Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Какого пациента медсестре следует осмотреть первым?

1. AПациента с новой невнятной речью и опущением лица, начавшимися 30 минут назад
2. BПациента с хронической болезнью почек, которому завтра предстоит диализ
3. CПациента с давним ревматоидным артритом и обычной утренней скованностью суставов
4. DПациента с диабетом 2 типа, спрашивающего о диете

При триаже START неходячий взрослый дышит 28 раз в минуту, лучевого пульса нет, капиллярное наполнение 4 секунды. В какую категорию он попадает?

1. AЗелёная (лёгкие)
2. BЧёрная (безнадёжные)
3. CКрасная (немедленная помощь)
4. DЖёлтая (отсроченная помощь), так как частота дыхания ниже 30/мин

Why are some patients screened with a nasal swab for MRSA on admission?

1. ATo find carriers so precautions or decolonization can be used
2. BTo check whether the patient is allergic to penicillin before surgery
3. CTo measure the patient’s immunity to MRSA
4. DTo diagnose a sinus infection

A patient on long-term high-dose corticosteroids asks for the nasal spray influenza vaccine. What should the nurse explain?

1. AEither type is fine, as long as it is given in the morning
2. BPeople on steroids should never have any influenza vaccine
3. CThe nasal spray is the best choice for people on steroids, because it is not injected
4. DThe nasal spray is a live vaccine, so the injected inactivated vaccine is used instead

A young adult with new diabetes has a very low C-peptide level. What does this suggest?

1. AThe kidneys are excreting all of the patient's insulin in urine
2. BThe pancreas is making very little insulin, as in type 1 diabetes
3. CThe patient has high insulin resistance, as in type 2 diabetes
4. DThe patient is injecting too much insulin and needs a lower dose

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. AIron-deficiency anemia
2. BAcute viral hepatitis
3. CPrimary hypothyroidism
4. DMultiple myeloma

A nurse gives a patient analgesia for post-operative pain. What should be done next?

1. AWait until the next shift before asking the patient about the pain
2. BGive a second analgesic straight away just in case
3. CAssume the pain has gone if the patient is quiet and has their eyes closed
4. DReassess the pain and any side effects once the drug has had time to work

Анализ крови пациента показывает калий 6,8 mmol/L, на ЭКГ — заострённые зубцы T. Какое лечение быстрее всего защищает сердце?

1. AПероральные препараты калия
2. BКальция глюконат внутривенно
3. CТолько диета с низким содержанием калия
4. DФуросемид в таблетках на следующий день

After an above-knee amputation, which measure helps prevent a hip flexion contracture?

1. ASitting in a chair for most of the day with the hips bent
2. BKeeping a pillow under the stump at all times, day and night
3. CKeeping the hip bent to reduce stump swelling
4. DLying prone for periods and avoiding pillows under the stump

On the first day after abdominal surgery, a patient has a temperature of 37,8 °C, SpO₂ 93% on air and reduced breath sounds at both bases. They have stayed in bed because of pain. What is the most likely cause and response?

1. AAtelectasis: give analgesia, deep breathing and mobilisation
2. BNormal recovery; no action is needed
3. CPulmonary oedema: restrict all oral fluids and give a diuretic
4. DWound infection: open the wound fully and swab it for culture

Why can a patient with an insulin pump develop DKA within hours if the pump stops working?

1. AThe pump gives only rapid-acting insulin, so there is no long-acting reserve
2. BThe body becomes allergic to insulin when the pump stops
3. CThe battery in the pump releases chemicals into the blood
4. DThe pump gives long-acting insulin, which builds up and stops working all at once

After a TURP, a patient on bladder irrigation has bladder spasms. The drainage has slowed and contains clots, and the bag holds less than the irrigant given. What should the nurse do first?

1. AEncourage the patient to strain to pass the clots
2. BTurn off the irrigation and leave the catheter alone
3. CSuspect a clot in the catheter and follow the protocol
4. DGive an antispasmodic and recheck in four hours

Пациент с илеальным кондуитом (уростомой) беспокоится из-за слизи в моче. Какое объяснение правильно?

1. AЭто означает, что стома не функционирует и нужна операция
2. BЭто показывает, что развивается непроходимость кишечника
3. CЭто нормально, так как кондуит сделан из тонкой кишки
4. DЭто признак камня в почке, и об этом нужно сообщить сегодня

A 62-year-old with known reflux reports burning central chest pain with sweating and breathlessness that began while walking. What should the nurse do first?

1. ARecord a 12-lead ECG and escalate as possible cardiac pain
2. BBook a routine endoscopy for later in the week
3. CAdvise the patient to avoid spicy food at future meals
4. DGive an antacid and reassess the pain in an hour