Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Какое утверждение показывает правильное понимание подотчётности при делегировании?

1. A«Помощник отвечает за то, правильно ли было делегировать задачу».
2. B«Когда я делегирую задачу, это больше не моя забота».
3. C«Если задача выполнена неправильно, отвечает только помощник».
4. D«Я остаюсь подотчётной за решение делегировать и за контроль результата».

A patient who is 7 weeks pregnant has one-sided lower abdominal pain, pain in the shoulder tip, a heart rate of 120/min and a blood pressure of 88/54 mmHg. What is most likely?

1. AA urinary tract infection
2. BA normal early pregnancy
3. CSevere morning sickness
4. DA ruptured ectopic pregnancy

Why can side rails be dangerous for a confused, restless patient?

1. ASide rails stop staff from reaching the patient in an emergency
2. BThe patient may climb over them or get trapped in gaps
3. CSide rails always cause pressure injuries
4. DSide rails make the bed move by itself

A patient with depression has suddenly become calm and is giving away personal possessions. What does this suggest?

1. AThat the patient is now ready for discharge today
2. BA possibly increased suicide risk that needs immediate assessment
3. CThat the depression has resolved and observation can be reduced
4. DThat the patient wants to make new friends on the unit

Глюкоза натощак у пациента сегодня 98 mg/dL (5,4 mmol/L), но HbA1c 8,9% (74 mmol/mol). Какова лучшая интерпретация?

1. AHbA1c отражает только последние 24 часа
2. BСегодняшний хороший результат показывает, что диабет хорошо контролируется
3. CУ пациента нет диабета
4. DКонтроль глюкозы был плохим в последние 2–3 месяца

Two sets of blood cultures were taken from separate sites. Only one bottle in one set grows coagulase-negative staphylococci, and the patient has no line or implant. What is the most likely interpretation?

1. AProof that the patient has infective endocarditis
2. BCertain bloodstream infection needing treatment
3. CInfection with a resistant organism such as MRSA
4. DProbable skin contamination of the sample

A patient says they are "allergic" to codeine because it made them constipated. How should this be recorded?

1. AIt should not be recorded at all
2. BAs a side effect or intolerance, not a true allergy
3. CAs a severe anaphylactic allergy to all opioids
4. DAs an allergy to all painkillers

Which sign is often a late finding in hypovolaemic shock in a young, previously fit adult?

1. AA fall in blood pressure
2. BA slightly raised respiratory rate
3. CCool peripheries
4. DA rise in heart rate

Какая шкала тяжести пневмонии использует спутанность, мочевину, частоту дыхания, артериальное давление и возраст?

1. AШкала Уэллса
2. BCURB-65
3. CNEWS2
4. DCHA₂DS₂-VASc

Three days after an MI, a patient faints on the commode while straining hard to open the bowels. The heart rate was 42/min at the time. What is the most likely mechanism?

1. AA vagal response to straining
2. BAn allergic reaction to the commode
3. CLow blood glucose from fasting
4. DA new pulmonary embolism

A patient with multiple sclerosis says their symptoms get worse after a hot bath. What should the nurse explain?

1. AHeat can briefly worsen MS symptoms, which settle when they cool down
2. BHot baths cause new areas of damage in the brain
3. CThis shows that the disease has entered a new progressive stage
4. DThey should take very cold baths to reverse the damage

A patient with a subarachnoid haemorrhage develops a low sodium. Why is fluid restriction usually avoided in this patient?

1. AFluid restriction would cause the aneurysm to re-bleed
2. BLow blood volume can worsen vasospasm and brain ischaemia
3. CFluid restriction raises the risk of seizures
4. DLow sodium in this condition always corrects itself

Which pain pattern classically suggests a duodenal rather than a gastric ulcer?

1. APain only on deep breathing that eases when sitting forwards
2. BPain in the right lower abdomen with fever and vomiting
3. CPain straight after eating that is worsened by food
4. DPain 2–3 hours after meals and at night, eased by eating

Какая тактика обычно рекомендуется при стабильном, сухом, целом чёрном струпе на пятке у пациента с плохим кровообращением?

1. AОставить его нетронутым, разгрузить пятку и направить на осмотр
2. BКаждый день размачивать его в воде для размягчения
3. CУдалить его острым путём у постели сегодня
4. DЗакрыть тугой компрессионной повязкой