Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

Before accessing a central venous catheter, what should the nurse do to prevent infection?

1. ATouch the hub to check it is clean
2. BRinse the hub with tap water and dry it
3. CBlow on the hub to remove any dust before connecting the syringe or line
4. DScrub the hub with an antiseptic such as chlorhexidine and let it dry

A patient opens their eyes only to pain, uses inappropriate words and withdraws from pain. What is the Glasgow Coma Scale score?

1. A7
2. B9
3. C11
4. D13

Why is “QD” (once daily) on The Joint Commission’s “Do Not Use” list?

1. AIt is only allowed for intravenous medicines
2. BIt means “every day at bedtime” in some hospitals
3. CIt can be misread as QID or QOD, so the drug is given too often or too rarely
4. DIt is a Latin abbreviation, and only plain English abbreviations may be used

A 2-year-old living in a house built many decades ago has anemia, irritability and poor appetite. Which cause should the nurse suspect?

1. ALead poisoning from old paint dust or chips
2. BA food allergy to cow’s milk proteins
3. CCarbon dioxide from a gas cooker
4. DIron overload from eating too much red meat

Глюкоза натщесерце в пацієнта сьогодні 98 mg/dL (5,4 mmol/L), але HbA1c 8,9% (74 mmol/mol). Яке тлумачення найкраще?

1. AУ пацієнта немає діабету
2. BСьогоднішній добрий результат показує, що діабет добре контрольований
3. CHbA1c відображає лише останні 24 години
4. DКонтроль глюкози був поганим протягом останніх 2–3 місяців

A patient with acute kidney injury after severe dehydration has a rising creatinine. Which urine findings support a prerenal cause rather than acute tubular necrosis (ATN)?

1. AWhite cell casts with positive nitrites on the dipstick
2. BRed cell casts with heavy protein loss in the urine
3. CLow urine sodium and concentrated urine with a high specific gravity
4. DHigh urine sodium and dilute urine with muddy brown granular casts

Why is oxygen often humidified for a patient with a tracheostomy?

1. AHumidification lowers the oxygen concentration to a safer level
2. BDry oxygen causes high blood glucose
3. CThe tube bypasses the nose, which normally warms and moistens air
4. DHumidity is needed for the oxygen to work as a drug

An older patient with delirium is trying to leave the ward at night, saying he must go home. What is the best initial approach?

1. APhysically restrain him in bed until the morning so that he cannot fall
2. BCalmly reassure and redirect him while the team assesses his capacity and safety
3. CLet him leave, because adults can always do as they wish whatever their state
4. DGive a sedative straight away without a prescription

Why is a beta-blocker started at a low dose and increased slowly in heart failure?

1. AIt must be stopped as soon as symptoms improve
2. BIt is safe only at the highest possible dose from the very start
3. CIt can briefly worsen symptoms before long-term benefit appears
4. DIt works only if the dose is never changed after the first day

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. ANormal pacemaker function
2. BFailure to capture
3. CFailure to sense
4. DAtrial fibrillation

Which headache feature most suggests raised intracranial pressure from a brain tumour?

1. ABetter in the morning and worse with stress
2. BOnly present after reading for a long time
3. CA tight band across the forehead that eases with rest
4. DWorse on waking and on coughing, with vomiting

The night after hip surgery, an 84-year-old becomes suddenly confused and tries to pull out their IV line. What is the most appropriate first step?

1. AAsk for a strong sedative so that the patient can sleep
2. BLook for causes such as low oxygen, pain, retention or infection
3. CTell the family that this is the start of dementia
4. DApply wrist restraints to protect the IV line

Which advice helps a person with diabetes prevent foot ulcers?

1. AWear tight shoes to support the ankles
2. BCheck the feet every day and never walk barefoot
3. CSoak the feet in very hot water every evening
4. DCut corns off at home with a sharp blade

A patient on warfarin has a major upper GI bleed with an INR of 5. Which treatment should the nurse anticipate to reverse the warfarin?

1. AProthrombin complex concentrate with IV vitamin K
2. BProtamine sulfate on its own
3. COral aspirin to balance the clotting system quickly
4. DMore warfarin to stabilise the INR