Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient has a serum potassium of 6,8 mEq/L. Which action comes first?

1. AEncourage foods high in potassium
2. BGive the patient’s scheduled potassium supplement
3. CRecheck the level next week
4. DPlace the patient on a cardiac monitor

A patient with COPD on 2 L/min oxygen becomes drowsy and hard to wake. The SpO₂ is 93%. What is the priority?

1. ALet the patient sleep, because the saturation is above target
2. BAssess breathing and escalate for a blood gas, as carbon dioxide may be rising
3. CIncrease the oxygen to 6 L/min so that the saturation goes even higher than now
4. DGive the as-needed sedative so the patient rests comfortably

A patient cannot bear weight and cannot help with transfers. Which method is safest to move the patient from bed to chair?

1. AA mechanical lift used by enough trained staff
2. BOne nurse doing a standing pivot transfer
3. CTwo nurses lifting the patient under the arms
4. DAsking the patient to stand and try their best

A patient has signed a surgical consent form but tells the nurse, “I don’t really understand what they are going to do.” What should the nurse do?

1. AInform the surgeon so the procedure can be explained again before any sedation
2. BGive the preoperative sedative so the patient relaxes
3. CReassure the patient that the surgeon knows best and continue with the preparation
4. DExplain the risks and benefits in place of the surgeon

A patient takes high-dose biotin supplements for hair and nails. Why should the nurse report this before blood tests?

1. ABiotin causes a true rise in blood glucose in all patients
2. BBiotin can distort some immunoassays, such as troponin or TSH
3. CBiotin makes the blood clot in the tube before testing
4. DBiotin lowers the hemoglobin by destroying the red cells

Which set of results most strongly suggests hemolytic anemia?

1. ALow hemoglobin, high reticulocytes, high unconjugated bilirubin, high LDH
2. BLow hemoglobin, low reticulocytes, low MCV, low ferritin
3. CLow hemoglobin, low platelets, low white cells, low reticulocytes
4. DLow hemoglobin, high MCV, low vitamin B₁₂, normal bilirubin

Which measure helps reduce the risk of surgical site infection?

1. ARemoving hair, if needed, with clippers rather than a razor
2. BShaving the area with a razor the night before surgery
3. CChanging the wound dressing every hour
4. DLeaving the patient cool during surgery to slow bacterial growth

A nurse phones a doctor about a deteriorating patient using SBAR. Which statement belongs in the "R" section?

1. A"Please review him within the next 15 minutes."
2. B"He was admitted three days ago with pneumonia."
3. C"His blood pressure is 85/50 and he is confused."
4. D"I am calling about Mr Smith, who is breathless."

A patient in cardiac rehabilitation asks how hard to exercise. Which simple guide is commonly taught?

1. AExercise only until the heart rate rises even slightly
2. BExercise so they are a little breathless but can still talk
3. CExercise until they are too breathless to speak at all
4. DExercise until chest pain starts, then stop

Пациент на ИВЛ в отделении интенсивной терапии подвержен риску вентилятор-ассоциированной пневмонии. Какая сестринская мера помогает снизить этот риск?

1. AНе проводить уход за полостью рта, чтобы не вызвать кровоточивость дёсен
2. BМенять трубки аппарата ИВЛ каждые несколько часов
3. CДержать изголовье кровати приподнятым на 30–45°
4. DДержать пациента горизонтально, чтобы защитить эндотрахеальную трубку

A patient with a suspected basal skull fracture needs a gastric tube. Which route is preferred?

1. AThrough the nose (nasogastric)
2. BThrough the mouth (orogastric)
3. CThrough the nose with a guidewire
4. DThrough a fine-bore nasal tube

A patient with an acute stroke has a glucose of 15 mmol/L (270 mg/dL). They do not have known diabetes. What is appropriate?

1. AGive glucose gel to stabilise the level
2. BIgnore it, because stress always raises glucose
3. CStop all IV fluids to lower the glucose
4. DReport it and monitor glucose, as it can worsen outcome

A patient is starting regular oral morphine. Which bowel advice is most appropriate?

1. AStart a regular laxative at the same time
2. BStop eating fibre completely
3. CTake a bulk-forming laxative only with very little water
4. DWait until there has been no stool for a week

A patient is splashed in the eye with an alkaline cleaning product. What is the first action?

1. ACover the eye with a pad and wait for a doctor to examine it first
2. BIrrigate the eye at once with large volumes of water or saline
3. CAsk the patient to rub the eye to clear it
4. DAdd a few drops of vinegar to neutralise it