NCLEX Tarzı Önceliklendirme ve Görev Devri: hızlı tekrar paketi

On the first day after abdominal surgery, a patient has a temperature of 37,9 °C and reduced breath sounds at the lung bases. Which nursing action is most helpful?

1. AKeep the patient lying flat in bed to rest the incision fully
2. BEncourage deep breathing, coughing and use of the incentive spirometer
3. CRestrict oral fluids so that the lungs do not fill up with extra fluid
4. DGive a cough suppressant so that the incision is not strained

Bir hemşire yardımcısı, bir hastanın ilk morfin dozundan 15 dakika sonra yaşam bulgularını ölçtü. Solunum sayısının 10/dk olduğunu ve hastanın zor uyandığını bildiriyor. Hemşire ne yapmalıdır?

1. AHastayı görmeden önce istem almak için sağlık profesyonelini aramak
2. BYardımcıdan solunum sayısını 15 dakika sonra yeniden kontrol etmesini ve bildirmesini istemek
3. CBulguları belgelemek ve sağlık profesyoneline bir sonraki planlı turda söylemek
4. DHemen gitmek, hastayı uyandırmak, solunumu desteklemek ve istem uyarınca naloksonu hazırlamak

An order uses the abbreviation “MS”. Why is this unsafe?

1. AIt can mean either morphine sulfate or magnesium sulfate
2. BIt means the drug must be given by mouth only
3. CIt is reserved for drugs used in multiple sclerosis
4. DIt is the abbreviation for milliseconds, not a drug

Bir gece hemşiresi, sakin ama dolaşan bir hastanın “bu gece daha az personelle idare edebilmek için” kısıtlanmasını öneriyor. Hangi yanıt doğrudur?

1. AKısıtlama asla personelin rahatlığı için değildir; düzenli kontrol turu veya refakatçi kullanılır
2. BPersonel az olduğunda geceleri kısıtlama kabul edilebilir
3. CAile önceden yazılı olarak onaylarsa kısıtlama kabul edilebilir
4. DSabah çıkarılırsa kısıtlama kabul edilebilir

A patient's levothyroxine dose was changed today. When is the TSH usually rechecked?

1. AAfter about 3 days
2. BAfter about 24 hours
3. CAfter about 6–8 weeks
4. DAfter about 1 year

At the start of a shift, the nurse reviews four new results. Which patient needs attention first?

1. AHemoglobin 11,0 g/dL (110 g/L) in a patient with rheumatoid arthritis
2. BPotassium 5,2 mEq/L in a patient with stable chronic kidney disease
3. CSodium 119 mEq/L in a patient with new confusion and vomiting
4. DGlucose 180 mg/dL (10 mmol/L) after a meal in a patient with diabetes

Kalp yetmezliği olan bir hasta iki günde 2 kg alıyor. Bu en olası neyi gösterir?

1. ASıvı tutulumu
2. BBaşarılı tedavi
3. CKas kütlesi artışı
4. DDehidratasyon

A patient with several days of vomiting and diarrhoea has low blood pressure, low urine output and a rising creatinine. Which description fits best?

1. AIntrinsic kidney injury from glomerulonephritis, treated with high-dose steroids
2. BPre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
3. CPost-renal acute kidney injury from obstruction, treated with a catheter
4. DChronic kidney disease, treated with long-term dialysis three times a week

A nurse measures blood pressure on a large upper arm using a cuff that is too small. What effect will this have?

1. AOnly the pulse rate will be affected
2. BThe reading will be falsely low
3. CThe reading will be accurate but slower
4. DThe reading will be falsely high

The monitor of a patient with a permanent pacemaker shows pacing spikes, but none of them is followed by a QRS complex. What does this mean?

1. AFailure to capture
2. BAtrial fibrillation
3. CNormal pacemaker function
4. DFailure to sense

Hangi sonuç seti HHD'den (HHS) çok DKA'yı destekler?

1. A30 mmol/L'nin üzerinde glukoz ve normal pH
2. BNormal ketonlar ve normal bikarbonat
3. CYüksek ketonlar, 7,3'ün altında pH ve düşük bikarbonat
4. DKanda yalnızca iz keton ile çok yüksek ozmolalite

A nurse teaches a patient about peritoneal dialysis. Which statement shows a need for further teaching?

1. A"I will weigh myself daily and record my fluid balance."
2. B"I will wash my hands carefully before each exchange."
3. C"I will check my exit site every day."
4. D"If the fluid is cloudy, I'll see if it clears next time."

Which task for a stable patient with an established ileostomy can usually be delegated to a trained healthcare assistant (nursing assistant)?

1. AEmptying the pouch and measuring the output
2. BTeaching the patient about high-output risks
3. CAssessing the stoma for signs of necrosis
4. DDeciding whether IV fluids are needed

A patient with a PICC line develops swelling and aching of the same arm and prominent veins on the chest. What should the nurse suspect?

1. AA catheter-related deep vein thrombosis
2. BLymphoedema from a previous operation
3. CAn allergy to the dressing
4. DNormal swelling after line insertion