Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A nurse cannot read part of a medication order. What should the nurse do?

1. ASkip the drug and not tell anyone until the next ward round
2. BGive the usual dose of the drug the nurse thinks was meant
3. CContact the prescriber to clarify the order before giving the drug
4. DAsk another nurse to guess what the order most likely says, then give it

Пациент получает парентеральное питание через центральный катетер. Какая находка требует немедленных действий?

1. AПотливость, дрожь и глюкоза 62 mg/dL (3,4 mmol/L) после неожиданной остановки инфузии
2. BГлюкоза 150 mg/dL (8,3 mmol/L) во время инфузии
3. CПрибавка массы 0,2 кг со вчерашнего дня
4. DСухая целая повязка над катетером

Which PPE does a nurse wear when giving an IV chemotherapy drug?

1. AOne pair of standard latex gloves, changed after the infusion is started
2. BA reusable cloth gown and one pair of gloves
3. CA surgical mask and no gloves
4. DTwo pairs of chemotherapy-tested gloves and a disposable impermeable gown

Медсестра не уверена, коснулась ли стерильная перчатка края стерильного поля. Какое действие правильно?

1. AСчитать перчатку загрязнённой и заменить её
2. BПротереть перчатку спиртом
3. CСпросить пациента, не видел ли он этого
4. DПродолжить, потому что медсестра не уверена

A tired patient with heavy menstrual periods has a normal hemoglobin and MCV but a ferritin of 8 ng/mL. What does this show?

1. AIron deficiency without anemia yet
2. BIron overload from too much iron
3. CA completely normal iron status
4. DVitamin B₁₂ deficiency anemia

A patient with acute kidney injury has a potassium of 6,8 mEq/L despite medical treatment, a pH of 7,12 and pulmonary edema not responding to diuretics. Which treatment is most likely needed?

1. AA potassium supplement
2. BAn IV magnesium dose
3. CMore oral fluid
4. DUrgent dialysis

For a patient in skin traction on the leg, which is correct?

1. AThe weights rest on the floor overnight
2. BThe weights hang freely and do not rest on the bed or floor
3. CThe weights are removed whenever the patient feels uncomfortable
4. DThe rope is tied to the bed frame to keep it still

Which statement about oxygen in a patient with suspected acute coronary syndrome is correct?

1. AOxygen must never be given in chest pain
2. BHigh-flow oxygen should always be given, whatever the SpO₂
3. COxygen is given if the SpO₂ is below the target range
4. DOxygen replaces the need for an ECG

A patient with angle-closure glaucoma needs nebulised ipratropium. What precaution is sensible?

1. AMix it with an eye drop before putting it in the nebuliser
2. BUse a mouthpiece or protect the eyes from the mist
3. CGive it only with the patient lying completely flat
4. DRun it at the highest possible gas flow

A patient with rheumatoid arthritis is due to start an anti-TNF biologic drug. Which screening is essential beforehand?

1. AScreening for latent tuberculosis
2. BA sweat chloride test
3. CA peak flow diary for a month
4. DAn exercise ECG test on a treadmill

Several hours after a carotid endarterectomy, which finding needs the most urgent action?

1. AA small amount of dried blood on the dressing
2. BAn expanding neck swelling with noisy breathing
3. CA blood pressure slightly above the baseline
4. DMild pain at the incision site

A patient on insulin has worsening chronic kidney disease and is having more hypos. What is the best explanation?

1. AThe patient is eating far more carbohydrate than before
2. BThe kidneys clear less insulin, so it lasts longer
3. CKidney disease makes the meter read too low
4. DKidney disease makes the body resistant to insulin

Why is blood lactate measured when sepsis is suspected?

1. AIt shows which bacteria are causing the infection
2. BIt replaces the need for blood cultures
3. CA raised level suggests poor tissue perfusion
4. DIt measures the effect of antibiotics on the kidney

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