Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient had a colostomy formed yesterday. Which stoma appearance should be reported straight away?

1. ADark purple or black
2. BSlightly swollen
3. CMoist and pink-red
4. DA little bleeding when cleaned

An infant is choking and cannot cry or breathe. Which technique is correct?

1. AAbdominal thrusts, as in adults
2. BA blind finger sweep of the mouth
3. CHolding the infant upside down by the feet
4. DBack blows and chest thrusts

A patient is receiving opioids for pain. Which sign usually comes before opioid-induced respiratory depression?

1. AIncreasing sedation
2. BDilated pupils
3. CDiarrhea
4. DRising blood pressure

Patients contaminated with radioactive dust arrive at the hospital. Which step removes most of the external contamination?

1. AGiving the patient potassium iodide
2. BWrapping the patient in a blanket
3. CRemoving the patient’s clothing
4. DScrubbing the skin until it is red

A woman who is 30 weeks pregnant has a new blood pressure of 152/98 mm Hg. Which urine finding would most support preeclampsia?

1. AGlucose in the urine
2. BKetones in the urine
3. CNitrites in the urine
4. DProtein in the urine

У пациента на тиазидном диуретике натрий 129 mEq/L, калий 3,2 mEq/L, он чувствует слабость. Какое объяснение подходит лучше всего?

1. AРезультаты типичны для почечной недостаточности
2. BУ пациента первичный гиперальдостеронизм с высоким натрием
3. CУ пациента гипергидратация только из-за внутривенных жидкостей
4. DДиуретик вызывает потерю натрия и калия

Why are patients encouraged to use an incentive spirometer after abdominal surgery?

1. ATo strengthen the abdominal muscles around the wound
2. BTo encourage deep breaths that prevent atelectasis and chest infection
3. CTo lower their heart rate before mobilising
4. DTo measure their lung function so the result can go in the discharge letter

A patient with a central venous catheter develops fever and rigors shortly after the line is flushed, with no other obvious source. What should be suspected?

1. ANormal response to line use
2. BA pulmonary embolism
3. CAn allergic reaction to the saline flush
4. DA catheter-related bloodstream infection

Какой совет помогает предотвратить тромбоз глубоких вен при длительном перелёте или после операции?

1. AРегулярно выполнять упражнения для голеностопа и пить достаточно жидкости
2. BМеньше пить, чтобы не вставать в туалет
3. CНосить тугие эластичные ленты чуть ниже колена
4. DСидеть, закинув ногу на ногу, для удобства

A nurse teaches a patient with heart failure who takes ramipril and spironolactone. Which statement shows a need for further teaching?

1. A"I will use a salt substitute instead of ordinary salt."
2. B"I will weigh myself every morning after I go to the toilet."
3. C"I will call if I gain weight quickly or get more breathless."
4. D"I will avoid ibuprofen for my joint pain."

A patient with untreated hyperthyroidism is losing weight. Which diet is most appropriate until the condition is controlled?

1. AA diet very high in caffeine for energy
2. BA low-calorie diet to protect the heart
3. CA high-calorie diet with enough protein
4. DA strict low-protein diet

A large pituitary tumour presses on the optic chiasm. Which visual field defect is most typical?

1. ALoss of the inner half of the field in both eyes
2. BComplete blindness in one eye only
3. CLoss of central vision in both eyes
4. DLoss of the outer half of the field in both eyes

Какая фаза заживления ран включает образование грануляционной ткани и новых кровеносных сосудов?

1. AФаза гемостаза (свёртывания)
2. BВоспалительная фаза
3. CФаза созревания
4. DПролиферативная фаза

A nurse teaches a patient going home between chemotherapy cycles. Which statement shows a need for further teaching?

1. A"I'll wash my hands often and avoid people with infections."
2. B"If I get a fever, I'll take paracetamol and see if it settles."
3. C"I'll keep the emergency number and call if I feel shivery."
4. D"I'll check my temperature whenever I feel hot, shivery or unwell."