Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Какую задачу RN наиболее уместно делегировать LPN/LVN?

1. AУстановку постоянного мочевого катетера стабильному пациенту
2. BОбучение при выписке пациента, которому только что начали инсулин
3. CПроведение оценки нового пациента при поступлении
4. DНачало переливания первой дозы эритроцитов

При катастрофе с очень ограниченными ресурсами пострадавшего с тяжёлыми ожогами почти всего тела помечают чёрным. Какой принцип объясняет это решение?

1. AЛечить пострадавших в порядке прибытия
2. BПринести наибольшую пользу наибольшему числу людей
3. CЛечить сначала самых молодых пострадавших
4. DЛечить сначала самого тяжелораненого

How does a nurse add a sterile gauze pack to a sterile field that is already set up?

1. APlace the whole wrapped pack on the field and open it there with sterile gloves
2. BTip the item onto the field and push it into place with the wrapper
3. CReach across the field with clean gloves to place the item
4. DOpen the wrapper away from the field and drop the item on it without reaching over

An audit shows poor hand hygiene compliance on a ward. Which plan is most likely to improve it?

1. ARemoving all sinks so staff must use hand rub
2. BDisciplining staff who are seen not cleaning their hands, with no other change
3. CA combined approach with education, hand rub at every bedside, regular audits and feedback
4. DA single poster about hand hygiene placed in the staff room

Число лейкоцитов у пациента 16 × 10³/µL с высокой долей незрелых нейтрофилов (палочкоядерных). На что это, скорее всего, указывает?

1. AНа нормальный результат
2. BНа железодефицитную анемию
3. CТолько на хроническое вирусное заболевание
4. DНа острую бактериальную инфекцию

Which cerebrospinal fluid (CSF) pattern most strongly suggests bacterial meningitis?

1. AClear fluid, high glucose, low protein, many red cells
2. BCloudy fluid, low glucose, high protein, many neutrophils
3. CClear fluid, normal glucose, normal protein, no white cells
4. DClear fluid, normal glucose, mildly raised protein, lymphocytes

A patient is having a 12-lead ECG. Where are the chest electrodes placed?

1. AIn a straight line down the centre of the sternum from top to bottom
2. BOn both shoulders and both hips only
3. CIn standard numbered positions across the front and left of the chest
4. DAnywhere on the chest where the skin is clear

Вскоре после начала трансфузии у пациента появились одышка, свистящее дыхание, гипотензия и отёк лица. Что медсестра должна сделать в первую очередь?

1. AОстановить трансфузию, сохранить внутривенный доступ и срочно вызвать помощь
2. BБыстро перелить дозу до конца, чтобы как можно сильнее сократить время воздействия
3. CЗамедлить скорость трансфузии и перепроверить показатели через час
4. DДать парацетамол и антигистаминный препарат и продолжить трансфузию

A peripheral cannula site is red, warm, tender and swollen along the vein. What should the nurse do?

1. ACover the site and keep using it until it blocks
2. BRemove the cannula, document and monitor the site
3. CFlush the cannula hard to clear it
4. DLeave it in place, as this is normal after 24 hours

During a cardiac arrest, the monitor shows an organised rhythm, but there is no pulse. What should the team do?

1. AContinue CPR and give adrenaline (epinephrine), as the rhythm is non-shockable
2. BStop CPR, because an organised rhythm on the monitor means recovery
3. CGive adenosine to slow the rhythm down
4. DDeliver an unsynchronised shock at once and then check the pulse

A patient is due a rapid-acting insulin dose before lunch, but the meal trays are delayed. What should the nurse do?

1. AGive the insulin now and the meal when it comes
2. BGive the insulin with a glass of water instead
3. COmit the dose entirely for the rest of the day
4. DWait to give the insulin until the meal arrives

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

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

How can low-dose opioids help a patient with breathlessness from advanced cancer?

1. AThey cure the underlying lung disease
2. BThey increase the oxygen level in the blood
3. CThey open the airways like an inhaler
4. DThey reduce the feeling of breathlessness

An hour after a line flush, a patient receiving parenteral nutrition has rigors and a temperature of 39,1 °C. What should the nurse suspect and do?

1. AA normal reaction; give paracetamol and continue the infusion
2. BLine infection; escalate and take blood cultures
3. CFluid overload; reduce the infusion rate only
4. DLow blood glucose; give a sugary drink