Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

При триаже START неходячий взрослый дышит 36 раз в минуту. В какую категорию он попадает?

1. AЧёрная (безнадёжные)
2. BЗелёная (лёгкие)
3. CЖёлтая (отсроченная помощь)
4. DКрасная (немедленная помощь)

У пациента с центральным венозным катетером при удалении катетера внезапно появляются одышка, боль в груди и падающая SpO₂. Что медсестра делает первым?

1. AЗакрывает место введения, поворачивает на левый бок головой вниз, даёт кислород и зовёт на помощь
2. BСажает пациента вертикально и быстро завершает удаление катетера
3. CПромывает катетер физраствором, чтобы устранить любую закупорку
4. DПросит пациента делать медленные глубокие вдохи и продолжает

A parent says, “I tell my son his medicine is candy so he takes it.” What should the nurse teach?

1. ADo not call medicine candy, because the child may take it when no one is watching
2. BThis is a good idea and makes giving medicine easier
3. CIt only matters for medicines that taste bitter or are hard to swallow
4. DIt is fine as long as the medicine is kept in the fridge

A patient has signed a surgical consent form but tells the nurse, “I don’t really understand what they are going to do.” What should the nurse do?

1. AInform the surgeon so the procedure can be explained again before any sedation
2. BGive the preoperative sedative so the patient relaxes
3. CExplain the risks and benefits in place of the surgeon
4. DReassure the patient that the surgeon knows best and continue with the preparation

A patient has a calcium of 11,8 mg/dL (2,95 mmol/L) from bone metastases. Which nursing measure is appropriate?

1. AEncourage bed rest and limit oral fluids
2. BGive calcium carbonate antacids for nausea
3. COffer extra milk and cheese at each meal
4. DEncourage fluids and mobility as tolerated

A patient with severe sepsis is oozing blood from IV sites. Platelets 40 × 10³/µL, fibrinogen low, D-dimer very high, PT and aPTT both prolonged. Which condition fits best?

1. AHeparin-induced thrombocytopenia (HIT)
2. BHemophilia A (factor VIII deficiency)
3. CImmune thrombocytopenic purpura (ITP)
4. DDisseminated intravascular coagulation (DIC)

Which blood result often rises in an upper GI bleed because blood is digested in the gut?

1. ASodium
2. BGlucose
3. CUrea (blood urea nitrogen)
4. DCalcium

A patient has a full-thickness burn all the way round the forearm. Which complication must be watched for closely?

1. ADelayed hair growth on the arm
2. BLoss of circulation to the hand as swelling builds under tight burned skin
3. CHypoglycaemia caused by the body using glucose to heal the burn
4. DExcessive bleeding from the burn surface needing an urgent blood transfusion

Какое указание обычно дают в первые несколько недель после установки постоянного кардиостимулятора?

1. AДважды в день сильно массировать рану
2. BНе поднимать руку на этой стороне выше уровня плеча
3. CСовсем не принимать душ и не мыться шесть недель
4. DДержать руку полностью неподвижно в повязке шесть месяцев и дольше

A patient with a valid, documented do-not-attempt-CPR decision (DNACPR in the UK, DNR or DNAR in the US) is found in cardiac arrest. What should the nurse do?

1. ANot start CPR, call for support, and provide dignity and comfort
2. BStart full CPR because the patient's family is not present
3. CCall the arrest team and let them decide whether to resuscitate
4. DStart CPR but use only chest compressions

A patient with type 1 diabetes has gastroenteritis and cannot eat. Which sick-day advice is correct?

1. AAvoid drinking fluids to reduce the vomiting
2. BCheck glucose once a day only and rest in bed until better
3. CKeep taking basal insulin and check glucose and ketones more often
4. DStop all insulin until normal eating restarts

During a TURP, a patient becomes confused and nauseated, with a slow pulse and a raised BP. The sodium is 121 mmol/L. What is most likely?

1. AA normal reaction to the spinal anaesthetic
2. BHypoglycaemia from fasting for many hours before surgery
3. CAn allergic reaction to the catheter
4. DTURP syndrome from absorbed irrigation fluid

Какая повязка обычно подходит для раны с обильным экссудатом?

1. AГидрогелевая пластина
2. BСухая марля, меняемая раз в неделю
3. CАльгинат или пенная повязка
4. DТонкая прозрачная плёнка

A bag of parenteral nutrition runs out and the next one will not arrive for several hours. Which risk should the nurse anticipate?

1. ARaised intracranial pressure
2. BSevere hyperkalaemia
3. CRebound hypoglycaemia
4. DAcute urinary retention