Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A nurse teaches a patient to use an incentive spirometer. Which statement shows a need for further teaching?

1. A“I will try to hold my breath for a few seconds at the top.”
2. B“I will blow into it as hard and fast as I can.”
3. C“I will breathe in slowly and deeply through the mouthpiece.”
4. D“I will use it several times every hour while awake.”

A patient at 36 weeks of pregnancy has sudden severe abdominal pain, a hard, board-like uterus and dark vaginal bleeding. What should the nurse suspect?

1. APlacenta previa, which is usually painless
2. BA urinary tract infection
3. CPlacental abruption, which is an emergency
4. DNormal labor contractions starting

A new antibiotic is prescribed for a patient. What should the nurse check before giving the first dose?

1. AThe patient’s allergies, by checking the record and asking the patient
2. BOnly the time of the patient’s last meal and drink
3. CThe patient’s preferred pharmacy
4. DOnly the patient’s blood pressure and pulse before giving the drug

A nurse has a needlestick from a patient known to have hepatitis C. Which statement about management is correct?

1. AHepatitis C immune globulin is given within 24 hours, followed by a booster dose
2. BThere is no preventive drug, so baseline and follow-up testing are done to detect infection early
3. CNo follow-up is needed because hepatitis C does not spread by needles
4. DThe hepatitis C vaccine series is started at once, with a booster dose six months later

A patient has taken hydrochlorothiazide for several years. Which laboratory change is a recognized effect of this drug?

1. AA fall in serum calcium
2. BA rise in serum potassium
3. CA fall in blood glucose
4. DA rise in serum uric acid

Which patient should the nurse assess first?

1. AStable angina with a total cholesterol of 245 mg/dL (6,3 mmol/L)
2. BHypertension with a potassium of 3,6 mEq/L on a thiazide
3. CHeart failure with a BNP lower than the result on admission
4. DChest pain with troponin rising from the first to the second sample

У пациента, принимающего дигоксин, тошнота, пульс 48/мин, и он жалуется, что всё видит в жёлтом цвете. Что следует заподозрить?

1. AГипертиреоз
2. BОбычный побочный эффект, не требующий действий
3. CИнтоксикацию дигоксином
4. DГипогликемию

An older patient with delirium is trying to leave the ward at night, saying he must go home. What is the best initial approach?

1. AGive a sedative straight away without a prescription
2. BLet him leave, because adults can always do as they wish whatever their state
3. CPhysically restrain him in bed until the morning so that he cannot fall
4. DCalmly reassure and redirect him while the team assesses his capacity and safety

Какое сочетание классов препаратов улучшает выживаемость при сердечной недостаточности со сниженной фракцией выброса?

1. AНПВП, аспирин, статин и тиазидный диуретик
2. BОдин петлевой диуретик в максимально переносимой дозе
3. CПетлевой диуретик, дигоксин, нитрат и блокатор кальциевых каналов
4. DИнгибитор АПФ или АРНИ, бета-блокатор, антагонист минералокортикоидных рецепторов и ингибитор SGLT2

A patient with a stab wound to the chest has a hole that sucks air with each breath. What is the immediate management?

1. ALeave it open and give a nebuliser
2. BCover it with a vented chest seal or a dressing taped on three sides
3. CPack the wound tightly with gauze pushed deep into the chest
4. DSeal it completely with tape on all four sides and leave it alone

A patient taking warfarin is diagnosed with an intracerebral haemorrhage. What is the priority treatment?

1. ADoubling the warfarin dose to stabilise the INR
2. BStarting aspirin to prevent further clots
3. CIV thrombolysis within 4,5 hours
4. DUrgent reversal of the anticoagulant effect

After a stroke, a patient suddenly cries or laughs at odd moments. They say they do not feel sad. Which response is most appropriate?

1. AExplain that this is emotional lability after stroke and help the family understand
2. BTell the patient that crying will slow their recovery
3. CAsk the doctor for a sedative to stop the outbursts
4. DIgnore it, because it shows that the patient is seeking attention from the staff

Why are antibody levels checked after a healthcare worker receives the hepatitis B vaccine?

1. ATo confirm that the vaccine produced immunity
2. BTo measure liver damage caused by the vaccine
3. CTo decide whether they need a liver biopsy
4. DTo check whether they caught hepatitis B from the vaccine

A nurse finds a dislodged sealed radiation source in the bed of a patient receiving brachytherapy. What should the nurse do?

1. APick it up with gloved hands and put it in the nearest sharps bin quickly
2. BThrow it in the clinical waste bag
3. CUse long-handled forceps to put it in the lead container; report it
4. DLeave it in the bed until the end of the shift