Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

A young adult has just started an SSRI antidepressant for major depression. What should the nurse monitor most closely in the first weeks?

1. ARising blood glucose levels
2. BThoughts of suicide or self-harm
3. CWeight loss from too much appetite
4. DHair growth and skin color

A child with sickle cell disease in a pain crisis develops chest pain, fever and an SpO₂ of 89%. What does this most likely mean?

1. AAn ordinary pain crisis that will improve with rest
2. BAnxiety that will settle with reassurance
3. CA minor chest infection that can safely wait until the morning round
4. DAcute chest syndrome, which needs urgent escalation and oxygen

How should a newborn be moved through hospital corridors?

1. AIn a bassinet, not carried in the arms
2. BCarried in the nurse’s arms for comfort
3. COn the mother’s lap in a wheelchair, without staff
4. DIn the arms of any visitor who offers to help

A patient’s blood splashes onto a nurse’s forearm. The skin is intact. What is the correct response?

1. ADo nothing, because intact skin cannot be contaminated
2. BStart HIV post-exposure prophylaxis right away, before any other step is taken
3. CScrub the area with undiluted bleach
4. DWash the area with soap and water, then follow the reporting policy

A patient has macrocytic anemia with numbness and tingling of the feet and poor balance. Which deficiency is most likely?

1. AVitamin C (ascorbic acid)
2. BIron (low ferritin)
3. CFolate (folic acid)
4. DVitamin B₁₂

Two weeks after a sore throat, a child develops dark (cola-colored) urine, puffy eyes and high blood pressure. Urinalysis shows red cell casts and protein. Which condition is most likely?

1. APost-streptococcal glomerulonephritis
2. BKidney stone in the ureter
3. CPrerenal acute kidney injury
4. DLower urinary tract infection (cystitis)

A patient taking a statin reports unexplained muscle pain and weakness. What should the nurse do?

1. AReassure them that this is a sign the drug is working
2. BReport it, as statins can cause muscle damage
3. CAdvise more vigorous exercise to work through it
4. DTell them to double the dose

Why must blood samples for a cross-match be labelled at the bedside immediately after they are taken?

1. ATo speed up the laboratory's computer system and reduce the waiting time
2. BTo let the patient sign the label
3. CTo keep the sample warm so the cells do not break down in transit
4. DTo prevent "wrong blood in tube" errors that can cause fatal reactions

How do clopidogrel and ticagrelor work?

1. AThey dissolve fibrin in existing clots
2. BThey inhibit the vitamin K-dependent clotting factors in the liver
3. CThey directly inhibit thrombin in the plasma
4. DThey block the platelet ADP (P2Y₁₂) receptor

A patient with small-cell lung cancer becomes confused. Sodium is 122 mmol/L (122 mEq/L) with concentrated urine, and there are no signs of dehydration. What is the most likely cause?

1. ACranial diabetes insipidus from brain metastases
2. BSyndrome of inappropriate ADH secretion
3. CExcess salt in the diet over several weeks
4. DSevere dehydration from poor oral intake

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

1. AA tight band across the forehead that eases with rest
2. BBetter in the morning and worse with stress
3. CWorse on waking and on coughing, with vomiting
4. DOnly present after reading for a long time

Which task can the registered nurse delegate to a trained healthcare assistant (nursing assistant)?

1. ADeciding the dose of correction insulin from the glucose result
2. BTeaching a new patient how to inject insulin
3. CAssessing a confused patient whose glucose is 2,6 mmol/L (47 mg/dL)
4. DChecking pre-meal glucose and reporting results out of range

Which practice is correct when giving parenteral nutrition through a central line?

1. ADisconnect and reconnect the line without cleaning the hub
2. BGive other IV drugs through the same lumen to save time
3. CLet the bag hang at room temperature for several days
4. DUse a dedicated lumen and strict aseptic technique

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. AA healing category 1 ulcer
2. BOsteomyelitis
3. CVenous insufficiency
4. DSimple dry skin