Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient with asthma uses a peak flow meter. A reading below 50% of personal best is in the red zone. Which statement shows correct understanding?

1. A“I will wait until tomorrow morning to see if the reading gets better on its own.”
2. B“I will go for a short run to open up my lungs.”
3. C“I will stop all my inhalers until the reading is back up.”
4. D“I will use my reliever inhaler and get emergency help straight away.”

A marathon runner is confused, with a temperature of 41 °C and hot skin. What is the priority?

1. AAsking the runner to rest in the shade and drink slowly
2. BGiving an antipyretic tablet and waiting for it to work
3. CWrapping the runner in a blanket to prevent shivering
4. DRapid cooling while supporting airway and circulation

What is the main aim of purposeful hourly rounding?

1. ATo wake the patient every hour to check orientation
2. BTo count the patient’s medications every hour and check that none are missing
3. CTo replace the need for a call light
4. DTo check pain, toileting, position and personal items before the patient needs to ask

A patient who speaks little English is being discharged with new medications. The patient’s 12-year-old child offers to interpret. What should the nurse do?

1. AUse simple English and many hand gestures
2. BUse a professional medical interpreter
3. CLet the child interpret, because the family prefers it
4. DGive written instructions in English only

A patient has macrocytic anemia with numbness and tingling of the feet and poor balance. Which deficiency is most likely?

1. AIron (low ferritin)
2. BVitamin B₁₂
3. CFolate (folic acid)
4. DVitamin C (ascorbic acid)

An older adult has bone pain, fatigue and frequent infections. Results show anemia, a calcium of 12,4 mg/dL (3,1 mmol/L), a raised total protein and a rising creatinine. Which condition should be suspected?

1. AIron-deficiency anemia
2. BMultiple myeloma
3. CPrimary hypothyroidism
4. DAcute viral hepatitis

Why must a patient with a new coronary stent not stop their antiplatelet medicines without specialist advice?

1. AStopping early greatly increases the risk of a clot forming in the stent
2. BStopping causes immediate kidney failure
3. CStopping causes severe low blood pressure
4. DThe stent will dissolve if the drugs are stopped before the course ends

У пациента с черепно-мозговой травмой балл ШКГ снизился с 14 до 10, а один зрачок расширился и медленно реагирует. Что должна сделать медсестра?

1. AПерепроверить ШКГ при следующем плановом обходе
2. BНемедленно сообщить о неотложном неврологическом состоянии
3. CПредложить пациенту поспать
4. DДать седативное средство, чтобы успокоить пациента

A patient on theophylline develops nausea, vomiting, a fast heart rate and restlessness. What should the nurse suspect?

1. AA theophylline allergy causing a rash
2. BTheophylline toxicity
3. CHypoglycaemia caused by the drug
4. DAn expected sign that the drug is working

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. BTube displacement, disconnection or obstruction
3. CNormal variation that needs no action
4. DA sudden improvement in the patient's lung function

У пациента с острой травмой спинного мозга на уровне C6 какая картина указывает на нейрогенный шок?

1. AНормальное артериальное давление, частый пульс и высокая лихорадка
2. BВысокое артериальное давление, редкий пульс и пульсирующая головная боль
3. CНизкое артериальное давление, редкий пульс и тёплая сухая кожа
4. DНизкое артериальное давление, частый пульс и холодная влажная кожа

У пациента с травмой спинного мозга на уровне T4 пульсирующая головная боль, АД 210/110 mmHg, покрасневшая потная кожа выше уровня травмы и пульс 50/мин. После того как пациента посадили, каков следующий приоритет?

1. AНайти и устранить триггер, начиная с мочевого пузыря
2. BВвести быстрый болюс внутривенной жидкости для поддержки кровообращения
3. CДать седативное средство и перепроверить давление через час
4. DСнова уложить пациента плашмя и поднять ноги на подушки

How should a patient with facial burns usually be positioned?

1. ALying flat with the head lower than the feet
2. BWith the head of the bed raised to reduce swelling
3. CIn any position that keeps the face covered
4. DLying face down on the pillow to protect the airway

During preoperative assessment, a patient says their brother had a "very high fever" during an anaesthetic. What is the most important action?

1. ARecord it as a family allergy to paracetamol
2. BReassure the patient that fevers after anaesthesia are always harmless
3. CInform the anaesthetist, as malignant hyperthermia may run in the family
4. DGive paracetamol before surgery to prevent fever