NCLEX Tarzı Önceliklendirme ve Görev Devri: hızlı tekrar paketi

Bir hemşire, bir hemşire yardımcısından “hastanın ağrısını değerlendirmesini ve hastanın daha fazla ilaca ihtiyacı olup olmadığına karar vermesini” istiyor. Görev devrinin hangi doğrusu ihlal edilmiştir?

1. ADoğru görev
2. BDoğru kişi
3. CDoğru gözetim ve değerlendirme
4. DDoğru koşul

Four patients arrive at the emergency department at the same time. Who should be seen first?

1. AAn adult with kidney stone pain of 9/10 and stable vital signs
2. BA child with a temperature of 39 °C who is alert and drinking
3. CA young adult with a swollen, painful ankle after a fall on the stairs
4. DAn older adult with weakness on one side that began 40 minutes ago

A patient is booked for an MRI scan. What must the nurse check beforehand?

1. AWhether the patient has had a hearing test this year
2. BWhether the patient’s blood glucose has been in the normal range today
3. CWhether the patient has eaten a large meal recently
4. DWhether the patient has any metal implants or devices, such as a pacemaker

Which position is especially dangerous for a patient in physical restraints?

1. ALying on the back with the head raised
2. BLying face down (prone)
3. CSitting upright in bed
4. DLying on the side

A stable adult who is not bleeding receives one unit of packed red cells. By about how much is the hemoglobin expected to rise?

1. AAbout 5 g/dL (50 g/L)
2. BAbout 0,1 g/dL (1 g/L)
3. CAbout 1 g/dL (10 g/L)
4. DAbout 3 g/dL (30 g/L)

The nurse teaches a patient with severe neutropenia after chemotherapy. Which statement shows a need for further teaching?

1. A"I'll avoid people who have a cold or the flu"
2. B"I'll wash my hands before eating and after the toilet"
3. C"I'll call the clinic if my temperature rises"
4. D"I'll check my temperature rectally to be accurate"

A dying patient can no longer drink and has a dry mouth. What is the most appropriate nursing care?

1. AStarting a fast intravenous infusion to correct the dryness
2. BInserting a nasogastric tube for fluids
3. CLeaving the mouth alone to avoid disturbing them
4. DFrequent mouth care that keeps the lips and mouth moist

A patient with a possible neck injury after a fall needs their airway opened. Which manoeuvre is preferred?

1. AHead tilt with chin lift
2. BHyperextending the neck
3. CJaw thrust
4. DTurning the head to one side

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

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

Shortly after a thoracentesis, a patient becomes breathless with sharp chest pain and reduced breath sounds on the same side. What complication is most likely?

1. APneumothorax
2. BInfection at the puncture site
3. CPulmonary embolism from the leg
4. DRe-accumulation of the effusion

A patient with a suspected basal skull fracture needs a gastric tube. Which route is preferred?

1. AThrough the nose (nasogastric)
2. BThrough the mouth (orogastric)
3. CThrough a fine-bore nasal tube
4. DThrough the nose with a guidewire

At bedtime, a patient was given their rapid-acting insulin by mistake instead of their long-acting insulin. What should the nurse do?

1. ATell the prescriber and check glucose often overnight
2. BGive glucagon now, before the glucose has fallen
3. CGive the long-acting dose as well and check glucose at breakfast
4. DSay nothing, because the patient is asleep and seems fine

Which treatment often relieves pain from a bone metastasis?

1. APalliative radiotherapy to the area
2. BA diet low in calcium and vitamin D
3. CIron supplements by mouth for several months
4. DComplete bed rest for a month

Kalça ameliyatından sonraki 3. günde yaşlı bir hasta akut konfüze oluyor; dikkati dalgalanıyor ve ajite. Hemşire önce ne yapmalıdır?

1. AYatışsın diye ailesinden hastayı eve götürmesini istemelidir
2. BBunun demans olduğunu varsayıp bakım planını değiştirmeden sürdürmelidir
3. CHastayı kısıtlamalı ve hemen yüksek doz sedatif vermelidir
4. DHipoksi, enfeksiyon, ağrı veya ilaçlar gibi nedenleri araştırmalı ve üst basamağa bildirmelidir