Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient is booked for a CT scan with iodinated contrast. Which of the patient’s medications may need to be held according to protocol?

1. AMetformin
2. BLevothyroxine
3. COmeprazole
4. DAcetaminophen (paracetamol)

A patient at 34 weeks of pregnancy has painless, bright red vaginal bleeding. Which action should the nurse avoid?

1. AMeasuring the blood pressure and pulse
2. BMonitoring the fetal heart rate
3. CWeighing the pads to estimate blood loss
4. DA vaginal examination

Which measure is part of the bundle for inserting a central venous catheter to prevent bloodstream infection?

1. ARoutine replacement of the catheter on a fixed schedule, such as every three days
2. BGiving antibiotics to every patient before insertion
3. CChoosing the femoral vein as the first site in adults
4. DChlorhexidine-alcohol skin antisepsis and maximal sterile barrier precautions

Пациент с тяжёлой иммуносупрессией после трансплантации стволовых клеток находится в защитной среде. Какой предмет нельзя вносить в палату?

1. AСобственная чистая одежда пациента
2. BСемейное фото в рамке, которую протёрли
3. CЧистый дезинфицированный планшет
4. DСвежие цветы или комнатные растения в горшках

A urine culture is ordered for a patient with an indwelling urinary catheter. How should the nurse collect the sample?

1. APour urine from the drainage bag into a sterile cup
2. BAspirate from the sampling port with a sterile syringe
3. CRemove the catheter and culture the catheter tip
4. DDisconnect the catheter from the tubing and let it drain

An RN cares for a patient on a 24-hour urine collection. Which task can be delegated to unlicensed assistive personnel (UAP), such as a nursing or healthcare assistant?

1. ADeciding whether to restart the collection after a missed sample
2. BInterpreting the creatinine clearance result when it comes back
3. CSaving all urine in the collection container as instructed
4. DTeaching the patient why the 24-hour collection is needed

Why is lactulose given to a patient with hepatic encephalopathy?

1. ATo increase the liver's production of albumin
2. BTo stop bleeding from varices
3. CTo lower the blood glucose
4. DTo reduce the absorption of ammonia from the gut

After a viral illness, a patient has sharp chest pain that is worse lying flat and eased by sitting forward. What is the most likely cause?

1. APulmonary oedema
2. BAortic dissection
3. CPericarditis
4. DStable angina

A patient is going home with a 24-hour Holter monitor. Which instruction is most important?

1. AKeep a diary of symptoms and activities with the times
2. BRemove the monitor whenever symptoms occur and restart it
3. CShower as normal with the monitor on
4. DStay in bed for the full 24 hours so the trace is clear

Two days after coronary artery bypass surgery, a patient feels palpitations. The pulse is irregularly irregular at 140/min and BP is 112/70 mmHg. Which rhythm is most likely?

1. AVentricular fibrillation
2. BComplete heart block
3. CAtrial fibrillation
4. DSinus tachycardia

What is the main purpose of continuous bladder irrigation after a transurethral resection of the prostate (TURP)?

1. ATo treat a urinary infection after the operation
2. BTo give the patient extra fluids
3. CTo measure the size of the bladder
4. DTo stop blood clots from blocking the catheter

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

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

Which advice has good evidence for reducing cancer-related fatigue?

1. ARegular light to moderate activity, such as walking
2. BDrinking several strong coffees every evening
3. CComplete bed rest for the whole course of treatment
4. DAvoiding all daily activities

Кожа вокруг илеостомы пациента красная, мокнущая и воспалённая, мешок часто протекает. Какая причина наиболее вероятна?

1. AИшемия стомы, требующая срочной операции
2. BАллергия на сам стул, требующая стероидов
3. CОтделяемое на коже, часто из-за плохо подобранного мешка
4. DНормальная реакция, не требующая изменения ухода