Приоритизация и делегирование в стиле NCLEX: шпаргалка-пакет

A patient with schizophrenia says voices are telling him to hurt his roommate. What is the priority?

1. ATell him the voices are not real and leave him alone
2. BAsk the roommate to stay in the room with him and help calm him down
3. CIgnore the comment, because voices are part of his illness
4. DKeep everyone safe and tell the team, as the risk of harm is high

Which patient is the most appropriate to assign to an LPN/LVN?

1. AA patient who has just arrived from the emergency department with pneumonia and confusion
2. BA patient with a long-standing tracheostomy who needs routine suctioning and care
3. CA patient with a tracheostomy placed this morning who is coughing up blood
4. DA patient on a new IV medication that needs frequent titration

Сканер штрихкода предупреждает, что препарат не соответствует записи пациента. Что должна сделать медсестра?

1. AДать препарат и сообщить о предупреждении позже в течение смены
2. BОтсканировать браслет другого пациента
3. CПроигнорировать предупреждение и дать препарат
4. DОстановиться и выяснить причину, прежде чем давать препарат

A nurse caring for a patient with influenza on droplet precautions will assist with an aerosol-generating procedure, such as bronchoscopy. What change in PPE is needed?

1. AWear gloves only, because the procedure is short
2. BWear two surgical masks, one on top of the other, for the length of the procedure
3. CWear a fit-tested respirator (N95 or FFP3) and eye protection instead of a surgical mask
4. DNo change, because influenza only needs droplet precautions

In the third trimester of pregnancy, a woman's alkaline phosphatase (ALP) is about twice the usual adult range, and the other liver tests are normal. What is the best interpretation?

1. AA sign of new bone cancer
2. BA normal rise from placental ALP
3. CA sign of blocked bile ducts
4. DA sign of acute viral hepatitis

A patient in DKA is receiving IV fluids and insulin. The glucose has fallen to about 220 mg/dL (12,2 mmol/L), but the anion gap is still high. What change would the nurse expect?

1. AStop the insulin infusion because the glucose is near normal
2. BGive an IV bolus of sodium bicarbonate at once
3. CStop the IV fluids and start oral fluids only
4. DAdd dextrose to the IV fluids and continue the insulin

Which group of symptoms suggests hypercalcaemia?

1. AThirst, constipation, confusion and abdominal pain
2. BTingling lips, muscle cramps and spasms of the hands and feet
3. CWeight gain, feeling cold and a slow pulse
4. DSweating, tremor and sudden hunger

Which action is most important in protecting a patient with severe neutropenia from infection?

1. AStrict hand hygiene by everyone who has contact with the patient
2. BGiving routine intramuscular injections
3. CKeeping fresh flowers and plants in the room to help the patient's mood
4. DTaking rectal temperatures regularly

Что такое фракция выброса?

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

A patient regains a pulse after a ventricular fibrillation arrest that was probably caused by a heart attack. Which investigation is most urgent?

1. AA lumbar puncture
2. BAn abdominal ultrasound
3. CSpirometry
4. DA 12-lead ECG

A patient has had a calcium oxalate kidney stone. Which advice best helps prevent another?

1. ADrink plenty of fluid so the urine stays pale
2. BCut all calcium out of the diet
3. CDrink only a little to avoid diluting the urine
4. DTake extra vitamin C supplements

A nurse teaches a carer to give buccal midazolam for prolonged seizures. Which statement shows a need for further teaching?

1. A"I will write down the time the seizure started and the time I gave the dose."
2. B"I will give it into the space between his gum and cheek."
3. C"I will put something between his teeth so he does not bite his tongue."
4. D"I will call an ambulance if the care plan tells me to."

When is cold therapy most useful for pain?

1. ADirectly on skin with poor circulation
2. BSoon after an acute soft tissue injury, to reduce swelling
3. CFor long-term muscle stiffness, applied continuously for several hours
4. DOver numb areas where sensation is lost

Which history should most alert the nurse to a possible latex allergy before surgery?

1. AItching with bananas, avocado and kiwi, and many operations
2. BA rash after taking amoxicillin as a child, with a family history of asthma
3. CHay fever every spring since childhood
4. DFeeling sick after eating shellfish once