Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A nurse teaches a patient to use an incentive spirometer. Which statement shows a need for further teaching?

1. A“I will use it several times every hour while awake.”
2. B“I will try to hold my breath for a few seconds at the top.”
3. C“I will blow into it as hard and fast as I can.”
4. D“I will breathe in slowly and deeply through the mouthpiece.”

After a head injury, a patient has clear fluid dripping from the nose. Which action should the nurse avoid?

1. APlacing a loose gauze under the nose
2. BInforming the provider about the drainage
3. CInserting a tube or suction catheter through the nose
4. DChecking the fluid for glucose or a halo sign on gauze

How should a nurse handle soiled bed linen?

1. AHold it away from the uniform and place it straight into a linen bag
2. BPut it on the floor until the bed is made
3. CShake it out first to check for lost items
4. DCarry it bundled against the body to the soiled utility room down the hall

A nurse teaches a patient about home oxygen safety. Which statement shows a need for further teaching?

1. A“I will keep my oxygen away from the stove.”
2. B“I can light candles at dinner if my oxygen is turned down low.”
3. C“I will keep my spare cylinders upright and secured.”
4. D“I will put a ‘no smoking’ sign on my front door for visitors.”

A nurse completed the hepatitis B vaccine series. Which result shows protective immunity?

1. AAnti-HBs of 10 mIU/mL or more
2. BA positive IgM anti-HBc
3. CA raised ALT level
4. DA positive HBsAg test

A young woman with frequent self-induced vomiting has swollen salivary glands. Which laboratory pattern is most likely?

1. AHigh potassium, low bicarbonate and low amylase
2. BLow sodium, low bicarbonate and high lipase
3. CHigh calcium, high phosphate and high glucose
4. DLow potassium, high bicarbonate and high amylase

Пациент с сердечной недостаточностью прибавил 2 кг за два дня. Что это вероятнее всего означает?

1. AУспешное лечение
2. BРост мышечной массы
3. CЗадержку жидкости
4. DОбезвоживание

A patient with hyperkalaemia is given IV insulin with glucose. What is the purpose, and what must be monitored?

1. ATo remove potassium from the body; urine output must be stopped for a time
2. BTo shift potassium into cells; blood glucose must be monitored for hypoglycaemia
3. CTo treat hidden diabetes; HbA1c must be checked daily
4. DTo protect the heart muscle directly; the patient must be kept nil by mouth

A patient on furosemide has a serum potassium of 3,0 mmol/L (3,0 mEq/L). Which symptoms may this cause?

1. AMuscle weakness, cramps and an irregular pulse
2. BTingling around the lips and painful spasm of the hands
3. CSevere headache and a stiff neck
4. DFacial flushing, fever and a skin rash

У пациента, принимающего дабигатран, тяжёлое желудочно-кишечное кровотечение. Какой специфический антидот можно использовать?

1. AИдаруцизумаб
2. BПротамина сульфат
3. CТолько транексамовую кислоту
4. DФитоменадион (витамин K)

A routine blood test shows a potassium of 6,4 mmol/L. The lab reports that the sample was haemolysed. The patient feels well. What should the nurse do?

1. AIgnore it, because haemolysis always gives a normal result
2. BGive oral potassium supplements straight away
3. CInform the doctor and arrange an urgent repeat sample
4. DStart dialysis as soon as possible

Three days after a stroke, a patient with dysphagia on a modified diet has a temperature of 38,2 °C (100,8 °F), a respiratory rate of 24/min and crackles at the right lung base. What should the nurse do?

1. ASuspect aspiration pneumonia, stop oral intake and escalate for review
2. BEncourage more fluids by mouth to treat the fever
3. CGive paracetamol (acetaminophen) and continue the modified diet as before
4. DRecord the findings and recheck them at the next routine observation

Which task for a stable patient with an established ileostomy can usually be delegated to a trained healthcare assistant (nursing assistant)?

1. ADeciding whether IV fluids are needed
2. BEmptying the pouch and measuring the output
3. CAssessing the stoma for signs of necrosis
4. DTeaching the patient about high-output risks

A patient with lung cancer becomes hypotensive and breathless, with distended neck veins and quiet heart sounds. What should the nurse suspect?

1. ACardiac tamponade from a pericardial effusion
2. BHypercalcaemia of malignancy from bone metastases
3. CA side effect of anti-sickness drugs
4. DSuperior vena cava obstruction from the tumour