Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A nurse teaches a patient about levothyroxine. Which statement shows a need for further teaching?

1. A“I will take it at the same time each morning.”
2. B“I will keep taking it even when I feel well.”
3. C“I will take it at breakfast with my calcium tablet.”
4. D“I will take it on an empty stomach with a glass of water.”

A patient with raised intracranial pressure is being nursed on the ward. Which position is best?

1. ASitting forward with the chin on the chest
2. BFlat on the back with the head turned well over to one side
3. CHead of the bed at about 30 degrees with the neck straight
4. DHead down with the legs raised above the heart

Which nursing care reduces the risk of ventilator-associated pneumonia?

1. AChanging the ventilator circuit every few hours
2. BRegular oral care to reduce bacteria in the mouth
3. CLying the patient flat for most of the day
4. DLeaving secretions in the mouth to protect the airway

A patient’s blood splashes onto a nurse’s forearm. The skin is intact. What is the correct response?

1. AWash the area with soap and water, then follow the reporting policy
2. BStart HIV post-exposure prophylaxis right away, before any other step is taken
3. CDo nothing, because intact skin cannot be contaminated
4. DScrub the area with undiluted bleach

A patient with a potassium of 2,8 mEq/L has potassium chloride prescribed IV. Which statement about giving it is correct?

1. AIt is given as an undiluted bolus into a large vein to avoid irritation
2. BIt is always diluted and given by infusion pump, never as an IV push
3. CIt is added to the IV bag without mixing, so it stays at the bottom
4. DIt may be given as a slow IV push over one minute if the level is very low

A woman who is 34 weeks pregnant has high blood pressure, right upper abdominal pain, a platelet count of 70 × 10³/µL, raised ALT and AST, and a raised LDH. Which condition fits best?

1. AHELLP syndrome
2. BAcute cholecystitis
3. CGestational diabetes
4. DPhysiologic anemia of pregnancy

Compared with a colostomy, a patient with an ileostomy is at greater risk of:

1. AUrinary retention
2. BDehydration and electrolyte loss from liquid output
3. CHard stools, straining and constipation from slow transit
4. DLow blood glucose after meals

Why are patients with nephrotic syndrome at increased risk of blood clots?

1. AThey lose all their red cells in the urine, which thickens the remaining blood
2. BAnticoagulant proteins are lost in the urine and clotting factors rise
3. CTheir blood pressure is always very low
4. DThey lose most of their platelets in the urine every day

A woman with hypertension who takes lisinopril says she is planning a pregnancy. What should the nurse advise?

1. AStop all blood pressure treatment straight away without telling anyone
2. BDouble the dose to protect the baby from high blood pressure
3. CDiscuss switching medicine with the prescriber before trying to conceive
4. DContinue lisinopril, as it is the safest blood pressure drug in pregnancy

On a ventilated patient, the end-tidal CO₂ waveform suddenly drops to zero. What should the nurse suspect first?

1. ATube displacement, disconnection or obstruction
2. BA sudden improvement in the patient's lung function
3. CA rise in the patient's body temperature over the last hour
4. DNormal variation that needs no action

A patient has Cushing's syndrome. Which nursing assessment is especially important?

1. ARegular blood glucose checks
2. BChecking for low blood pressure
3. CWatching for weight loss
4. DMonitoring for a high potassium

Через два дня после травмы спинного мозга на уровне C5 пациент тревожен, частота дыхания 30/мин и жизненная ёмкость лёгких снижается. Что должна сделать медсестра?

1. AДать седативное средство, чтобы замедлить дыхание и уменьшить тревогу
2. BПовторно проверить жизненную ёмкость лёгких примерно через 12 часов
3. CСрочно сообщить выше: отёк спинного мозга может вызвать дыхательную недостаточность
4. DУложить пациента плашмя с запрокинутой головой для открытия дыхательных путей

Why is an ankle-brachial pressure index (ABPI) measured before compression bandaging for a leg ulcer?

1. ATo find the bacteria in the wound
2. BTo find out how deep the ulcer is
3. CTo check for a leg bone fracture
4. DTo exclude significant arterial disease

A patient admitted for an elective general anaesthetic mentions that they ate a slice of toast 3 hours ago. What should the nurse do?

1. AGive a large drink to wash the food through
2. BInform the anaesthetist, as surgery may be delayed
3. CAsk the patient to try to vomit to empty the stomach
4. DSay nothing, since toast is a light food