Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

Медсестра просит помощника использовать механический подъёмник. Помощник говорит, что его никогда не обучали им пользоваться. Какое «правильное» делегирования было бы нарушено, если бы медсестра настаивала?

1. AПравильные указания и коммуникация
2. BПравильный надзор и оценка
3. CПравильный человек
4. DПравильная задача

A dehydrated child is to receive IV fluids with added potassium. Which finding should the nurse confirm first?

1. AThat the child is passing urine
2. BThat the child can walk without help
3. CThat the child’s temperature is normal
4. DThat the child is hungry

What is the main aim of purposeful hourly rounding?

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

Ночная медсестра предлагает зафиксировать спокойного, но бродящего пациента, «чтобы справляться меньшим числом сотрудников этой ночью». Какой ответ правильный?

1. AФиксация никогда не применяется для удобства персонала; используйте регулярные обходы или сиделку
2. BФиксации допустимы ночью, когда персонала мало
3. CФиксации допустимы, если их снимают утром
4. DФиксации допустимы, если семья заранее письменно согласна

A patient takes high-dose biotin supplements for hair and nails. Why should the nurse report this before blood tests?

1. ABiotin can distort some immunoassays, such as troponin or TSH
2. BBiotin makes the blood clot in the tube before testing
3. CBiotin lowers the hemoglobin by destroying the red cells
4. DBiotin causes a true rise in blood glucose in all patients

A patient using an insulin pump has a glucose of 300 mg/dL (16,7 mmol/L) that has not fallen 2 hours after a correction bolus through the pump. Blood ketones are 1,8 mmol/L. What is the most likely problem and action?

1. AInsulin delivery failure; inject a correction dose by pen and change the set
2. BRebound after a hypo; give fast-acting carbohydrate and recheck in 15 minutes
3. CInsulin overdose from the pump; suspend the pump and stop all insulin for a day
4. DNormal pump function; wait for the next mealtime bolus to lower the glucose

How does ulcerative colitis differ from Crohn's disease?

1. AUlcerative colitis typically causes patchy "skip" lesions
2. BUlcerative colitis can affect any part of the gut from mouth to anus
3. CUlcerative colitis always affects the full thickness of the bowel wall
4. DUlcerative colitis affects only the colon, continuously from the rectum

Several hours after thyroid surgery, a patient has increasing neck swelling, stridor and difficulty breathing. What is most likely?

1. AHypocalcaemia from parathyroid damage
2. BNormal postoperative swelling
3. CA thyroid storm
4. DA haematoma compressing the airway

A patient with an implantable cardioverter-defibrillator asks what to do if it fires. Which teaching is correct?

1. ARemove the device battery at home if it fires more than once
2. BDrive straight to hospital alone after any shock so the device can be checked by the team
3. COne shock and well: contact the device clinic; repeated shocks or unwell: call emergency services
4. DIgnore any shock at all, because the device is designed to fire every day and needs no follow-up

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. BCall the arrest team and let them decide whether to resuscitate
3. CStart CPR but use only chest compressions
4. DStart full CPR because the patient's family is not present

A patient is starting lamotrigine. Which teaching point is most important?

1. AReport any skin rash promptly, especially in the first weeks
2. BExpect an orange tint to tears and urine
3. CTake it with a glass of grapefruit juice to improve its absorption
4. DDouble the dose if a seizure happens

An older man was found on the floor after lying there for many hours. His urine is dark brown, and his creatine kinase is very high. What is the main kidney risk and the key treatment?

1. AAKI from rhabdomyolysis, treated with generous IV fluids
2. BA urinary infection, treated with oral antibiotics only
3. CHypothermia, treated with a fluid restriction
4. DA kidney stone, treated with strong pain relief

Какая картина электролитов типична для синдрома лизиса опухоли?

1. AВысокие натрий и кальций при низкой мочевой кислоте
2. BНизкие калий и фосфат при высоком кальции
3. CВысокие калий, фосфат и мочевая кислота; низкий кальций
4. DНизкие калий, фосфат и мочевая кислота

A 60 kg adult with 25% TBSA burns arrives 2 hours after the injury, having had no IV fluids. Using the Parkland formula, what hourly rate is needed for the rest of the first 8 hours?

1. A1000 mL/h
2. B250 mL/h
3. C500 mL/h
4. D375 mL/h