Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Several patients on a gastroenterology unit need care. Which patient should the nurse see first?

1. ALong-standing back pain, asking for the usual analgesic
2. BUlcerative colitis, asking about diet changes for home
3. CTwo hours after a colonoscopy: rigid abdomen and severe new pain
4. DCrohn disease, waiting to be taken down for a scheduled CT scan

A patient was knocked out briefly in a fall, then woke and talked normally. Two hours later the patient becomes drowsy and one pupil is larger. What is the most likely cause?

1. AA mild concussion that is settling
2. BNormal tiredness after a fall
3. CLow blood sugar from missing a meal
4. DAn epidural hematoma

A patient with poorly controlled seizures asks about activities at home. Which advice is most important?

1. AAvoid all forms of exercise
2. BAvoid drinking water before bed
3. CSleep sitting up in a chair
4. DNever swim or bathe alone

A nurse notices that the pharmacy has sent the wrong dose and corrects it before giving it. Should the event be reported?

1. ANo, because the patient was not harmed
2. BOnly if the same error happens three times
3. CYes, near misses are reported so system weaknesses can be fixed
4. DNo, because reporting near misses only blames the pharmacy staff for nothing

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 laboratory error in the first sample
2. BA sudden failure of the bone marrow
3. CIncreased red cell production
4. DDilution of the blood by the IV fluid

An older adult has bone pain, fatigue and frequent infections. Results show anemia, a calcium of 12,4 mg/dL (3,1 mmol/L), a raised total protein and a rising creatinine. Which condition should be suspected?

1. AAcute viral hepatitis
2. BPrimary hypothyroidism
3. CIron-deficiency anemia
4. DMultiple myeloma

A patient on the ward has shingles with open blisters. Which people are most at risk from contact?

1. ANo one, because shingles cannot spread
2. BPregnant women and immunocompromised people who have not had chickenpox
3. CPeople who have already had chickenpox in childhood and are now healthy
4. DOnly people over 80 who have already had shingles themselves

A nurse teaches a patient with reflux disease. Which statement shows a need for further teaching?

1. A"I will try to lose some weight over the next months."
2. B"I will cut down on alcohol."
3. C"A big meal just before bed is fine if I take my tablet."
4. D"I will raise the head of my bed with blocks."

During airway suctioning, when should suction be applied?

1. ABefore the catheter enters the airway
2. BOnly while withdrawing the catheter
3. CContinuously for at least 30 seconds
4. DOnly while inserting the catheter

У пациента, начавшего принимать ингибитор АПФ вчера, появились отёк губ и языка и осиплость голоса. Что должна сделать медсестра в первую очередь?

1. AОбъяснить, что это ожидаемый безвредный побочный эффект
2. BОценить дыхательные пути, срочно позвать на помощь и не давать следующие дозы
3. CПриложить лёд к губам и пересмотреть состояние утром
4. DДать следующую дозу раньше, это быстро уменьшит отёк

Which statement about the PSA blood test is correct?

1. AIt can be raised by benign problems as well as by cancer
2. BA normal result always rules out any prostate cancer
3. CIt is only raised in women with bladder cancer
4. DA raised result always means prostate cancer

A patient with gastroparesis has hypos soon after their meal-time insulin, then high glucose several hours later. What is the best explanation?

1. AFood is absorbed slowly, so the insulin peaks before the glucose rises
2. BThe patient is secretly eating sweets between meals
3. CThe meter gives false results for several hours after every meal
4. DThe insulin has gone off and needs replacing

Какие оценки у постели используют для наблюдения за асцитом?

1. AПиковая скорость выдоха и сатурация кислорода
2. BКапиллярная глюкоза перед каждым приёмом пищи
3. CРазмер зрачков и реакция дважды в день
4. DЕжедневная масса тела и окружность живота

Какая стратегия инфузионной терапии обычно рекомендуется в первые часы острого панкреатита?

1. AОчень большие объёмы независимо от ответа пациента
2. BЦеленаправленный сбалансированный кристаллоид с ориентиром на ответ
3. CТолько внутривенный альбумин вместо любого кристаллоида
4. DНикаких внутривенных жидкостей, только небольшие глотки воды