Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

A patient speaks little English, and the nurse needs to explain a new procedure. What is the best way to communicate?

1. AAsk the patient’s 10-year-old child to translate
2. BUse hand gestures and hope the patient understands
3. CSpeak loudly and slowly in English
4. DUse a professional medical interpreter

A patient with SIADH has a serum sodium of 120 mEq/L and is newly confused. Which nursing action has priority?

1. ASeizure precautions and close neurological checks
2. BTeaching the patient about a low-sodium diet at home
3. CHelping the patient to walk in the corridor alone
4. DEncouraging the patient to drink plenty of water

Before inserting a peripheral IV, the nurse cleans the skin with chlorhexidine-alcohol. What should the nurse do next?

1. ALet it dry fully and do not touch the site again
2. BFeel for the vein again with an ungloved finger
3. CWipe it off with a dry gauze straight away
4. DBlow on the site so it dries faster

Пацієнт із тяжким імунодефіцитом після трансплантації стовбурових клітин перебуває в захисному середовищі. Який предмет не слід приносити до палати?

1. AРодинне фото в рамці, яку протерли
2. BЧистий продезінфікований планшет
3. CВласний чистий одяг пацієнта
4. DСвіжі квіти чи кімнатні рослини в горщиках

Why is a blood β-hydroxybutyrate level often preferred to a urine ketone dipstick in DKA?

1. AThe urine dipstick only detects ketones in people without diabetes
2. BIt measures the main ketone in DKA, and the dipstick may miss it
3. CIt is the only test that can measure glucose and ketones together
4. DIt shows the average ketone level over the past three months

An 82-year-old woman without a catheter has a urine culture growing bacteria, but no fever, urinary symptoms or change in mental state. What is the best interpretation?

1. AA urinary tract infection that needs urgent IV antibiotics
2. BPyelonephritis, which needs admission and IV fluids today
3. CContamination, so the culture must be repeated every week
4. DAsymptomatic bacteriuria, usually not treated with antibiotics

Пацієнт з нейтропенією після хіміотерапії має температуру 38,3 °C. Що є пріоритетом?

1. AДати лише парацетамол і знову перевірити температуру завтра
2. BЗаохотити пацієнта прогулятися
3. CЧекати 24 години, чи минеться гарячка
4. DЛікувати як нейтропенічний сепсис і терміново ввести внутрішньовенні антибіотики

The fluid in an underwater seal chest drain has stopped swinging with breathing. What could this mean?

1. AThe tube may be kinked or blocked, or the lung may have fully re-expanded
2. BThe drain is working perfectly and needs no checks
3. CThe patient's breathing has become normal and the drain can be pulled out by the nurse
4. DThe water seal has been set up correctly for the first time

A patient has chest pain at rest in the early morning with brief ST elevation that resolves. Coronary arteries are later found to be clear. Which condition is most likely?

1. AStable exertional angina from a fixed plaque
2. BAortic stenosis
3. CVasospastic (Prinzmetal) angina
4. DAcute pericarditis

Перед ранковою дозою дигоксину в пацієнта апікальний пульс 54/хв, і його нудить. Що має зробити медсестра?

1. AДати половину дози й перевірити пульс через годину
2. BДати дозу, бо враховується лише променевий пульс
3. CДати дозу та протиблювотний засіб, а пульс перевірити завтра
4. DУтриматися від дози й повідомити, бо можлива токсичність

A patient with type 1 diabetes plans a long cycle ride. Which advice is most appropriate?

1. ASkip breakfast so the exercise burns body fat
2. BAvoid checking glucose until the ride is over
3. CCheck glucose before and after, and carry fast-acting carbohydrate
4. DTake an extra dose of rapid-acting insulin before setting off

After removal of a cortisol-producing adrenal adenoma, why may the patient need hydrocortisone for months?

1. AHydrocortisone helps the wound to heal
2. BThe other adrenal gland has been suppressed
3. CThe tumour will grow back quickly without it
4. DThe operation always removes both adrenal glands

Which is a common side effect of opioids, especially when given by epidural or spinal route?

1. AHair growth
2. BIncreased hunger
3. CRinging in the ears
4. DItching

A patient with diabetes has a foot ulcer. A sterile probe touches bone at the base of the ulcer. What should the nurse suspect?

1. AOsteomyelitis
2. BA healing category 1 ulcer
3. CSimple dry skin
4. DVenous insufficiency