Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Стабильному взрослому с нормальными жизненными показателями нужно наложить швы на порез руки, ничего больше. Какой уровень ESI подходит?

1. AУровень 2
2. BУровень 5
3. CУровень 3
4. DУровень 4

Какого пациента в нефрологическом отделении медсестре следует осмотреть первым?

1. AПациента, у артериовенозной фистулы которого сильные дрожание и шум
2. BПациента на гемодиализе, пропустившего вчерашний сеанс, у которого теперь мышечная слабость и нерегулярный пульс
3. CПациента, просящего совета по диете с низким содержанием фосфатов
4. DПациента на перитонеальном диализе, у которого слитая жидкость прозрачная

Which kitchen practice helps prevent scald burns in young children?

1. ATurn pot handles toward the back of the stove
2. BHold the child while drinking a hot drink
3. CLet the child stand on a chair beside the stove
4. DLeave hot drinks at the edge of the table

A patient asks for a pain tablet. The record shows none has been given, but the patient says, “The other nurse gave me one earlier.” What should the nurse do?

1. ATell the patient they must be confused
2. BCheck with the other nurse and the records before giving another dose
3. CGive half a tablet now, to be safe, and the other half later if needed
4. DGive the tablet, because the record shows none was given

A patient is on an IV insulin infusion protocol in the ICU. How often is the blood glucose usually checked?

1. AOnce a day before breakfast
2. BOnly if symptoms occur
3. CAbout every hour
4. DOnce every 12 hours

A patient has eaten very little for 2 weeks and has received broad-spectrum antibiotics. The INR is now 2,3 without warfarin, and the platelets are normal. What is the most likely cause?

1. AIron-deficiency anemia
2. BHemophilia A
3. CVitamin K deficiency
4. DImmune thrombocytopenia

Что пациенту с хронической болезнью почек обычно нужно ограничивать в питании?

1. AТолько водорастворимые витамины
2. BУглеводы полностью
3. CКалий и фосфор
4. DВитамин C и клетчатку

Why can sepsis be missed in older adults?

1. AOlder adults always have a very high fever
2. BBlood tests are not useful in older people
3. COlder adults cannot develop sepsis because their immune system is weaker
4. DThey may have no fever and present with confusion, falls or reduced mobility

A patient has episodes of severe headache, sweating and palpitations with very high blood pressure. Which rare cause should be considered?

1. AStable angina
2. BAortic stenosis
3. CAsthma
4. DPhaeochromocytoma

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

Какое утверждение о внутривенном введении фенитоина верно?

1. AЕго вводят в 0,9% хлориде натрия при кардиомониторинге
2. BНе требуется контроль сердечного ритма и артериального давления
3. CЕго можно добавлять в любую инфузию глюкозы
4. DЕго следует вводить быстро, за несколько секунд

Which task can the registered nurse delegate to a trained healthcare assistant (nursing assistant)?

1. AAssessing a confused patient whose glucose is 2,6 mmol/L (47 mg/dL)
2. BChecking pre-meal glucose and reporting results out of range
3. CTeaching a new patient how to inject insulin
4. DDeciding the dose of correction insulin from the glucose result

Which long-term effect must be monitored in patients receiving anthracyclines such as doxorubicin?

1. APermanent high blood glucose
2. BDamage to the heart muscle
3. CExcess growth of body hair
4. DLoss of the sense of smell

A patient with facial burns from a house fire was talking normally on arrival. Two hours later, the voice is hoarse and there is stridor. What should the nurse do?

1. ACall for urgent anaesthetic help, as the airway is swelling
2. BEncourage the patient to rest the voice and reassess tomorrow
3. CLay the patient flat to help them sleep
4. DGive a warm drink to soothe the throat