Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient uses patient-controlled analgesia (PCA) after surgery. Which statement by a family member shows a need for further teaching?

1. A“I will tell the nurse if she becomes very sleepy or hard to wake.”
2. B“Only she should press the button when she needs pain relief.”
3. C“I will press the button for her while she is asleep so she stays comfortable.”
4. D“The pump has limits set by the nurse so she cannot get too much at once.”

Which finding after a laparoscopic cholecystectomy is expected and needs only reassurance and comfort measures?

1. AYellow skin with dark urine on the second day
2. BA heart rate of 125/min with a falling blood pressure
3. CRight shoulder pain from the gas used during surgery
4. DIncreasing abdominal pain with a temperature of 39 °C

Какая мера безопасности наиболее уместна для пациента с аллергией на латекс?

1. AИспользовать латексные перчатки и тщательно мыть руки после этого
2. BИспользовать оборудование без латекса и чётко задокументировать аллергию
3. CИспользовать только латексные перчатки с пудрой
4. DНе надевать никакие перчатки при уходе за пациентом

A nurse has weeping dermatitis on both hands. What is the most appropriate action?

1. AContinue care as usual and wear one pair of gloves
2. BCover the lesions with a waterproof bandage and keep working with patients as usual
3. CUse extra alcohol hand rub on the lesions
4. DAvoid direct patient care and handling of equipment until it heals, and see occupational health

A patient takes high-dose furosemide. Besides potassium, which electrolyte is most commonly lowered?

1. APhosphate
2. BUric acid
3. CMagnesium
4. DSodium bicarbonate

At the start of a shift, the nurse reviews four new results. Which patient needs attention first?

1. AHemoglobin 11,0 g/dL (110 g/L) in a patient with rheumatoid arthritis
2. BGlucose 180 mg/dL (10 mmol/L) after a meal in a patient with diabetes
3. CSodium 119 mEq/L in a patient with new confusion and vomiting
4. DPotassium 5,2 mEq/L in a patient with stable chronic kidney disease

A patient on the ward has shingles with open blisters. Which people are most at risk from contact?

1. AOnly people over 80 who have already had shingles themselves
2. BPregnant women and immunocompromised people who have not had chickenpox
3. CPeople who have already had chickenpox in childhood and are now healthy
4. DNo one, because shingles cannot spread

Вскоре после начала трансфузии у пациента появились одышка, свистящее дыхание, гипотензия и отёк лица. Что медсестра должна сделать в первую очередь?

1. AОстановить трансфузию, сохранить внутривенный доступ и срочно вызвать помощь
2. BБыстро перелить дозу до конца, чтобы как можно сильнее сократить время воздействия
3. CДать парацетамол и антигистаминный препарат и продолжить трансфузию
4. DЗамедлить скорость трансфузии и перепроверить показатели через час

When should an adult with cystic fibrosis take pancreatic enzyme capsules?

1. AOnly at bedtime
2. BOnly when they have diarrhoea
3. COnce a day on waking, at least an hour before any food
4. DWith all meals and snacks that contain fat

A patient with severe sepsis becomes increasingly breathless over 24 hours. SpO₂ stays low despite high-flow oxygen, and the chest X-ray shows bilateral infiltrates. The heart function is normal. Which condition is most likely?

1. AAn acute asthma attack
2. BAcute respiratory distress syndrome
3. CAcute left ventricular failure after an MI
4. DSpontaneous pneumothorax

A patient is starting nitrofurantoin for a UTI. Which teaching point is correct?

1. AIt must be taken only once a week
2. BIt turns the tears and sweat bright orange
3. CIt should be taken on an empty stomach with milk
4. DIt may turn the urine dark yellow or brown

У 22-летнего пациента с диабетом 1 типа глюкоза 28 mmol/L, кетоны 5,2 mmol/L, pH 7,10 и калий 5,9 mmol/L. Какое утверждение о калии верно?

1. AИнсулин следует отложить, чтобы уровень калия оставался стабильным
2. BОбщий калий в организме низок, и уровень упадёт при лечении
3. CОбщий калий в организме высок, поэтому сейчас нужен связывающий калий препарат
4. DКалий не нужно повторно проверять после начала инсулина

Which factor can precipitate hepatic encephalopathy in a patient with cirrhosis?

1. AA low-salt diet
2. BA high fluid intake
3. CRegular gentle walking
4. DConstipation

During radiotherapy to the chest, a patient develops pain on swallowing and is eating less. What is the most likely cause and nursing focus?

1. AA stomach ulcer; give an antacid after meals only
2. BNormal ageing; no action needed
3. CA heart attack; give aspirin and arrange an ECG
4. DRadiation oesophagitis; analgesia, soft food and nutrition support