Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

Which patient is most suitable for the nurse to assign to a nurse who has just finished orientation?

1. AA patient with a new tracheostomy who needs frequent suctioning
2. BA patient on a continuous heparin infusion with rising aPTT values
3. CA patient with stable cellulitis on scheduled IV antibiotics
4. DA patient with sepsis whose blood pressure is falling

A trauma patient has an open leg fracture, absent breath sounds on one side, a trachea shifted to the other side and a falling blood pressure. Which problem is the priority?

1. AThe pain from the fracture
2. BThe suspected tension pneumothorax
3. CThe open fracture of the leg
4. DThe risk of wound infection

Which nursing care reduces the risk of ventilator-associated pneumonia?

1. ALeaving secretions in the mouth to protect the airway
2. BRegular oral care to reduce bacteria in the mouth
3. CLying the patient flat for most of the day
4. DChanging the ventilator circuit every few hours

A patient arrives in the operating room for knee surgery, and the site has not been marked. What should happen?

1. ADo not start until the site is marked and verified with the patient
2. BMark the site after the patient is anesthetized and draped
3. CStart the surgery, because the consent form shows the side
4. DLet the circulating nurse mark the site from memory of the surgeon’s plan

A patient on peritoneal dialysis notices that the drained fluid is cloudy and has abdominal pain. What should the nurse do?

1. ARecord it as normal and continue the usual exchanges
2. BAdd more glucose to the next bag to clear the fluid
3. CStop dialysis for a week and recheck the fluid later
4. DSend the fluid for cell count and culture and report it

Рівень літію 1,0 mEq/L було взято через 2 години після ранкової дози пацієнта, і лікар планує збільшити дозу. На що має вказати медсестра?

1. AРівні літію можна брати в будь-який час доби без впливу на результат
2. BРівень токсичний, тому літій слід остаточно припинити
3. CРівень надто низький, тож велике збільшення очевидно безпечне
4. DЗразок взято надто рано після дози, тому це недійсний рівень

A pressure ulcer shows full-thickness tissue loss with exposed bone. Which category (stage) is this?

1. ACategory 3
2. BCategory 4
3. CCategory 2
4. DCategory 1

A patient with a COPD exacerbation remains acidotic with a high PaCO₂ despite optimal medical treatment and controlled oxygen. Which treatment is usually considered next?

1. ASedation to slow the breathing
2. BStopping all oxygen therapy
3. C15 L/min oxygen via a non-rebreathe mask
4. DNon-invasive ventilation

A peripheral cannula site is red, warm, tender and swollen along the vein. What should the nurse do?

1. ACover the site and keep using it until it blocks
2. BRemove the cannula, document and monitor the site
3. CFlush the cannula hard to clear it
4. DLeave it in place, as this is normal after 24 hours

On the first day after abdominal surgery, a patient has a temperature of 37,8 °C, SpO₂ 93% on air and reduced breath sounds at both bases. They have stayed in bed because of pain. What is the most likely cause and response?

1. APulmonary oedema: restrict all oral fluids and give a diuretic
2. BWound infection: open the wound fully and swab it for culture
3. CNormal recovery; no action is needed
4. DAtelectasis: give analgesia, deep breathing and mobilisation

Why should antiepileptic drugs not be stopped suddenly?

1. AStopping them suddenly causes permanent damage to the liver and kidneys
2. BStopping them suddenly causes a dangerous rise in blood pressure
3. CSudden withdrawal can trigger seizures, including status epilepticus
4. DThe drugs build up in the body and become toxic after stopping

A nurse teaches foot care to a patient with diabetic neuropathy. Which statement shows a need for further teaching?

1. A"I will buy corn plasters from the pharmacy for my corn."
2. B"I will check that the bath water is not too hot using my elbow."
3. C"I will wear socks and shoes that fit well and do not rub."
4. D"I will check my feet every day, using a mirror for the soles."

Які ЗІЗ зазвичай рекомендують при введенні цитотоксичної хіміотерапії?

1. AПаперова хірургічна маска без рукавичок
2. BЗвичайні бавовняні рукавички та пластиковий фартух
3. CРукавички, перевірені для хіміотерапії, та непроникний халат
4. DЖодних ЗІЗ, бо пакет для інфузії герметичний

У пацієнта з кишковою непрохідністю з'являється постійний сильний біль (більше не переймоподібний), гарячка, ЧСС 120/хв і напружений болючий живіт. Що це вказує?

1. AЗапор, який слід лікувати стимулювальним послаблювальним
2. BСтрангуляцію або перфорацію, що потребує термінового хірургічного огляду
3. CНепрохідність минає, бо кишка починає рухатися
4. DНормальний перебіг, який потребує лише регулярного простого знеболення