Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Which newborn finding needs prompt reporting?

1. AMild jaundice that first appears on the third day
2. BMilia (small white spots) on the nose
3. CJaundice that appears within the first 24 hours
4. DBluish hands and feet in the first hours

A patient arrives one hour after the start of stroke symptoms. Which step must happen before a thrombolytic drug can be given?

1. AA brain scan to rule out bleeding
2. BAn echocardiogram to look for clots
3. CA full lipid profile to check cholesterol
4. DA swallow test with a cup of water

Which practice makes shift handoff safer?

1. AUsing a standard format such as SBAR or I-PASS, with time for questions
2. BLeaving written notes only, without a chance for questions
3. CGiving handoff in a busy corridor so that the outgoing nurse can leave on time
4. DGiving handoff from memory without any structure

У пациента была MRSA в ране, и теперь нужна смена повязки. Какие средства индивидуальной защиты уместны?

1. AТолько респиратор N95, потому что MRSA — устойчивый возбудитель
2. BХалат и перчатки, а также защита глаз и маска, если вероятны брызги
3. CТолько стерильные перчатки, без халата и другой защиты
4. DНикаких, если потом обработать руки

A patient with an upper gastrointestinal bleed has a BUN of 48 mg/dL (urea 17 mmol/L) and a normal creatinine. What is the most likely explanation?

1. AThe liver has stopped making urea because of the bleeding
2. BSkeletal muscle is breaking down because of the blood loss
3. CDigested blood adds protein, which the liver turns into urea
4. DThe kidneys have suddenly lost most of their function

The nurse teaches a patient with chronic kidney disease about a potassium-restricted diet. Which statement shows a need for further teaching?

1. A"I can leach potatoes by soaking them before cooking them"
2. B"I'll limit bananas, oranges and potatoes in my meals"
3. C"I'll check food labels and ask my dietitian about portion sizes"
4. D"Dried apricots and raisins will be a good snack for me now"

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. BБронхиальная астма
3. CПневмония
4. DНапряжённый пневмоторакс

A nurse teaches a patient with hypertension about their medicines. Which statement shows a need for further teaching?

1. A"I'll keep taking my tablets even if I feel well."
2. B"I'll stop my tablets once my readings are normal."
3. C"I'll have my blood pressure checked regularly."
4. D"I'll get up slowly from sitting."

Before the first treatment dose of a low-molecular-weight heparin for a PE, what does the nurse need to make sure of?

1. AThe patient has fasted for 12 hours
2. BA chest drain is in place
3. CThe patient's blood glucose is above 10 mmol/L (180 mg/dL)
4. DAn accurate, recent body weight is recorded

The monitor shows a regular broad-complex tachycardia at 180/min. The patient is alert with BP 126/78 mmHg and no chest pain. What is the most appropriate plan?

1. ARecord a 12-lead ECG, call senior help and anticipate an antiarrhythmic
2. BReassure the patient, as this is a normal rhythm
3. CStart chest compressions straight away and give a dose of IV adrenaline
4. DDeliver an unsynchronised shock immediately, before any other assessment

У пациента с ОПП мочевой катетер ничего не отводит. Какая быстрая проверка у постели помогает исключить постренальную причину?

1. AПобуждать пациента выпить два литра воды
2. BПроверить катетер на перегибы или закупорку и выполнить сканирование мочевого пузыря
3. CСразу ввести большой болюс внутривенной жидкости
4. DОтправить образец мочи на посев и ждать результата лаборатории

A man with chronic urinary retention is catheterised. Over the next hours he passes very large volumes of urine. What is the main nursing concern?

1. ARupture of the bladder from the catheter
2. BFluid and electrolyte loss from post-obstructive diuresis
3. CA rise in blood glucose from the urine
4. DA urinary infection caused by the high flow of urine

Which wound drain observation should be reported immediately?

1. ASmall amounts of pink serous fluid
2. BDrainage slowly falling each day
3. CA little dried blood around the drain site
4. DA sudden large volume of fresh red blood

У пациента с раком лёгкого развиваются отёк лица, вздутые шейные вены и одышка, усиливающаяся в положении лёжа. Какое неотложное состояние вероятно?

1. AГиперкальциемия при злокачественной опухоли
2. BКомпрессия спинного мозга
3. CМассивная тромбоэмболия лёгочной артерии
4. DОбструкция верхней полой вены