Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient uses patient-controlled analgesia (PCA) after surgery. Which statement by a family member shows a need for further teaching?

1. A“Only she should press the button when she needs pain relief.”
2. B“The pump has limits set by the nurse so she cannot get too much at once.”
3. C“I will tell the nurse if she becomes very sleepy or hard to wake.”
4. D“I will press the button for her while she is asleep so she stays comfortable.”

При триаже START взрослый не дышит. Дыхательные пути перепозиционированы, но пострадавший по-прежнему не дышит. Какая категория верна?

1. AЖёлтая, и вернуться позже
2. BКрасная, и сразу начать СЛР
3. CКрасная, так как отсутствие дыхания — самая срочная находка
4. DЧёрная (умерший или безнадёжный)

Какая практика обращения с флаконами и шприцами безопасна?

1. AИспользовать новую стерильную иглу и шприц каждый раз, когда прокалывают флакон
2. BОставлять иглу в пробке флакона для последующего использования
3. CПовторно использовать шприц, если надета новая игла
4. DИспользовать один шприц для двух пациентов, если его промыть

A patient’s allergy band says “penicillin”, and an order has been written for amoxicillin. What should the nurse do?

1. AGive the drug and watch the patient closely
2. BGive an antihistamine first and then the drug
3. CAsk the patient whether they would like to take it anyway
4. DHold the drug and contact the prescriber

A patient's levothyroxine dose was changed today. When is the TSH usually rechecked?

1. AAfter about 3 days
2. BAfter about 24 hours
3. CAfter about 6–8 weeks
4. DAfter about 1 year

A woman who is 34 weeks pregnant has high blood pressure, right upper abdominal pain, a platelet count of 70 × 10³/µL, raised ALT and AST, and a raised LDH. Which condition fits best?

1. AHELLP syndrome
2. BPhysiologic anemia of pregnancy
3. CAcute cholecystitis
4. DGestational diabetes

Which equipment must always be kept at the bedside of a patient with a tracheostomy?

1. AA blood glucose meter and a spare urinary catheter of the same size
2. BSpare tracheostomy tubes, including one a size smaller, and working suction
3. CA blood pressure cuff and a spare nasal cannula and oxygen mask only
4. DA peak flow meter and a nebuliser

How should pain be assessed in a patient with advanced dementia who cannot describe it?

1. ABy asking the patient to rate their pain on a numerical scale from 0 to 10
2. BBy assuming the patient has no pain unless they are crying out or calling for help
3. CWith an observational pain tool that scores facial expression, behaviour and body language
4. DBy checking the blood pressure only

A patient uses a salbutamol (albuterol) inhaler and a steroid inhaler at the same times each day. Which order is usually taught?

1. AThe order makes no difference to either drug
2. BSalbutamol first, then the steroid after a short wait
3. CSteroid first, then salbutamol straight afterwards
4. DBoth inhalers puffed together in one breath

Twelve hours after a coronary stent, a patient has sudden severe chest pain again with new ST elevation in the same leads. What is the most likely cause?

1. ANormal pain from the procedure site
2. BPericarditis from the catheter
3. CIndigestion from the hospital meal
4. DAcute stent thrombosis

How does bladder training help urge incontinence?

1. AA catheter is used every night
2. BThe patient goes to the toilet every 15 minutes
3. CThe patient drinks as little as possible
4. DThe time between voids is slowly increased

A patient with motor neurone disease reports morning headaches, poor sleep and sleepiness during the day. What do these symptoms suggest?

1. ANormal tiredness that needs no specific action
2. BA side effect of riluzole, which should be stopped straight away by the nurse
3. CWeak breathing at night, so a review for ventilation support
4. DLow mood, which should be treated with an antidepressant first

Which rule about the sterile field is correct?

1. ASterile items can be passed across a non-sterile area freely
2. BThe area below a gowned person's waist is sterile
3. CIf sterility is in doubt, the item is treated as contaminated
4. DA sterile pack stays sterile even when it is wet

An older patient on regular opioids has small amounts of liquid stool leaking all day, but has not had a formed bowel movement for 6 days. What is the most likely cause?

1. AFaecal impaction with overflow
2. BA flare of ulcerative colitis
3. CAcute infective gastroenteritis
4. DNormal stool pattern on opioids