Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Two nursing assistants argue loudly at the station about their assignments. What is the charge nurse’s best first step?

1. AMeet both of them privately to hear each side
2. BReport them to human resources at once
3. CChange both of their assignments without any discussion
4. DIgnore it and hope they sort it out

Which assignment by the charge nurse should be changed?

1. AAn RN is assigned to a patient receiving a blood transfusion
2. BAn LPN/LVN is assigned to give oral medications to stable patients
3. CA nursing assistant is assigned to help several stable patients with their meals
4. DAn LPN/LVN is assigned to admit a new patient from the emergency department

Which practice is safe when transferring a patient from a bed to a stretcher?

1. ALock the wheels of both the bed and the stretcher before moving the patient
2. BHave the patient slide across without help or a slide sheet
3. CLower the stretcher side rails during transport
4. DLeave the stretcher wheels unlocked so it can move with the patient

An 80-year-old patient took a sleeping tablet an hour ago and now wants to go to the bathroom. What should the nurse do?

1. ATell the patient to wait until the morning
2. BRaise all four side rails so the patient stays in bed
3. CTell the patient to go alone and use the call light if needed
4. DWalk with the patient to the bathroom and stay close by

A patient on carbamazepine becomes confused and has a headache. Which laboratory result would most likely explain this?

1. AA high serum calcium
2. BA low serum magnesium
3. CA high serum potassium
4. DA low serum sodium

Two sets of blood cultures were taken from separate sites. Only one bottle in one set grows coagulase-negative staphylococci, and the patient has no line or implant. What is the most likely interpretation?

1. ACertain bloodstream infection needing treatment
2. BProbable skin contamination of the sample
3. CInfection with a resistant organism such as MRSA
4. DProof that the patient has infective endocarditis

Какое нарушение электролитов наиболее опасно для сердечного ритма?

1. AВысокий хлор
2. BНизкий натрий
3. CПовышенный или пониженный калий
4. DНизкий фосфат

Why might a patient with diabetes who takes a beta-blocker not notice hypoglycaemia early?

1. ABeta-blockers stop the liver from responding to insulin
2. BBeta-blockers make the patient sleep through the night
3. CBeta-blockers raise blood glucose, so true hypoglycaemia cannot happen at all
4. DBeta-blockers can mask warning signs such as tremor and a fast heart rate

How can a patient reduce wound pain when coughing after abdominal surgery?

1. AAvoid coughing completely until all the stitches are removed
2. BHold a pillow firmly against the wound while coughing
3. CHold the breath for as long as possible
4. DLie flat on the back with the legs straight

Two days after a coronary stent, a patient on aspirin and ticagrelor has black, tarry stools and feels faint on standing. What should the nurse do?

1. AGive a laxative and repeat the observations tomorrow
2. BStop both antiplatelet drugs permanently on the nurse's own decision
3. CCheck vital signs, report urgently and anticipate a blood count
4. DReassure the patient that iron tablets cause black stools

Why does a patient with untreated hypothyroidism need extra care when given opioids or sedatives?

1. AThey clear the drugs too fast, so higher doses are needed
2. BThese drugs make the thyroid gland overactive
3. CThere is no difference compared with other patients
4. DThey break the drugs down slowly and are more sensitive to them

A patient with a head injury now has a blood pressure of 190/70 mmHg, a pulse of 48/min and irregular breathing. How should the nurse interpret this?

1. AA normal stress response to pain, anxiety and the noise of the ward
2. BNeurogenic shock from a spinal cord injury
3. CCushing's triad, a late sign of raised intracranial pressure
4. DHypovolaemic shock from internal bleeding

What is the most important safety point about misoprostol?

1. AIt causes severe constipation in most patients
2. BIt must be given only by deep intramuscular injection
3. CIt strongly raises blood glucose in people with diabetes
4. DIt can cause miscarriage and must not be used in pregnancy

A worker has a hydrofluoric acid burn on the hand and severe pain. After irrigation with water, which specific treatment is commonly applied?

1. ASilver sulfadiazine cream
2. BCalcium gluconate gel
3. CIce cubes wrapped in a cloth
4. DSodium bicarbonate paste