Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A nurse has called the rapid response team for a deteriorating patient. What should the nurse do while waiting for the team?

1. ALeave the patient for a few minutes to find the relatives and explain what is happening
2. BGive a dose of every as-needed medication on the chart
3. CGo to the station to finish documentation for other patients
4. DStay with the patient, give oxygen as prescribed and have recent vital signs ready

A patient has full-thickness burns all the way around the chest and is finding it harder to breathe, although the airway is clear. What does this suggest?

1. AThe patient is anxious and only needs reassurance
2. BThe patient has had too little IV fluid and needs a fast bolus to improve the breathing
3. CThe tight burned skin is restricting chest movement, so an escharotomy may be needed
4. DThe burns are healing and the skin is tightening normally

A patient is on seizure precautions. Which equipment should be ready at the bedside?

1. ARestraints ready for all four limbs
2. BAn ice pack to place on the forehead
3. CWorking suction and oxygen equipment
4. DA tongue blade to put between the teeth

Пациент получает препарат высокого риска в виде постоянной инфузии. Какая практика при передаче смены наиболее безопасна?

1. AПроверяют только скорость, а не препарат или концентрацию
2. BОбе медсестры проверяют насос и пакет по назначению
3. CЗаступающая медсестра проверяет его в конце смены
4. DУходящая медсестра говорит на посту, что «с насосом всё в порядке»

A patient with sickle cell disease takes hydroxyurea. Which laboratory test is monitored regularly for an adverse effect?

1. AComplete blood count
2. BUrine ketone level
3. CSerum lithium level
4. DSerum amylase level

A patient has eaten very little for 2 weeks and has received broad-spectrum antibiotics. The INR is now 2,3 without warfarin, and the platelets are normal. What is the most likely cause?

1. AImmune thrombocytopenia
2. BVitamin K deficiency
3. CHemophilia A
4. DIron-deficiency anemia

A patient is having a 12-lead ECG. Where are the chest electrodes placed?

1. AOn both shoulders and both hips only
2. BIn a straight line down the centre of the sternum from top to bottom
3. CIn standard numbered positions across the front and left of the chest
4. DAnywhere on the chest where the skin is clear

Why must a unit of red cells be transfused within the set time limit (commonly four hours) after it leaves controlled cold storage?

1. AThe blood group of the cells changes after a few hours
2. BThe bag stops dripping after four hours
3. CBacteria can grow in the blood at room temperature
4. DThe red cells break down and turn into plasma

Where is the V1 electrode placed for a 12-lead ECG?

1. AThe fourth intercostal space just right of the sternum
2. BJust below the left collarbone
3. CThe fifth intercostal space in the mid-axillary line
4. DOver the left nipple

On day 2 after a surgical tracheostomy, the tube falls out. The patient is breathing but distressed. What should the nurse do first?

1. ACover the stoma completely with a sealed dressing and wait for help
2. BLeave the patient alone while fetching a new tube
3. CForce the tube back through the stoma immediately with firm pressure
4. DCall for expert help and give oxygen to both the face and the stoma

Why is an ACE inhibitor often given to a patient with diabetes and albumin in the urine?

1. AIt lowers the blood glucose to normal
2. BIt protects the kidneys and reduces albumin loss
3. CIt stops the kidneys from passing so much urine at night
4. DIt raises potassium to protect the heart

A patient with myasthenia gravis took extra pyridostigmine doses. They now have more weakness, heavy salivation, sweating, diarrhoea, small pupils and a slow pulse. What is most likely?

1. AAn allergic reaction to the drug
2. BA myasthenic crisis from too little medication
3. CA normal response to a higher dose
4. DA cholinergic crisis from too much medication

How should a patient use an incentive spirometer after surgery?

1. ABreathe quickly in and out ten times in a row
2. BBlow out as hard and as fast as possible
3. CBreathe in slowly and deeply, then hold briefly
4. DUse it once a day, just before going to sleep at night

A nurse teaches a patient with GORD. Which statement shows a need for further teaching?

1. A"Peppermint tea after dinner will settle my reflux."
2. B"I'll try to lose some weight over the next months."
3. C"I'll keep a diary of foods that trigger my symptoms."
4. D"I'll stop smoking because it makes reflux worse."