Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Какую задачу RN наиболее уместно делегировать LPN/LVN?

1. AПроведение оценки нового пациента при поступлении
2. BУстановку постоянного мочевого катетера стабильному пациенту
3. CОбучение при выписке пациента, которому только что начали инсулин
4. DНачало переливания первой дозы эритроцитов

An 85-year-old resident becomes newly confused and is falling, but has no fever. Which cause should the nurse consider first?

1. AA sudden worsening of long-standing dementia that needs no tests
2. BNormal aging that needs no assessment
3. CBoredom from not having enough activities
4. DAn infection, such as a urinary tract infection, presenting atypically

Why are some patients screened with a nasal swab for MRSA on admission?

1. ATo check whether the patient is allergic to penicillin before surgery
2. BTo find carriers so precautions or decolonization can be used
3. CTo diagnose a sinus infection
4. DTo measure the patient’s immunity to MRSA

A patient rescued from a house fire has a headache and confusion, but the pulse oximeter reads 99%. Why might this reading be misleading?

1. APulse oximetry cannot tell carbon monoxide-bound hemoglobin from oxygen-bound hemoglobin
2. BPulse oximeters always read falsely low after any kind of smoke exposure
3. CConfusion and headache make pulse oximetry readings inaccurate in every patient
4. DThe reading is accurate, so carbon monoxide poisoning is ruled out

A breathless patient in the emergency department has a BNP below 100 pg/mL. What does this suggest?

1. ASevere heart failure is certainly the cause of the problem
2. BThe patient has had a myocardial infarction in the past day
3. CHeart failure is an unlikely cause of the breathlessness
4. DThe kidneys are failing and the patient needs dialysis

A health care worker's hepatitis B tests show: HBsAg negative, anti-HBs positive, anti-HBc positive. What does this mean?

1. ANot immune and never exposed to the virus
2. BPast infection that has resolved, with immunity
3. CImmunity from vaccination only, never infected
4. DCurrent chronic hepatitis B infection

When is a rapid-acting insulin such as insulin aspart usually given?

1. ATwo hours after finishing a meal
2. BOnce a week
3. COnly at bedtime
4. DJust before or with a meal

Why is a large pleural effusion drained slowly rather than all at once?

1. ARapid drainage can cause re-expansion pulmonary oedema
2. BSlow drainage stops the patient needing oxygen
3. CQuick drainage causes the effusion to spread to the other lung
4. DFluid drained quickly turns into blood

How is the jugular venous pressure usually assessed?

1. APatient lying completely flat with the head turned to the right
2. BPatient sitting upright with the arms raised above the head
3. CPatient reclined at 45° with the head turned slightly to the left
4. DPatient standing with the neck flexed forward

A healthcare assistant (unlicensed assistive personnel) reports four observations. Which one needs the nurse's attention first?

1. AA patient with COPD whose SpO₂ is 90% on 1 L/min, which is usual for him
2. BA patient after a PCI asking for a cup of tea
3. CA patient with heart failure who is newly confused, with SpO₂ 89%
4. DA patient with a DVT whose leg is less swollen today

A patient takes levodopa for Parkinson's disease. Which teaching point is correct?

1. AThe tablets work best taken with a large steak dinner
2. BLarge high-protein meals can reduce how well the drug works
3. CStop the drug for a day each week to avoid tolerance
4. DThe drug cures the disease if taken for a full year

A patient with a known ureteric stone develops a fever of 39 °C (102,2 °F) and rigors. Scanning shows a blocked, swollen kidney. What is needed?

1. AUrgent drainage of the kidney plus IV antibiotics
2. BOral antibiotics and waiting for the stone to pass
3. CStrong pain relief alone, then discharge
4. DA fluid restriction to reduce the swelling

Какая область используется для быстрой оценки 1% площади поверхности тела при небольших или разбросанных ожогах?

1. AНоготь большого пальца пациента
2. BЛадонь осматривающего вместе с пальцами
3. CКисть и предплечье пациента
4. DЛадонь пациента вместе с пальцами

During a nerve block, a patient reports a metallic taste and ringing in the ears, then has a seizure. Besides calling for help and supporting the airway, which specific treatment is given?

1. AIV glucose 50%
2. BIV naloxone
3. CIV lipid emulsion
4. DIV dantrolene