Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Старшей медсестре нужно освободить койку. Какой пациент наиболее подходит для выписки или перевода на более низкий уровень помощи?

1. AПоступил два часа назад с болью в груди; результат тропонина ещё не готов
2. B3-й день после неосложнённой аппендэктомии, ест, на пероральном обезболивании
3. CПневмония, потребность в кислороде за ночь выросла с 2 до 4 L/min
4. D1-й день после операции на кишечнике с новой температурой 38,5 °C

During a power cut, which patient is the nurse’s first priority?

1. AA patient whose bed will not raise electrically
2. BA patient who depends on a ventilator
3. CA patient whose call light is not working
4. DA patient watching television when it switched off

A nurse wants to set up a sterile field in the morning for a procedure that will take place after lunch. What is correct?

1. ASet it up in the morning and cover it with a clean towel until the procedure starts
2. BSet it up in the morning and leave it uncovered in an empty room
3. CSet it up in the morning and ask a colleague to check it once
4. DSet it up just before the procedure, because a waiting field may become contaminated

A nursing student describes how they remove PPE (gown, gloves and a mask worn for splash protection) at the doorway before leaving a contact precautions room. Which statement shows a need for further teaching?

1. A“I roll the gown inward as I take it off.”
2. B“I clean my hands as soon as all the PPE is off.”
3. C“I remove my gloves without touching the outside with my bare hand.”
4. D“I take off my mask first, and then I take off my gloves.”

During a red cell transfusion, when are serious acute reactions most likely, so the nurse stays with the patient?

1. AThe next morning
2. BIn the first 15 minutes
3. CAfter the last drop is given
4. DAfter about 2 hours

A patient with a heart murmur and fever has three sets of blood cultures, taken hours apart, all growing the same Streptococcus species. What does this suggest?

1. AA normal finding in patients with heart murmurs
2. BA urinary tract infection that has spread to the skin
3. CContamination of all three samples during collection
4. DPersistent bacteremia, as in infective endocarditis

У пациента после дорожно-транспортного происшествия тяжёлая одышка, отсутствие дыхательных шумов с одной стороны, низкое давление и смещение трахеи в другую сторону. Каков вероятный диагноз?

1. AОтёк лёгких
2. BНапряжённый пневмоторакс
3. CБронхиальная астма
4. DПневмония

A patient with an epidural catheter develops new back pain and increasing leg weakness when the block should be wearing off. What should be suspected?

1. AThe normal expected effect of the local anaesthetic
2. BAn epidural haematoma or abscess compressing the spinal cord
3. CMild hypokalaemia
4. DMuscle strain from lying in the same position in bed for many hours

A patient's blood pressure is high in clinic but normal on home readings. Which step best confirms the diagnosis?

1. AStarting two antihypertensive drugs at once at full dose
2. BAmbulatory or structured home blood pressure monitoring
3. CA chest X-ray
4. DA single repeat reading in the same clinic visit

A patient has been on continuous NIV via a full-face mask for two days. Which nursing measure helps prevent the most common complication?

1. AUse the same mask size for every patient
2. BRemove the mask for an hour each time the alarm sounds
3. CTighten the straps as far as they will go to stop any leak
4. DCheck mask fit and protect the bridge of the nose

Why should antiepileptic drugs not be stopped suddenly?

1. AStopping them suddenly causes permanent damage to the liver and kidneys
2. BStopping them suddenly causes a dangerous rise in blood pressure
3. CSudden withdrawal can trigger seizures, including status epilepticus
4. DThe drugs build up in the body and become toxic after stopping

Пациент с диабетом 1 типа не принимает ничего через рот перед операцией завтра. Какой план наиболее безопасен?

1. AПродолжить какой-то инсулин (базальный или внутривенную инфузию с переменной скоростью) с контролем глюкозы
2. BПрекратить весь инсулин, пока пациент снова не будет нормально есть и пить
3. CВвести инсулин, только если кетоны в моче станут резко положительными ночью
4. DВвести обычный инсулин на приём пищи, хотя еды не будет

Which advice is appropriate for a patient with a very low platelet count?

1. AUse a soft toothbrush and an electric razor
2. BUse a razor blade for shaving every day
3. CTake aspirin regularly for headaches
4. DFloss hard every day to prevent gum disease

On day 3 after laparoscopic cholecystectomy, a patient has abdominal pain, fever and mild jaundice, and green fluid is draining from the drain. What is most likely?

1. AA bile leak
2. BA wound haematoma
3. CUrinary retention
4. DNormal post-operative drainage