Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Before accessing a central venous catheter, what should the nurse do to prevent infection?

1. AScrub the hub with an antiseptic such as chlorhexidine and let it dry
2. BTouch the hub to check it is clean
3. CRinse the hub with tap water and dry it
4. DBlow on the hub to remove any dust before connecting the syringe or line

Which patient needs airborne precautions rather than droplet precautions?

1. AAn adult with influenza
2. BA teenager with mumps
3. CA child with pertussis (whooping cough)
4. DA child with chickenpox (varicella)

Какую медсестру нельзя назначать на уход за пациентом с закрытым радиоактивным имплантатом?

1. AБеременную медсестру
2. BМедсестру, которая работает в отделении два года
3. CМедсестру, прошедшую обучение по радиационной безопасности
4. DМедсестру с дозиметром на бейдже

A patient dies after a wrong-drug error, and the hospital carries out a root cause analysis. What is its main focus?

1. AEstimating the legal costs for the hospital
2. BIdentifying which staff member made the error and should be disciplined
3. CFinding the system and process weaknesses that allowed the error
4. DDeciding whether to tell the family about the error

A healthy patient's result is slightly outside the laboratory reference range, and all other results are normal. Which statement best explains why this can happen?

1. AReference ranges include every healthy person without exception
2. BAny result outside the range always means disease is present
3. CRanges cover about 95% of healthy people, so some fall outside
4. DReference ranges are the same in every laboratory worldwide

Вечером после операции гемоглобин у пациента упал с 12,5 g/dL до 8,1 g/dL (с 125 до 81 g/L), а ЧСС 118/мин. Какая проблема наиболее вероятна?

1. AНормальное разведение после операции, не требующее действий
2. BКровотечение
3. CУлучшающееся состояние
4. DОбезвоживание

During a vesicant chemotherapy infusion, the patient reports burning and swelling at the cannula site. What should the nurse do first?

1. AFlush the cannula hard with saline
2. BApply a warm pack and continue the infusion
3. CStop the infusion straight away and follow the extravasation protocol
4. DIncrease the rate so that the infusion finishes as quickly as possible

У пациента три дня тошнота и рвота, и он принимает фуросемид. Какое нарушение электролитов наиболее вероятно?

1. AГиперкальциемия
2. BТолько гипернатриемия
3. CГипокалиемия
4. DГиперкалиемия

Which foot care advice is correct for a patient with peripheral arterial disease?

1. AUse a hot water bottle on the feet at night
2. BCheck the feet daily and wear well-fitting shoes
3. CCut corns with a razor blade to prevent pressure
4. DWalk barefoot at home to strengthen the feet

A patient being treated for infective endocarditis of the mitral valve suddenly develops slurred speech and weakness of the right arm. What is the most likely cause?

1. AA side effect of the IV antibiotic on the nerves
2. BA migraine aura triggered by the fever
3. CLow blood glucose from a reduced appetite
4. DAn embolus from a valve vegetation causing a stroke

A patient has had a calcium oxalate kidney stone. Which advice best helps prevent another?

1. ATake extra vitamin C supplements
2. BCut all calcium out of the diet
3. CDrink only a little to avoid diluting the urine
4. DDrink plenty of fluid so the urine stays pale

A patient received IV insulin and glucose for hyperkalaemia an hour ago. What must the nurse monitor over the next few hours?

1. APupils, for raised intracranial pressure
2. BCapillary glucose, for hypoglycaemia
3. CUrine colour, for blood in the urine
4. DSkin, for a drug rash

Which statement about pain relief in acute pancreatitis is correct?

1. AOpioids can be used, and good analgesia is a priority
2. BPain relief should be withheld until the diagnosis is certain
3. COnly paracetamol may be given
4. DOpioids must never be used in pancreatitis

У пациента с раком лёгкого развиваются отёк лица, вздутые шейные вены и одышка, усиливающаяся в положении лёжа. Какое неотложное состояние вероятно?

1. AОбструкция верхней полой вены
2. BМассивная тромбоэмболия лёгочной артерии
3. CГиперкальциемия при злокачественной опухоли
4. DКомпрессия спинного мозга