Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Which patient is at the highest risk of falling?

1. AA 45-year-old with asthma who is alert and independent
2. BA 60-year-old admitted for chest pain that has since been ruled out by tests
3. CA 30-year-old after an appendectomy who walks with steady steps
4. DAn 84-year-old taking a diuretic who has fallen before and gets up at night

A patient receiving comfort-focused end-of-life care is distressed by breathlessness. Which approach is most appropriate?

1. AStart a series of aggressive tests to find the exact cause of the breathlessness
2. BWithhold all opioids because they may slow breathing
3. CGive prescribed opioids and use positioning and a fan to relieve breathlessness
4. DLeave the patient alone so they can rest

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

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

A patient sitting in a chair starts to have a generalized seizure. What should the nurse do?

1. ALeave to get the provider, then return
2. BPut a padded tongue blade between the teeth to protect the tongue and airway
3. CEase the patient to the floor, protect the head and turn them on their side
4. DHold the patient firmly in the chair until the seizure stops

A patient on a heparin infusion has an aPTT below the target range on the protocol. What should the nurse do?

1. AAdjust the rate as the protocol directs and recheck as scheduled
2. BStop the infusion and give protamine sulfate as quickly as possible
3. CContinue the same rate and recheck the aPTT in a few days
4. DSwitch the infusion to oral warfarin without a prescription

После операции у пациента, получающего большие объёмы гипотонического внутривенного раствора, появляются головная боль, тошнота и спутанность. Какой результат лучше всего это объясняет?

1. AКальций 9,4 mg/dL (2,35 mmol/L)
2. BКалий 4,2 mEq/L
3. CНатрий 126 mEq/L
4. DГлюкоза 110 mg/dL (6,1 mmol/L)

A patient receives IV furosemide for fluid overload. Which findings show the treatment is working?

1. AA rise in blood pressure and a new cough
2. BIncreased urine output, less breathlessness and a falling weight
3. CA rise in weight and more lung crackles
4. DFalling urine output, new ankle swelling and a rise in weight

Пациент, длительно принимающий стероиды, после рвоты и пропуска доз находится в остром тяжёлом состоянии с гипотензией и спутанностью сознания. Какое неотложное состояние следует рассмотреть?

1. AНесахарный диабет
2. BТиреотоксический криз
3. CГиперкальциемию
4. DНадпочечниковый криз

Why are IV fluids given cautiously to a patient with heart failure?

1. AIV fluids lower the blood pressure dangerously
2. BIV fluids directly damage the heart valves
3. CExtra volume can quickly cause pulmonary oedema
4. DIV fluids stop diuretics from being absorbed

After a fall onto the chest, part of a patient's chest wall moves inward when they breathe in and outward when they breathe out. What does this indicate?

1. AA flail chest from ribs broken in more than one place
2. BA large pleural effusion pressing on the chest wall
3. CA single simple rib fracture with no lung injury
4. DNormal chest movement caused by pain on breathing

Why is propranolol given to a patient with hyperthyroidism?

1. ATo ease tremor and palpitations while other treatment starts
2. BTo destroy overactive thyroid tissue over a few weeks
3. CTo stop the thyroid gland from making any more hormones
4. DTo replace the hormone lost from the thyroid gland

A patient taking amiodarone has gained weight and feels tired and cold. Which blood test is most relevant?

1. ASerum ferritin
2. BBlood alcohol level
3. CSerum amylase and lipase levels
4. DThyroid function tests

Почему пациентов учат поддерживать рану на животе подушкой при кашле?

1. AЭто заменяет необходимость регулярного обезболивания
2. BЭто ускоряет заживление краёв кожи
3. CЭто уменьшает боль и напряжение, и они могут хорошо откашляться
4. DЭто ослабляет кашель, чтобы не подвергать рану риску

At the end of an operation, the final count shows one swab missing. What should happen?

1. ARecord the count as correct to avoid a delay
2. BClose the wound, as the swab was probably thrown away
3. CTell the surgeon, search, and X-ray if it is not found
4. DLet the patient leave and search the theatre later