Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

A patient’s urinary catheter has drained no urine for two hours, and the lower abdomen is swollen. What should the nurse do first?

1. ACheck the tubing for kinks or obstruction
2. BGive a prescribed diuretic straight away
3. CEncourage the patient to drink more water
4. DRemove the catheter and wait for the patient to void

Which nursing approach may raise intracranial pressure in a patient with a head injury?

1. AKeeping the head in line with the body
2. BSpacing out care with rest periods in between activities
3. CKeeping the room calm and quiet
4. DDoing suctioning, turning and bathing all at the same time

A patient receiving continuous nasogastric feeding has pulled the tube partly out. What should the nurse do first?

1. AStop the feeding until the tube position is checked
2. BIncrease the feed rate to make up for the lost time
3. CTape the tube in its new position and continue
4. DPush the tube back in and restart the feed

A patient has a rash, and both smallpox and chickenpox are considered. Which finding suggests smallpox?

1. ALesions all at the same stage, most dense on the face and limbs
2. BA rash that is very itchy and starts on the trunk
3. CLesions at different stages, most dense on the trunk
4. DSmall crops of new lesions appearing over several days in a row

How should a blood sample for serum ammonia be handled?

1. ALeft at room temperature for several hours first
2. BShaken firmly to mix it before it is sent away
3. CKept warm and sent with the next routine batch
4. DPlaced on ice and sent to the laboratory at once

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

A nurse gives a patient analgesia for post-operative pain. What should be done next?

1. AAssume the pain has gone if the patient is quiet and has their eyes closed
2. BWait until the next shift before asking the patient about the pain
3. CReassess the pain and any side effects once the drug has had time to work
4. DGive a second analgesic straight away just in case

Why should "units" never be abbreviated to "U" or "IU" on an insulin prescription?

1. AIt changes the type of insulin given
2. BPharmacists cannot dispense insulin written that way
3. CThe abbreviation is only allowed on prescriptions for children
4. DThe letters can be misread as a zero, causing a tenfold overdose

Which exercise advice is recommended for intermittent claudication?

1. AWalking only on days when the legs feel warm and painless
2. BComplete bed rest until the leg pain has gone for at least a month
3. CStopping walking at the very first twinge of pain each time
4. DSupervised walking until pain is near maximal, then rest and repeat

На 6-й день інфузії гепарину кількість тромбоцитів впала більш ніж наполовину, а в пацієнта з'явилася нова набрякла рука. Що має передбачати медсестра?

1. AВідміну всієї антикоагуляції на два тижні
2. BПерехід на НМГ, бо це інший препарат
3. CПродовження гепарину та переливання тромбоцитів
4. DВідміну всього гепарину та початок негепаринового антикоагулянту

A nurse is teaching a patient going home after a mild concussion. Which statement shows a need for further teaching?

1. A"Someone will stay with me for the first night."
2. B"I will return if my headache gets steadily worse."
3. C"A few drinks tonight will help me relax and sleep."
4. D"I will come back if I start vomiting again and again."

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

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

Why is IV hydration given with cisplatin?

1. ATo make the drug less effective
2. BTo raise the blood pressure during treatment
3. CTo protect the kidneys from damage
4. DTo prevent hair loss

A patient with facial burns from a house fire was talking normally on arrival. Two hours later, the voice is hoarse and there is stridor. What should the nurse do?

1. ACall for urgent anaesthetic help, as the airway is swelling
2. BEncourage the patient to rest the voice and reassess tomorrow
3. CLay the patient flat to help them sleep
4. DGive a warm drink to soothe the throat