Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Медсестра находит пациента на полу рядом с кроватью. Каково первое действие?

1. AОценить реакцию пациента и травмы, прежде чем двигать его
2. BПозвонить семье пациента, чтобы объяснить, что случилось
3. CСоставить акт о происшествии, пока свежи подробности
4. DСразу помочь пациенту вернуться в постель с помощью коллеги

A trauma patient has an open leg fracture, absent breath sounds on one side, a trachea shifted to the other side and a falling blood pressure. Which problem is the priority?

1. AThe open fracture of the leg
2. BThe risk of wound infection
3. CThe suspected tension pneumothorax
4. DThe pain from the fracture

A patient receiving continuous nasogastric feeding has pulled the tube partly out. What should the nurse do first?

1. ATape the tube in its new position and continue
2. BPush the tube back in and restart the feed
3. CIncrease the feed rate to make up for the lost time
4. DStop the feeding until the tube position is checked

A patient receiving chemotherapy has an absolute neutrophil count of 400/mm³ (0,4 × 10⁹/L) and a new temperature of 38,3 °C (100,9 °F). What should the nurse do?

1. AEncourage oral fluids and record the result in the chart
2. BReport it at once, because fever with severe neutropenia is an emergency
3. CGive an antipyretic and reassess at the next routine round
4. DRecheck the temperature in four hours before calling anyone about it

When blood is drawn from a central venous catheter, why is a small volume of blood usually discarded first, according to policy?

1. ATo lower the patient's hemoglobin for a blood transfusion
2. BTo avoid diluting the sample with flush or infusion fluid
3. CTo remove blood clots that form in all central lines
4. DTo check that the catheter tip is still in the right vein

A patient's AST is about twice the ALT, both moderately raised, and the GGT is high. Which cause is most likely?

1. AAlcohol-related liver disease
2. BAcute myocardial infarction
3. CGallstone blocking the bile duct
4. DAcute viral hepatitis A

Which finding with a groin hernia needs urgent surgical review?

1. AThe lump gets bigger when the patient coughs
2. BThe lump disappears completely when the patient lies down flat
3. CThe lump has become painful and tender and cannot be pushed back
4. DThe lump has been present for several years without pain

A patient with type 1 diabetes is nil by mouth before surgery. Why must their insulin not simply be stopped?

1. AStopping insulin causes immediate hypoglycaemia during the operation
2. BInsulin is needed for the anaesthetic to work
3. CInsulin prevents wound infection on its own
4. DWithout any insulin they can develop diabetic ketoacidosis

Что такое фракция выброса?

1. AОбъём крови, выбрасываемый при каждом сердечном сокращении
2. BОбъём крови, который сердце перекачивает за минуту
3. CПроцент крови желудочка, выбрасываемый при каждом сокращении
4. DДавление в левом желудочке в конце диастолического наполнения

A patient on an unfractionated heparin infusion has a nosebleed that will not stop, and the aPTT is far above the target range. What is the most appropriate action?

1. AIncrease the infusion, as the aPTT will settle
2. BGive vitamin K and continue the infusion at a slightly lower rate
3. CContinue the infusion at the same rate and pack the nose firmly
4. DStop the infusion, inform the prescriber and anticipate protamine

How does bladder training help urge incontinence?

1. AThe patient drinks as little as possible
2. BThe time between voids is slowly increased
3. CA catheter is used every night
4. DThe patient goes to the toilet every 15 minutes

Why may HbA1c be unreliable in a patient with haemolytic anaemia or a recent large blood transfusion?

1. AIt depends on how long red blood cells survive in the blood
2. BThe test only measures the glucose in the plasma, not in the cells
3. CBlood transfusions contain large amounts of glucose
4. DAnaemia always makes the HbA1c very high

A patient received IV morphine 20 minutes ago and the surgical consent form has not been signed. What should the nurse do?

1. ATell the surgeon, as the patient may not be able to consent now
2. BAsk the patient to sign quickly before they get sleepier
3. CAsk a relative to sign instead of the patient
4. DSign the form on the patient's behalf as a witness

A patient has had a large terminal ileum resection for Crohn's disease. Which long-term problems should the nurse anticipate?

1. AExcess vitamin D and calcium kidney stones in the first year
2. BIron overload and constipation
3. CInsulin deficiency and high blood glucose from loss of the islets
4. DVitamin B₁₂ deficiency and bile-acid diarrhoea