Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

An older patient with dementia is restless at night and keeps trying to get out of bed. Which measure should the nurse try first?

1. AGive a sedative from the as-needed list without first assessing the patient
2. BRaise all four bed rails so the patient cannot climb out
3. CCheck for pain, thirst or a full bladder, and offer toileting
4. DApply wrist restraints for the rest of the night

A victim heavily contaminated with an industrial chemical arrives at the emergency department with stable vital signs. What should happen first?

1. ATaking the victim straight to the X-ray department
2. BDecontamination before the victim enters the treatment area
3. CFull assessment inside the main department straight away
4. DPlacing the victim in the waiting room until a doctor is free

Which practice reduces back strain when a nurse moves a patient or heavy object?

1. AStand with the feet close together for balance
2. BKeep the load close to the body and avoid twisting
3. CHold the load at arm’s length to keep it steady
4. DBend at the waist and keep both knees straight

Медсестра, яка працює з пацієнтом на контактних запобіжних заходах, помічає розрив на рукаві халата. Що вона має зробити?

1. AПродовжити роботу, бо розрив малий і лише на рукаві
2. BЗаклеїти розрив смужкою пластиру й працювати далі
3. CНадіти другий халат поверх порваного
4. DВідійти від пацієнта, безпечно зняти ЗІЗ біля дверей, очистити руки й надіти новий халат

Яка зміна кальцію зазвичай супроводжує високий фосфат у сироватці при хронічній хворобі нирок?

1. AВисокий кальцій у сироватці
2. BНизький кальцій у сироватці
3. CБез змін кальцію
4. DЛише високий калій у сироватці, без змін кальцію

In the first 24 hours after a major burn, which laboratory pattern is most expected?

1. ALow potassium and low hematocrit
2. BHigh calcium and high albumin
3. CHigh potassium and high hematocrit
4. DLow sodium and low hematocrit

Which pattern is typical of relapsing–remitting multiple sclerosis?

1. AA single stroke that leaves permanent weakness
2. BConstant weakness that starts in the feet and spreads upwards after a viral illness
3. CSudden severe headache with neck stiffness
4. DAttacks of symptoms, such as visual loss or numbness, that improve between relapses

Which feature best distinguishes delirium from dementia?

1. ADelirium is permanent, while dementia is reversible
2. BDelirium starts suddenly and fluctuates, while dementia develops gradually
3. CDementia always causes visual hallucinations
4. DDelirium only affects people under 50, while dementia affects older people

A patient is starting doxazosin, an alpha-blocker, for hypertension. Which advice is most important?

1. ATake it with a large glass of grapefruit juice to improve absorption
2. BStop it suddenly if the heart rate rises after the first few doses
3. CTake the first dose at bedtime, as dizziness and fainting can occur
4. DAvoid all potassium-containing foods

A patient with stable severe COPD has a blood gas showing pH 7,37, a raised PaCO₂ and a raised bicarbonate. How should this be interpreted?

1. AA normal blood gas with no abnormality
2. BRespiratory alkalosis from hyperventilation
3. CAcute respiratory acidosis needing emergency intubation
4. DChronic respiratory acidosis with metabolic compensation

A routine blood test shows a potassium of 6,4 mmol/L. The lab reports that the sample was haemolysed. The patient feels well. What should the nurse do?

1. AStart dialysis as soon as possible
2. BIgnore it, because haemolysis always gives a normal result
3. CInform the doctor and arrange an urgent repeat sample
4. DGive oral potassium supplements straight away

A nurse teaches a patient with Hashimoto's thyroiditis about levothyroxine. Which statement shows a need for further teaching?

1. A"I will report palpitations or chest pain."
2. B"I will have regular blood tests to check my dose."
3. C"I can stop the tablets once I feel back to normal."
4. D"I will take the tablets at the same time each day."

Before an anti-TNF biologic such as infliximab is started for Crohn's disease, which screening is essential?

1. AA test of colour vision
2. BA bone density scan
3. CA test for coeliac disease
4. DScreening for tuberculosis

A patient finds daily wound dressing changes very painful. What is the most effective nursing approach?

1. AAvoid analgesia so the patient can report any problems during the change
2. BChange the dressing less often than the plan says
3. CDo the dressing quickly and give analgesia afterwards
4. DGive analgesia timed so it works during the dressing change