Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

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

1. A“My husband can smoke in my room if the window is open.”
2. B“I will not use oil-based creams on my face.”
3. C“I will keep the oxygen away from the gas stove.”
4. D“I will put up no-smoking signs at the front door and in my room.”

A nurse returns to the station to find four messages. Which one is answered first?

1. AA family member wants an update on their father’s progress
2. BThe pharmacy asks when the next delivery should be scheduled
3. CA colleague asks to swap shifts with them next week because of a family wedding
4. DThe laboratory is calling with a critical potassium result of 2,6 mEq/L

Which IV fluid can be given with packed red blood cells in the same line?

1. A0,9% sodium chloride
2. B5% dextrose in 0,45% sodium chloride
3. CLactated Ringer’s (Hartmann’s) solution
4. D5% dextrose in water

A small-bore feeding tube has just been inserted blindly at the bedside. Which method is the most reliable way to confirm its position before the first feeding?

1. ABy an x-ray reviewed by a competent clinician
2. BBy putting the end in water to look for bubbles
3. CBy listening over the stomach while injecting air
4. DBy checking that the patient can still talk

A patient taking spironolactone asks about using a salt substitute. What should the nurse explain?

1. ASalt substitutes are fine as long as the patient drinks more water
2. BSalt substitutes protect against the potassium loss caused by this drug
3. CMost salt substitutes contain potassium and can raise the level too high
4. DSalt substitutes are safe because they contain only sodium chloride

У пациента на внутривенной инфузии инсулина глюкоза крови 65 mg/dL (3,6 mmol/L). Какое действие лучшее?

1. AОстановить инфузию и отложить повторную проверку глюкозы до утра
2. BДать калий внутрь для защиты сердца
3. CДействовать по протоколу при низкой глюкозе и уведомить врача
4. DПродолжить с той же скоростью и перепроверить через четыре часа

Which is a recognised risk factor for postoperative nausea and vomiting?

1. ABeing a smoker
2. BUse of opioids after surgery
3. CA short operation under local anaesthetic
4. DBeing male

An older man has sudden severe abdominal and back pain, is hypotensive and has a pulsating mass in the abdomen. What should be suspected?

1. ARenal colic from a kidney stone
2. BA ruptured abdominal aortic aneurysm
3. CMusculoskeletal back pain
4. DAcute gastritis from anti-inflammatory drugs

Что означает повышенный результат D-димера?

1. AТромбоз глубоких вен надёжно исключён
2. BДоза антикоагулянта слишком мала и должна быть увеличена
3. CЕсть распад фибрина, но это не доказывает наличие сгустка
4. DПодтверждены тромбоэмболия лёгочной артерии или тромбоз глубоких вен

A nurse looked after a patient for a shift before smear-positive pulmonary TB was diagnosed, without wearing a respirator. What should happen?

1. AStart a full six-month course of TB drugs at once without any tests
2. BTake no action, as healthcare workers are immune to TB
3. CReport it so occupational health can arrange follow-up screening
4. DStay off work for six months in case symptoms develop

A patient with Conn's syndrome starts spironolactone. Which blood test should the nurse watch most closely?

1. AAmylase
2. BPotassium
3. CCalcium
4. DGlucose

The nurse has four neurology patients. Which one needs to be seen first?

1. AA patient with multiple sclerosis who is tired after physiotherapy
2. BA patient with Guillain–Barré syndrome whose vital capacity is falling
3. CA patient with Parkinson's disease whose next dose is due in one hour
4. DA patient with a headache after a lumbar puncture this morning

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

1. AПостоянное снижение температуры тела
2. BЗамедление пульса и низкое артериальное давление
3. CПокраснение кожи с падающим уровнем CO₂
4. DНеобъяснимый рост CO₂ в конце выдоха

A 60 kg adult with 25% TBSA burns arrives 2 hours after the injury, having had no IV fluids. Using the Parkland formula, what hourly rate is needed for the rest of the first 8 hours?

1. A375 mL/h
2. B250 mL/h
3. C500 mL/h
4. D1000 mL/h