Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient with a head injury is being monitored. Which set of findings suggests rising intracranial pressure?

1. ANormal blood pressure, normal pulse and clear speech
2. BLow temperature, fast breathing and a strong appetite
3. CFalling blood pressure, a fast pulse and warm, flushed dry skin
4. DRising systolic pressure, slow pulse and irregular breathing

After handover on a medical unit, which patient should the nurse see first?

1. APneumonia on 2 L/min oxygen, SpO₂ 93%, talking in full sentences
2. BDay 2 after a hernia repair, pain 6/10, oral analgesic due in 20 minutes, wants it now
3. CNew atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
4. DDeep vein thrombosis on a heparin infusion, aPTT in the target range

A patient has highly contagious viral conjunctivitis. Which teaching is most important?

1. AWash hands often and do not share towels, pillows or eye drops
2. BWear a surgical mask whenever someone else is in the room
3. CKeep using the same contact lenses to protect the eyes
4. DRub the eyes gently to remove the discharge

Who should mark the operative site before surgery?

1. AAny member of the operating room team after anesthesia starts
2. BThe person who will perform the procedure, with the patient involved where possible
3. CThe patient, alone, using a marker pen at home on the night before surgery
4. DThe admitting clerk, using the information written on the consent form

A patient on peritoneal dialysis notices that the drained fluid is cloudy and has abdominal pain. What should the nurse do?

1. AAdd more glucose to the next bag to clear the fluid
2. BSend the fluid for cell count and culture and report it
3. CStop dialysis for a week and recheck the fluid later
4. DRecord it as normal and continue the usual exchanges

После химиотерапии быстрорастущей лимфомы какая картина результатов указывает на синдром лизиса опухоли?

1. AТолько высокий натрий и низкая глюкоза
2. BНизкий калий, низкий фосфат, низкая мочевая кислота и повышенный кальций
3. CНормальные электролиты с высоким гемоглобином
4. DВысокий калий, высокий фосфат, высокая мочевая кислота и низкий кальций

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. BFalling urine output, new ankle swelling and a rise in weight
3. CIncreased urine output, less breathlessness and a falling weight
4. DA rise in weight and more lung crackles

A patient with a possible neck injury after a fall needs their airway opened. Which manoeuvre is preferred?

1. AJaw thrust
2. BTurning the head to one side
3. CHyperextending the neck
4. DHead tilt with chin lift

A patient taking simvastatin drinks a large glass of grapefruit juice every morning. Why is this a concern?

1. AIt stops the statin from being absorbed from the gut at all
2. BIt raises statin levels and the risk of muscle damage
3. CIt turns the statin into a blood thinner
4. DIt causes the cholesterol level to rise sharply

Why is the cuff pressure of an endotracheal or tracheostomy tube checked regularly?

1. AToo high a pressure damages the trachea; too low allows aspiration
2. BThe cuff pressure directly controls the patient's oxygen saturation
3. CThe cuff must be kept fully deflated in every ventilated patient
4. DThe cuff pressure sets the ventilator's breathing rate

A patient on peritoneal dialysis has gained weight and has higher glucose levels. Which part of the treatment is the likely cause?

1. AProtein lost into the dialysis fluid
2. BAir entering the abdomen during exchanges
3. CGlucose absorbed from the dialysis fluid
4. DSodium lost into the dialysis fluid

A patient with an insulin pump is admitted with nausea, a glucose of 19 mmol/L (342 mg/dL) and blood ketones of 3,1 mmol/L. What is the priority?

1. ADisconnect the pump and give no insulin until the ketones clear
2. BSuspect failed insulin delivery and give insulin by another route
3. CIncrease the pump rate and recheck the ketones in 12 hours
4. DGive an antiemetic only, because nausea is causing the high glucose

Что часто является самым ранним признаком злокачественной гипертермии во время анестезии?

1. AПостоянное снижение температуры тела
2. BПокраснение кожи с падающим уровнем CO₂
3. CНеобъяснимый рост CO₂ в конце выдоха
4. DЗамедление пульса и низкое артериальное давление

During bowel preparation, an older patient becomes dizzy and confused. Blood tests show sodium 127 mmol/L. What should the nurse do?

1. AGive the rest of the preparation more quickly
2. BEncourage plain water only, as much as possible
3. CStop the preparation and escalate to the medical team
4. DRecord it and continue as planned, as this is expected