Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

An older patient becomes confused over a few hours, with attention that comes and goes. What does this suggest?

1. ALong-standing dementia that is expected
2. BA personality change that is permanent and expected
3. CDelirium, which needs the cause found quickly
4. DNormal aging that needs no action

A patient’s serum potassium is 6,1 mEq/L. Which of the patient’s medications should the nurse question first?

1. AOmeprazole
2. BSpironolactone
3. CFurosemide
4. DHydrochlorothiazide

Where should the dispersive (grounding) pad for electrosurgery be placed?

1. AOver a bony prominence such as the hip bone
2. BOn skin that is wet with antiseptic prep
3. COn clean, dry skin over a well-perfused muscle, close to the surgical site
4. DOver an area with scar tissue or a tattoo, so that the pad does not slip

A patient on a general ward for two days is found to have smear-positive pulmonary TB. What should the nurse do besides moving the patient to an airborne isolation room?

1. AClose the ward to all new admissions for a full year
2. BNothing more, because the patient has now been isolated
3. CInform infection prevention so exposed patients and staff can be identified and followed up
4. DTell all the exposed patients to start TB drugs at once, before any testing

A patient with chronic kidney disease has a potassium of 5,6 mEq/L. Which food should the nurse advise the patient to limit?

1. AApples
2. BCabbage
3. CBananas
4. DWhite rice

A patient with schizophrenia drinks very large amounts of water each day. Sodium is 121 mEq/L, and the urine is very dilute (urine osmolality 70 mOsm/kg). Which explanation fits best?

1. AHyperosmolar hyperglycemic state
2. BSyndrome of inappropriate ADH
3. CPrimary (psychogenic) polydipsia
4. DCentral diabetes insipidus

У пациента в отделении после первой дозы бета-блокатора появились свистящее дыхание и одышка. Какой анамнез делает это наиболее вероятным?

1. AГипотиреоз
2. BМигрень
3. CБронхиальная астма
4. DОстеоартрит

A patient with myasthenia gravis develops increasing difficulty swallowing and weak, shallow breathing. What is the main danger?

1. AA sudden rise in blood glucose from the stress
2. BA urinary tract infection
3. CSevere hypertension from anxiety
4. DRespiratory failure from a myasthenic crisis

Why must inspired air be humidified for a patient with a tracheostomy?

1. ADry air is needed to stop secretions forming in the trachea
2. BThe nose and upper airway, which warm and moisten air, are bypassed
3. CHumidified air contains more oxygen than dry air at the same flow
4. DHumidification prevents the cuff from deflating

The stump of a recent below-knee amputation suddenly bleeds heavily through the dressing. What should the nurse do first?

1. ARemove all the dressings and wait for the bleeding to stop by itself
2. BEncourage the patient to walk on crutches to ease the pressure
3. CApply a warm compress to the stump
4. DApply firm direct pressure and call for urgent surgical help

Why can a patient with an insulin pump develop DKA within hours if the pump stops working?

1. AThe battery in the pump releases chemicals into the blood
2. BThe body becomes allergic to insulin when the pump stops
3. CThe pump gives long-acting insulin, which builds up and stops working all at once
4. DThe pump gives only rapid-acting insulin, so there is no long-acting reserve

Пациенту с повышенным внутричерепным давлением нужна эндотрахеальная аспирация. Какой подход наиболее уместен?

1. AУложить пациента плашмя с повёрнутой головой на время аспирации
2. BАспирировать каждые 15 минут по расписанию, даже без секрета
3. CПредварительно оксигенировать, делать каждый проход коротким и ограничить число проходов
4. DАспирировать не менее 30 секунд, чтобы убрать весь секрет сразу

Which liver function test pattern suggests bile duct obstruction?

1. AA low albumin with all other results normal
2. BNormal bilirubin with a low ALP and low GGT
3. CVery high ALT with a normal bilirubin only
4. DHigh bilirubin with a markedly raised ALP and GGT

An incontinent patient has diffuse, shiny, red and broken skin in the natal cleft and buttocks with irregular edges, not over a bony prominence. What is most likely?

1. AAn arterial ulcer caused by poor circulation
2. BA full-thickness burn
3. CIncontinence-associated dermatitis
4. DA category 4 pressure ulcer over the sacrum