Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

A patient arrives in the recovery room after general anesthesia. What does the nurse assess first?

1. AUrine output
2. BThe pain score
3. CThe surgical dressing and the drains
4. DAirway patency and breathing

After the RN taught a patient to inject insulin, an LPN/LVN reports that the patient still cannot draw up the dose correctly. What should happen next?

1. AThe patient is discharged with a leaflet to read at home
2. BThe RN reassesses the patient’s learning needs and adjusts the teaching
3. CThe LPN/LVN writes a new teaching plan and evaluates it at the end of the shift
4. DThe nursing assistant shows the patient again at lunch

A nurse pours sterile saline into a bowl on a sterile field. Which technique is correct?

1. AReach across the field to fill the bowl at the far side
2. BPour from below the level of the field to reduce splashing
3. CHold the bottle with the label in the palm and pour without touching the bowl
4. DRest the lip of the bottle on the edge of the bowl so that the saline does not splash

A small-bore feeding tube has just been inserted blindly at the bedside. Which method is the most reliable way to confirm its position before the first feeding?

1. ABy listening over the stomach while injecting air
2. BBy putting the end in water to look for bubbles
3. CBy checking that the patient can still talk
4. DBy an x-ray reviewed by a competent clinician

Пацієнт на варфарині почав щодня їсти великі порції капусти кале та шпинату. МНВ знизилося. Яка порада найдоречніша?

1. AПодвоїти дозу варфарину, не повідомляючи лікаря
2. BНіколи більше не їсти зелених овочів
3. CПідтримувати споживання продуктів, багатих на вітамін K, стабільним з дня на день
4. DПрипинити варфарин, доки харчування не нормалізується

An 82-year-old woman without a catheter has a urine culture growing bacteria, but no fever, urinary symptoms or change in mental state. What is the best interpretation?

1. AContamination, so the culture must be repeated every week
2. BAsymptomatic bacteriuria, usually not treated with antibiotics
3. CPyelonephritis, which needs admission and IV fluids today
4. DA urinary tract infection that needs urgent IV antibiotics

Which technique is correct when suctioning through a tracheostomy?

1. AKeep suctioning for at least a minute each time to clear all the secretions
2. BApply suction continuously while inserting the catheter as far as it will go
3. CApply suction only while withdrawing the catheter, for no more than about 10–15 seconds
4. DSuction every 15 minutes whether or not secretions are present

Which feature best distinguishes delirium from dementia?

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

Пацієнт із гіпертензією приймає амлодипін. Який побічний ефект медсестра найімовірніше спостерігатиме?

1. AСвистячі хрипи
2. BГіперкаліємію
3. CСухий, дратівливий кашель
4. DНабряк щиколоток

Four surgical patients need VTE prevention. For which patient is mechanical prophylaxis alone most appropriate?

1. AAn obese patient after hip surgery
2. BA patient with cancer having bowel surgery
3. CA patient after an uncomplicated knee replacement
4. DA patient who had a brain haemorrhage two days ago

A patient has a nephrostomy tube. Which finding needs urgent action?

1. ASteady urine drainage into the bag
2. BLight pink urine on the first day after insertion
3. CDrainage that stops suddenly with new loin pain
4. DA dry, intact dressing at the site

After a TURP, a patient on bladder irrigation has bladder spasms. The drainage has slowed and contains clots, and the bag holds less than the irrigant given. What should the nurse do first?

1. AEncourage the patient to strain to pass the clots
2. BTurn off the irrigation and leave the catheter alone
3. CGive an antispasmodic and recheck in four hours
4. DSuspect a clot in the catheter and follow the protocol

Which statement correctly describes physical dependence on opioids?

1. AWithdrawal occurs if the drug is stopped suddenly
2. BThe patient always craves the drug and misuses it despite harm
3. CThe drug no longer has any side effects
4. DThe patient is allergic to opioids

A patient is splashed in the eye with an alkaline cleaning product. What is the first action?

1. AIrrigate the eye at once with large volumes of water or saline
2. BAsk the patient to rub the eye to clear it
3. CCover the eye with a pad and wait for a doctor to examine it first
4. DAdd a few drops of vinegar to neutralise it