Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

An Rh-negative mother has just given birth to an Rh-positive baby. What does the nurse expect to give the mother?

1. ANo treatment is needed
2. BRh immunoglobulin within 72 hours
3. CVitamin K to the mother
4. DA dose of the hepatitis B vaccine instead

During an infusion of a thrombolytic drug for stroke, the patient develops a severe headache and starts vomiting. What should the nurse do first?

1. AContinue the infusion, because headache is expected
2. BStop the infusion and inform the provider at once
3. CGive a dose of aspirin for the headache
4. DSlow the infusion and give an antiemetic as prescribed

A patient in bed has a generalized tonic-clonic seizure. What should the nurse do?

1. AHold the arms and legs firmly to stop the movements
2. BTurn the patient on their side and protect them from injury without restraining
3. CPut a padded tongue blade between the teeth to protect the tongue from biting
4. DGive sips of water to keep the airway moist

A nurse has just started a unit of red blood cells when a colleague asks for urgent help with another patient. What is the best action?

1. ALeave to help the other patient, and check the transfusion again in about an hour
2. BStay with the transfusing patient for the first 15 minutes and ask another nurse to help
3. CPause the transfusion until the nurse is free again
4. DSpeed up the transfusion so it finishes sooner

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

1. AMagnesium
2. BPhosphate
3. CSodium bicarbonate
4. DUric acid

A woman who is 34 weeks pregnant has high blood pressure, right upper abdominal pain, a platelet count of 70 × 10³/µL, raised ALT and AST, and a raised LDH. Which condition fits best?

1. AHELLP syndrome
2. BPhysiologic anemia of pregnancy
3. CAcute cholecystitis
4. DGestational diabetes

A patient with Guillain–Barré syndrome has weakness spreading upwards from the legs. Which monitoring is most important?

1. AWeekly weight
2. BBreathing function, such as forced vital capacity
3. CVisual acuity
4. DBlood glucose, measured once a day before breakfast

A patient has a single hot, swollen, very painful knee and a fever. Why is urgent joint aspiration important?

1. ATo rule out septic arthritis, which can rapidly destroy the joint
2. BTo measure the patient's cholesterol
3. CTo prevent osteoporosis
4. DTo check for rheumatoid arthritis antibodies in the joint fluid

У пациента с заболеванием периферических артерий ночью болят ноги. Какое положение может облегчить боль?

1. AОбернуть ноги компрессионными бинтами
2. BПриложить грелку непосредственно к стопам
3. CСвесить ноги с края кровати
4. DПоднять ноги на подушках выше уровня сердца

After a car crash, a patient is severely breathless with absent breath sounds on the right, a deviated trachea, distended neck veins and BP 76/40 mmHg. What is the immediate management?

1. AUrgent needle or finger decompression of the right chest
2. BInsertion of a urinary catheter to monitor output
3. CLying the patient flat with the legs raised
4. DA chest X-ray to confirm the diagnosis before any treatment

A patient with Alzheimer's disease starts donepezil. Which side effects should the nurse look for?

1. ANausea, diarrhoea and a slow heart rate
2. BWeight gain, high glucose and swollen ankles
3. CA persistent dry cough and a raised potassium
4. DDry mouth, constipation and a fast heart rate

A patient with myasthenia gravis took extra pyridostigmine doses. They now have more weakness, heavy salivation, sweating, diarrhoea, small pupils and a slow pulse. What is most likely?

1. AA normal response to a higher dose
2. BA myasthenic crisis from too little medication
3. CAn allergic reaction to the drug
4. DA cholinergic crisis from too much medication

Which liver function test pattern suggests bile duct obstruction?

1. AHigh bilirubin with a markedly raised ALP and GGT
2. BA low albumin with all other results normal
3. CVery high ALT with a normal bilirubin only
4. DNormal bilirubin with a low ALP and low GGT

A patient with a PICC line develops swelling and aching of the same arm and prominent veins on the chest. What should the nurse suspect?

1. ALymphoedema from a previous operation
2. BA catheter-related deep vein thrombosis
3. CAn allergy to the dressing
4. DNormal swelling after line insertion