Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient taking clozapine reports a sore throat and fever. What is the priority action?

1. AAdvise the patient to gargle with warm salt water and rest in bed
2. BHold the dose and report so the white cell count can be checked
3. CIncrease the dose because the symptoms suggest a relapse
4. DOffer throat lozenges and continue the usual dose

Two hours after a femoral cardiac catheterization, the nurse sees blood spreading from the puncture site. What is the first action?

1. ARaise the head of the bed so the patient can sit up
2. BRemove the dressing and leave the site open to the air
3. CApply firm, direct pressure just above the puncture site
4. DAsk the patient to bend the leg at the hip to stop the bleeding

A nurse pours sterile saline into a bowl on a sterile field. Which technique is correct?

1. ARest the lip of the bottle on the edge of the bowl so that the saline does not splash
2. BPour from below the level of the field to reduce splashing
3. CHold the bottle with the label in the palm and pour without touching the bowl
4. DReach across the field to fill the bowl at the far side

Minutes after the first IV dose of an antibiotic starts, the patient develops wheezing, hives and low blood pressure. What should the nurse do first?

1. ASlow the infusion rate
2. BGive an oral antihistamine
3. CStop the infusion
4. DRecord the new allergy in the chart

A patient takes high-dose furosemide. Besides potassium, which electrolyte is most commonly lowered?

1. APhosphate
2. BMagnesium
3. CSodium bicarbonate
4. DUric acid

A patient with a stable INR on warfarin starts rifampin (rifampicin) for tuberculosis. Two weeks later the INR is 1,3. What is the most likely explanation?

1. ARifampin raises the INR, so it is wrong
2. BTuberculosis causes the INR to fall
3. CRifampin contains a lot of vitamin K
4. DRifampin speeds up warfarin metabolism

Why is oxygen often humidified for a patient with a tracheostomy?

1. AHumidification lowers the oxygen concentration to a safer level
2. BThe tube bypasses the nose, which normally warms and moistens air
3. CHumidity is needed for the oxygen to work as a drug
4. DDry oxygen causes high blood glucose

A patient with several days of vomiting and diarrhoea has low blood pressure, low urine output and a rising creatinine. Which description fits best?

1. APre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
2. BChronic kidney disease, treated with long-term dialysis three times a week
3. CIntrinsic kidney injury from glomerulonephritis, treated with high-dose steroids
4. DPost-renal acute kidney injury from obstruction, treated with a catheter

Why is a higher level of HDL cholesterol considered protective?

1. AHDL carries cholesterol from the tissues back to the liver
2. BHDL thins the blood in the same way as an anticoagulant
3. CHDL lowers the blood pressure directly
4. DHDL is converted into vitamin D in the walls of the arteries

Пациент с ХОБЛ на маске Вентури 28% (SpO₂ 90%) хочет поесть. Какой план наиболее уместен?

1. AОставить маску Вентури и давать только жидкости через соломинку
2. BПерейти на носовую канюлю с низким потоком, поддерживая SpO₂ 88–92%
3. CСнять весь кислород на время еды и надеть снова после
4. DПерейти на маску без повторного дыхания 15 L/min на время еды

A patient with a suspected basal skull fracture needs a gastric tube. Which route is preferred?

1. AThrough a fine-bore nasal tube
2. BThrough the nose (nasogastric)
3. CThrough the nose with a guidewire
4. DThrough the mouth (orogastric)

During haemodialysis, a patient suddenly becomes breathless with chest pain, and air is seen in the line. What should the nurse do first?

1. ASpeed up the pump to clear the air into the patient
2. BContinue the session and recheck in 30 minutes
3. CSit the patient upright and give a drink of water
4. DClamp the lines and lay the patient left side down, head low

Какая область используется для быстрой оценки 1% площади поверхности тела при небольших или разбросанных ожогах?

1. AЛадонь пациента вместе с пальцами
2. BКисть и предплечье пациента
3. CЛадонь осматривающего вместе с пальцами
4. DНоготь большого пальца пациента

On day 5 after bowel resection, a patient has a fever, tachycardia and worsening abdominal pain, and the drain contains brown, faeculent fluid. What is most likely?

1. AA normal day 5 recovery
2. BAn anastomotic leak
3. CPostoperative constipation
4. DA urinary tract infection