Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient on a continuous IV heparin infusion has new black, tarry stools and an aPTT well above the target range. What should the nurse do first?

1. AOffer an iron-rich meal to replace the lost blood
2. BStop the heparin infusion and inform the provider
3. CCheck the pump rate and leave the infusion running
4. DGive a dose of vitamin K by mouth

LPN/LVN сообщает, что у стабильного пациента появилась новая боль в груди. Что должна сделать RN?

1. AЛично оценить пациента и решить о дальнейших шагах
2. BПопросить LPN/LVN разобраться и сообщить в конце смены
3. CСказать LPN/LVN дать нитроглицерин по требованию без оценки
4. DПопросить помощника медсестры сделать ЭКГ и ждать результата

When should a nurse call the rapid response team?

1. AWhen a patient shows an acute decline, such as new confusion or a sharp change in vital signs
2. BOnly after a patient has had a cardiac or respiratory arrest on the ward
3. COnly when the provider has written an order for a rapid response call in the chart
4. DOnly when the patient’s family makes a complaint

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. ARaise all four side rails so the patient stays in bed
2. BTell the patient to wait until the morning
3. CWalk with the patient to the bathroom and stay close by
4. DTell the patient to go alone and use the call light if needed

A patient with chronic kidney disease receives an erythropoiesis-stimulating agent such as epoetin alfa. Which assessments are most important?

1. AHemoglobin and blood pressure
2. BSerum amylase and lipase
3. CSerum glucose and ketones
4. DLiver enzymes and bilirubin

A patient with kidney stones and fatigue has a calcium of 11,6 mg/dL (2,9 mmol/L), a high parathyroid hormone (PTH) and a low phosphate. Which condition is most likely?

1. AVitamin D deficiency
2. BHypoparathyroidism
3. CPrimary hyperparathyroidism
4. DCancer-related hypercalcemia

Какой препарат используют для нейтрализации нефракционированного гепарина?

1. AПротамина сульфат
2. BФлумазенил
3. CВитамин K (фитоменадион)
4. DНалоксон

Which sign is often a late finding in hypovolaemic shock in a young, previously fit adult?

1. AA rise in heart rate
2. BCool peripheries
3. CA slightly raised respiratory rate
4. DA fall in blood pressure

How big should a suction catheter be compared with the tracheostomy or endotracheal tube?

1. ANo more than half the internal diameter of the tube
2. BAny size, as the diameter does not matter
3. CLarger than the tube, so that it clears it completely
4. DExactly the same diameter as the tube, for a tight fit

A patient with crushing chest pain has ST elevation in leads V1–V4. Which coronary artery is most likely blocked?

1. AThe left anterior descending artery
2. BThe left subclavian artery
3. CThe right coronary artery and its branches
4. DThe circumflex artery

A patient's fistula starts to bleed at home after the needles were removed. What should they do first?

1. AWait for the next dialysis session
2. BApply a tight tourniquet above the fistula
3. CRaise the arm and let it bleed freely
4. DPress firmly on the site with clean gauze

A haemodialysis patient missed their last two sessions. They are breathless, with crackles, and the potassium is 6,9 mmol/L. What is the priority?

1. AOral potassium supplements and rest
2. BLarge IV fluid boluses to improve the circulation
3. CUrgent dialysis, with cardiac monitoring meanwhile
4. DA routine dialysis session at the next planned slot

У пациента с новой илеостомой очень высокое отделяемое. В чём главный риск?

1. AВысокий кальций и камни в почках в течение нескольких дней
2. BГиперволемия и отёк лодыжек
3. CОбезвоживание и потеря натрия, калия и магния
4. DЗапор и копростаз в кишке выше стомы

Which preoperative blood result should the nurse report to the team before elective surgery?

1. APotassium 2,9 mmol/L
2. BHaemoglobin 138 g/L (13,8 g/dL) in a man
3. CSodium 139 mmol/L
4. DFasting glucose 5,4 mmol/L (97 mg/dL)