux. Which statement shows a need for further teaching?

1. A"Fizzy drinks will help me bring up wind after meals."
2. B"I'll eat soft, moist food at first and chew it well."
3. C"I should eat smaller meals for a while after the operation."
4. D"Some difficulty swallowing can happen in the early weeks."