Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

В смешанном терапевтическом отделении какого пациента медсестре следует осмотреть первым?

1. AПациента с лёгкой головной болью напряжения, просящего ацетаминофен
2. BПациента с депрессией, раздавшего свои вещи и имеющего план самоубийства
3. CПациента, просящего письменную информацию о завтрашней выписке
4. DПациента с гипертонией, у которого давление 136/84 mmHg

A marathon runner is confused, with a temperature of 41 °C and hot skin. What is the priority?

1. AWrapping the runner in a blanket to prevent shivering
2. BAsking the runner to rest in the shade and drink slowly
3. CRapid cooling while supporting airway and circulation
4. DGiving an antipyretic tablet and waiting for it to work

How should a newborn be moved through hospital corridors?

1. ACarried in the nurse’s arms for comfort
2. BIn a bassinet, not carried in the arms
3. CIn the arms of any visitor who offers to help
4. DOn the mother’s lap in a wheelchair, without staff

A nurse teaches new parents about safe infant sleep. Which statement shows a need for further teaching?

1. A“We will put a soft bumper pad and a blanket in the crib so the baby is cozy.”
2. B“We will not smoke near the baby.”
3. C“We will lay the baby on the back for every sleep, including naps.”
4. D“We will keep the crib in our room, next to our bed, for the first months.”

A patient with suspected pulmonary TB needs sputum samples for acid-fast bacilli. Which instruction is correct?

1. AGive several deep-cough samples, often first thing in the morning
2. BGive one sample of saliva collected from the mouth at any time of day
3. CGive several samples of nasal mucus blown into a tissue
4. DGive one sample after brushing with mouthwash so it is clean

A patient on a stable dose of levothyroxine now has a TSH of 9,8 mIU/L. She recently started taking her calcium and iron supplements with her morning levothyroxine. What is the most likely explanation?

1. AThe supplements are causing an overactive thyroid gland
2. BThe TSH is low, showing that the dose is now too high
3. CThe result is normal for a person on levothyroxine therapy
4. DThe supplements are reducing levothyroxine absorption

What is the most common cause of hypernatraemia in frail older inpatients?

1. ATaking too many vitamins
2. BToo much exercise
3. CEating too much salt in one meal
4. DNot drinking enough water

У пациента после большой операции снижается давление, растёт ЧСС, живот вздут и напряжён, хотя повязка на ране сухая. Что следует заподозрить?

1. AНормальный послеоперационный отёк, не вызывающий опасений
2. BИнфекцию мочевыводящих путей
3. CВнутреннее кровотечение
4. DЗапор

A patient with a mechanical heart valve asks to switch from warfarin to apixaban. What is the correct response?

1. AAspirin alone can replace warfarin once the valve has healed
2. BMechanical valves do not need anticoagulation after the first month
3. CDirect oral anticoagulants are not used for mechanical valves
4. DAny anticoagulant works equally well once the valve is in place

As the defibrillator charges, a nurse sees a colleague still holding the patient's bed rail. What should the nurse do?

1. ADeliver the shock now, as the bed rail is not part of the patient
2. BTurn off the defibrillator and start a new cycle of CPR
3. CCall clearly for everyone to stand clear and check before the shock
4. DAsk the colleague to hold the patient's hand instead

A patient has Cushing's syndrome. Which nursing assessment is especially important?

1. AMonitoring for a high potassium
2. BWatching for weight loss
3. CChecking for low blood pressure
4. DRegular blood glucose checks

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. AA full bladder, so encourage oral fluids
2. BNormal constipation, so give a large meal to stimulate the bowel
3. CParalytic ileus, so keep nil by mouth and prepare for an NG tube
4. DAn allergic reaction to food, so give an antihistamine

Why might a patient's platelet count be monitored while they receive heparin?

1. ATo see whether the patient has an infection
2. BTo measure the heparin dose in the blood exactly
3. CTo detect heparin-induced thrombocytopenia
4. DTo check whether the heparin is causing anaemia

A 76-year-old with a past peptic ulcer needs long-term anti-inflammatory treatment for arthritis. Which plan best reduces GI bleeding risk?

1. AConsider an alternative; if an NSAID is needed, add a PPI
2. BTake the NSAID with a glass of milk instead of food
3. CUse the highest NSAID dose to shorten the course
4. DCombine two different NSAIDs at lower doses