Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient on a medical unit tells the nurse he has a plan to end his life and has saved tablets at home. What is the priority action?

1. AAsk him to promise he will not harm himself
2. BArrange a psychiatry appointment for next week
3. CReassure him that things usually look better in the morning after some sleep
4. DEnsure constant observation and remove anything he could use to harm himself

During a power cut, which patient is the nurse’s first priority?

1. AA patient whose bed will not raise electrically
2. BA patient whose call light is not working
3. CA patient watching television when it switched off
4. DA patient who depends on a ventilator

A patient on contact precautions must be taken to another department for a test. What is correct?

1. ACancel the test until the precautions are no longer needed, however urgent it is
2. BHave the patient wear an N95 respirator during transport
3. CCover wounds, give the patient a clean gown and tell the receiving department
4. DPut the patient in a separate elevator with the doors open

A patient weighs 180 kg and needs to be moved from bed to chair. The standard ceiling lift on the unit has a lower weight limit. What should the nurse do?

1. AUse the standard lift, because limits include a safety margin
2. BUse bariatric-rated equipment and enough trained staff
3. CAsk the patient to stand and pivot without help
4. DHave two staff lift the patient by hand

A patient with an upper gastrointestinal bleed has a BUN of 48 mg/dL (urea 17 mmol/L) and a normal creatinine. What is the most likely explanation?

1. ADigested blood adds protein, which the liver turns into urea
2. BThe kidneys have suddenly lost most of their function
3. CThe liver has stopped making urea because of the bleeding
4. DSkeletal muscle is breaking down because of the blood loss

A 5-year-old has new bruising and petechiae two weeks after a viral illness. Platelets are 12 × 10³/µL; hemoglobin, white cell count and clotting times are normal. Which condition is most likely?

1. AAcute leukemia
2. BDisseminated intravascular coagulation
3. CHemophilia A
4. DImmune thrombocytopenia (ITP)

Which features suggest Cushing's syndrome?

1. AWeight loss, heat intolerance, tremor and protruding eyes
2. BDark skin, low blood pressure, salt craving and a low blood sodium level
3. CWeight gain around the trunk, a rounded face and thin, easily bruised skin
4. DCoarse facial features and very large hands and feet

У пациента на внутривенном ванкомицине во время быстрой инфузии появились покраснение и зудящая красная сыпь на лице и шее. Какова наиболее вероятная причина и реакция на неё?

1. AНормальная реакция; увеличить скорость инфузии
2. BСолнечный ожог; нанести крем и продолжить
3. CПечёночная недостаточность; навсегда отменить все препараты
4. DИнфузионная реакция; остановить или замедлить инфузию и сообщить назначившему врачу

Что такое фракция выброса?

1. AДавление в левом желудочке в конце диастолического наполнения
2. BПроцент крови желудочка, выбрасываемый при каждом сокращении
3. CОбъём крови, который сердце перекачивает за минуту
4. DОбъём крови, выбрасываемый при каждом сердечном сокращении

On a ventilated patient, the end-tidal CO₂ waveform suddenly drops to zero. What should the nurse suspect first?

1. AA rise in the patient's body temperature over the last hour
2. BNormal variation that needs no action
3. CTube displacement, disconnection or obstruction
4. DA sudden improvement in the patient's lung function

A patient taking sodium valproate becomes tired and is vomiting, and the nurse notices yellowing of the eyes. What is the main concern?

1. ALiver toxicity from valproate
2. BA normal adjustment reaction to the drug
3. CA sign that the dose is too low
4. DDehydration from drinking too little

Three days after a stroke, a patient with dysphagia on a modified diet has a temperature of 38,2 °C (100,8 °F), a respiratory rate of 24/min and crackles at the right lung base. What should the nurse do?

1. AEncourage more fluids by mouth to treat the fever
2. BSuspect aspiration pneumonia, stop oral intake and escalate for review
3. CRecord the findings and recheck them at the next routine observation
4. DGive paracetamol (acetaminophen) and continue the modified diet as before

Какое нарушение электролитов может способствовать послеоперационному илеусу?

1. AГиперкалиемия
2. BГипернатриемия
3. CГипокалиемия
4. DГиперфосфатемия

A patient on immunotherapy for melanoma has six watery stools a day and abdominal cramps. What should the nurse do?

1. AAdvise eating more fibre and fruit to firm up the stools
2. BReassure that diarrhoea is normal and harmless
3. CEscalate urgently, as immune-related colitis is likely
4. DGive loperamide and review next week