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 admitted with a stroke this morning asks for a glass of water. What should the nurse do first?

1. AGive the water through a straw so it goes down slowly
2. BGive thickened fluids without checking the swallow
3. CAsk the family to help the patient drink while sitting upright in a chair at the bedside
4. DCheck that a swallow screen has been done before giving anything by mouth

Библиотека препаратов инфузионного насоса предупреждает, что запрограммированная доза выше безопасного предела. Что должна сделать медсестра?

1. AПроигнорировать сигнал, потому что сигналы насосов часто ошибочны
2. BОтключить библиотеку препаратов для этой инфузии
3. CПродолжить инфузию и перепроверить насос в конце смены
4. DСначала перепроверить назначение, расчёт и настройки насоса

Медсестра дала лекарство не тому пациенту. Пациент выглядит хорошо. Что приоритетно?

1. AПрежде всего заполнить отчёт об инциденте
2. BНичего не говорить пациенту, чтобы не волновать его
3. CПодождать до конца смены, прежде чем кому-либо сообщить
4. DОценить состояние пациента и наблюдать за действием препарата

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. BA laboratory error in the first sample
3. CDilution of the blood by the IV fluid
4. DIncreased red cell production

A patient with sepsis has the following new results. Which set best shows organ dysfunction?

1. APlatelets 70 × 10³/µL, creatinine doubled, bilirubin raised
2. BCalcium 9,4 mg/dL, phosphate 3,5 mg/dL, magnesium 1,9 mEq/L
3. CWBC 11,5 × 10³/µL, potassium 4,2 mEq/L, albumin 3,8 g/dL
4. DHemoglobin 12,5 g/dL, sodium 138 mEq/L, glucose 105 mg/dL

Which oxygen device delivers a precise, fixed concentration of oxygen?

1. ANasal cannula
2. BNon-rebreathe mask
3. CVenturi mask
4. DSimple face mask

An older man has sudden severe abdominal and back pain, is hypotensive and has a pulsating mass in the abdomen. What should be suspected?

1. AA ruptured abdominal aortic aneurysm
2. BRenal colic from a kidney stone
3. CAcute gastritis from anti-inflammatory drugs
4. DMusculoskeletal back pain

A patient who had a leg amputation says they feel burning pain in the missing foot. What is the best response?

1. AExplain that phantom limb pain is real and arrange treatment
2. BAdvise that it will be ignored until it stops
3. CExplain that burning pain in the missing foot shows wound infection
4. DTell the patient the pain must be imaginary as the foot has gone

Медсестра планирует уход за четырьмя пациентами. Какого пациента нужно осмотреть первым?

1. AПациента со стабильной сердечной недостаточностью, ожидающего ежедневного взвешивания
2. BПациента с контролируемой гипертонией, спрашивающего о соли
3. CПациента с ХОБЛ, у которого SpO₂ упала с 90% до 83% и появилась новая сонливость
4. DПациента с венозной язвой, которому пора менять повязку

A patient taking sodium valproate becomes tired and is vomiting, and the nurse notices yellowing of the eyes. What is the main concern?

1. ADehydration from drinking too little
2. BLiver toxicity from valproate
3. CA sign that the dose is too low
4. DA normal adjustment reaction to the drug

A patient on insulin has worsening chronic kidney disease and is having more hypos. What is the best explanation?

1. AThe patient is eating far more carbohydrate than before
2. BKidney disease makes the body resistant to insulin
3. CKidney disease makes the meter read too low
4. DThe kidneys clear less insulin, so it lasts longer

How is an uncomplicated sigmoid volvulus often first treated?

1. AHigh-dose laxatives taken by mouth
2. BEating a large high-fibre meal
3. CA barium meal given by mouth to untwist the bowel slowly
4. DDecompression with a flexible sigmoidoscope and flatus tube

After signing the consent form, a patient tells the nurse, "I don't really understand what they are going to do." What should the nurse do?

1. AExplain the surgical risks in detail without involving the surgeon
2. BInform the surgeon so that the procedure can be explained again
3. CIgnore the comment because the form is already signed
4. DReassure the patient that the surgeon knows best