Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

Two hours after birth, the nurse finds the uterus firm but above the umbilicus and pushed to the right. What should the nurse do first?

1. AHelp the patient empty her bladder
2. BGive a dose of oxytocin straight away
3. CAsk the patient to lie still for another hour
4. DMassage the uterus firmly for ten minutes

A patient with diabetic ketoacidosis is about to start an IV insulin infusion. The serum potassium is 3,0 mEq/L. What should the nurse do?

1. AGive the insulin as a fast bolus to bring the potassium up
2. BIgnore the result, since potassium is always high in this condition and will correct itself
3. CStart the insulin at once, because the glucose is the bigger problem
4. DReport the result before starting, because insulin will push potassium even lower

Which kitchen practice helps prevent scald burns in young children?

1. ATurn pot handles toward the back of the stove
2. BLet the child stand on a chair beside the stove
3. CHold the child while drinking a hot drink
4. DLeave hot drinks at the edge of the table

A nurse has worked three long shifts in a row and feels exhausted. The manager asks the nurse to stay for another shift. What is the most appropriate response?

1. AAgree and drink extra coffee to stay alert
2. BAgree, but skip the independent medication checks to save energy on the shift
3. CExplain that fatigue would make care unsafe and decline the extra shift
4. DAgree without telling anyone about the fatigue

When should the nurse check the glucose before giving a mealtime dose of rapid-acting insulin (such as lispro)?

1. ATwo hours after the meal, then giving the insulin dose
2. BAt bedtime only, then giving the mealtime insulin overnight
3. CJust before the meal, giving insulin when the food is ready
4. DOnly once a day, then giving the same dose before every meal

У пацієнта з давнім захворюванням легень бікарбонат у сироватці 32 mEq/L, артеріальний PaCO₂ стабільно високий, а pH 7,36. Який стан найкраще відповідає?

1. AГостре передозування аспірину зі швидким диханням
2. BГостра тяжка діарея з великими втратами бікарбонату
3. CГострий діабетичний кетоацидоз з тяжким зневодненням і блюванням
4. DХОЗЛ з хронічною затримкою CO₂ та метаболічною компенсацією

What is the recommended first aid for a thermal burn?

1. ASpread butter or oil over the burn
2. BApply ice directly to the burn until the pain stops completely
3. CBurst any blisters to release the fluid
4. DCool it under cool running water for about 20 minutes

Soon after starting chemotherapy for a high-grade lymphoma, a patient has rising potassium, phosphate and uric acid with falling urine output. What is the most likely cause?

1. AAdrenal insufficiency
2. BSyndrome of inappropriate ADH secretion
3. CRefeeding syndrome
4. DTumour lysis syndrome

A patient is starting long-term amiodarone. Which teaching and monitoring are most important?

1. AEat extra salt and stop the drug as soon as the pulse is regular
2. BAvoid dairy products and have the INR checked once at the start
3. CProtect skin from sunlight and have thyroid, liver and lung checks
4. DExpect orange urine and no need for blood tests

A ventilated patient with severe ARDS is to be turned prone. What is the main reason, and the key nursing risk?

1. AIt improves oxygenation; risks are pressure injury and tube displacement
2. BIt treats infection; the risk is fever
3. CIt improves digestion and gut motility; the main risk is constipation
4. DIt lowers the blood pressure; the main risk is rebound hypertension

Why is IV calcium gluconate given in severe hyperkalaemia?

1. AIt binds potassium in the gut
2. BIt moves potassium into the cells
3. CIt protects the heart from arrhythmias
4. DIt removes potassium through the kidneys

A patient with myasthenia gravis took extra pyridostigmine doses. They now have more weakness, heavy salivation, sweating, diarrhoea, small pupils and a slow pulse. What is most likely?

1. AAn allergic reaction to the drug
2. BA myasthenic crisis from too little medication
3. CA cholinergic crisis from too much medication
4. DA normal response to a higher dose

Which patient is at highest risk of refeeding syndrome?

1. AA patient who missed one lunch because of a scan
2. BA patient with a normal BMI eating three meals a day
3. CA healthy adult after an overnight fast for minor surgery
4. DAn underweight patient who has eaten very little for 10 days

У пацієнта з ілеостомою немає виділень 6 годин, є спазматичний біль, здуття, нудота й набрякла стома. Що має запідозрити медсестра?

1. AНормальний тихий період для нової ілеостоми
2. BЗакупорку стоми, часто їжею, що потребує огляду
3. CЗневоднення через дуже високе виділення з ілеостоми
4. DНезначний шкірний висип навколо стоми