Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

An older adult asks for something to help them sleep. Which drug is most likely to cause confusion and falls in this age group?

1. AAcetaminophen (paracetamol)
2. BMelatonin
3. CDiphenhydramine
4. DA warm milky drink

A patient on airborne precautions for suspected tuberculosis must go to the radiology department. What should the patient wear during transport?

1. AA surgical mask
2. BGloves and a gown only
3. CNothing, if the trip is short
4. DA fit-tested N95 respirator

Какая оценка важнее всего, пока пациент находится в фиксации запястий?

1. AСлух пациента на оба уха по тесту с часами
2. BПожелания пациента по еде и питью на день
3. CРост и масса тела пациента
4. DКровообращение, чувствительность и кожа дистальнее фиксатора

A 2-year-old living in a house built many decades ago has anemia, irritability and poor appetite. Which cause should the nurse suspect?

1. AIron overload from eating too much red meat
2. BCarbon dioxide from a gas cooker
3. CLead poisoning from old paint dust or chips
4. DA food allergy to cow’s milk proteins

When should a blood specimen tube be labeled?

1. AAt the nurses' station, after all samples for the shift are drawn
2. BIn the laboratory, by the staff who receive the unlabeled sample
3. CBefore entering the room, so tubes are ready for the next patients
4. DAt the bedside, in the patient's presence, using two identifiers

A patient has a continuous heparin infusion for a pulmonary embolism. A new nurse plans to adjust the infusion using today's INR of 1,1. What should the experienced nurse explain?

1. AHeparin is adjusted using the aPTT or anti-Xa level, not the INR
2. BThe INR is the correct test, and 1,1 means heparin is therapeutic
3. CHeparin needs no laboratory monitoring once the infusion is started
4. DThe INR of 1,1 means the heparin rate must be doubled at once

Why should a urinary catheter drainage bag be kept below the level of the bladder?

1. ATo make the bag easier for the nurse to empty
2. BTo prevent urine flowing back into the bladder
3. CTo keep the urine warm
4. DTo stop the catheter from falling out

A patient with stress incontinence is taught self-care. Which statement shows a need for further teaching?

1. A"I'll cut down on caffeine."
2. B"I'll do my pelvic floor exercises every day."
3. C"I'll drink as little as possible so I don't leak."
4. D"I'll try to lose some weight if I can."

A 70 kg patient has passed 20 mL of urine per hour for the last three hours. How should this be interpreted?

1. ANormal, because the target is 0,1 mL/kg/h
2. BNormal, because any measurable urine output is reassuring
3. CBelow 0,5 mL/kg/h, suggesting poor kidney perfusion
4. DHigh, suggesting fluid overload that needs a diuretic

A patient receiving weeks of IV antibiotics through a PICC line in the left arm develops swelling and aching of that arm and neck veins that look fuller on the left. What should the nurse suspect?

1. AAn expected effect of the antibiotic
2. BLymphoedema from lying in bed
3. CA local skin allergy to the dressing
4. DA catheter-related deep vein thrombosis

How does the nurse test the facial nerve (VII)?

1. AShine a light in each eye and check the pupil response
2. BAsk the patient to stick out the tongue and move it from side to side
3. CAsk them to raise the eyebrows, shut the eyes tightly and smile
4. DTouch the forehead, cheek and chin with cotton wool

A patient on warfarin starts levothyroxine for hypothyroidism. What should the nurse expect to monitor more closely?

1. AThe urine output, because it may stop
2. BThe blood glucose, because it may fall
3. CThe potassium, because it may rise
4. DThe INR, because it may rise

Why are accurate fluid balance charts kept after major surgery?

1. ATo check how far the patient has walked and how often they get out of bed
2. BTo decide which meal the patient will have next
3. CTo detect dehydration, fluid overload or kidney problems early
4. DTo record when visitors come and go

An older patient on regular opioids has small amounts of liquid stool leaking all day, but has not had a formed bowel movement for 6 days. What is the most likely cause?

1. AAcute infective gastroenteritis
2. BNormal stool pattern on opioids
3. CA flare of ulcerative colitis
4. DFaecal impaction with overflow