Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

Which patient on an addiction unit should the nurse see first?

1. ALast drink this morning; asking when lunch will arrive
2. BLast drink one week ago; asking about support groups
3. CLast drink two days ago; now shaking, sweating, heart rate 124/min and seeing insects
4. DIn recovery for a year; came to the clinic today for a routine check and a repeat prescription

After handover on a medical unit, which patient should the nurse see first?

1. ADay 2 after a hernia repair, pain 6/10, oral analgesic due in 20 minutes, wants it now
2. BDeep vein thrombosis on a heparin infusion, aPTT in the target range
3. CNew atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
4. DPneumonia on 2 L/min oxygen, SpO₂ 93%, talking in full sentences

A patient with a respiratory infection has a raised procalcitonin level. What does this most suggest?

1. AAn allergic reaction to a recent medication
2. BDehydration from poor intake
3. CA bacterial rather than a viral infection
4. DA purely viral illness

A nurse calls a provider using SBAR about a patient with falling blood pressure. Which statement is the “Recommendation”?

1. A“He is 72 and had a bowel resection yesterday.”
2. B“His blood pressure has fallen from 130/80 to 88/50 over the last two hours.”
3. C“I am calling about Mr. Jansen in room 12, who is hypotensive.”
4. D“I think he needs to be assessed now. Can you come within the next 15 minutes?”

How should a patient collect a clean-catch midstream urine sample?

1. AFill the cup completely, then add tap water if there is not enough
2. BCollect urine from the toilet bowl after voiding into the toilet
3. CCollect the very first urine of the stream directly in the sterile cup
4. DClean the area, start voiding into the toilet, then catch the middle part

The nurse teaches a patient about the HbA1c test. Which statement shows a need for further teaching?

1. A"The test shows my average glucose over the past few months"
2. B"A lower result means less risk of damage to my eyes and kidneys"
3. C"My daily finger-stick readings still matter between the tests"
4. D"I must not eat anything for 12 hours before the HbA1c test"

Яке спостереження найважливіше перевірити перед введенням бета-блокатора?

1. AЛише температуру
2. BЧастоту серцевих скорочень і артеріальний тиск
3. CЛише глюкозу крові
4. DВипорожнення

A patient with a possible neck injury after a fall needs their airway opened. Which manoeuvre is preferred?

1. AJaw thrust
2. BHead tilt with chin lift
3. CTurning the head to one side
4. DHyperextending the neck

A patient with heart failure starts dapagliflozin, an SGLT2 inhibitor. Which teaching is most relevant?

1. ATake an extra dose if the ankles swell
2. BExpect the urine to turn bright orange and stain underwear and clothes
3. CAvoid drinking any fluids at all for the first week of treatment
4. DKeep the genital area clean, as fungal infections are more common

Four hours after abdominal surgery, a patient's heart rate has risen from 84 to 122/min and they are restless and pale. BP is still 118/76 mmHg, and the surgical drain is filling with blood. What should the nurse conclude?

1. AThe tachycardia is from pain and needs only analgesia
2. BThe patient is stable because the blood pressure is normal
3. CThe drain is working well, so no action is needed
4. DEarly haemorrhagic shock is likely, so escalate urgently

A patient with advanced CKD asks how to manage indigestion. Which option should they avoid?

1. AEating smaller, more frequent meals
2. BAvoiding large meals late in the evening
3. CRaising the head of the bed at night
4. DMagnesium-containing antacids

An 84-year-old man became more confused a week after starting oxybutynin. Infection has been ruled out. What should the nurse suspect?

1. AAnticholinergic side effects of the drug
2. BA symptom of a high potassium from the drug
3. CNormal ageing that needs no review
4. DA sign that the drug dose is too low

How does sucralfate help a peptic ulcer heal?

1. AIt forms a protective coating over the ulcer base
2. BIt speeds up emptying of the stomach
3. CIt kills H. pylori in the stomach lining
4. DIt blocks histamine receptors on parietal cells

A dying patient has noisy, rattling breathing. The patient seems unaware, but the family is distressed. What is the best nursing approach?

1. APerform deep suction every hour
2. BGive large volumes of IV fluid to loosen and thin the secretions
3. CReposition, explain the cause and give prescribed drugs if needed
4. DAsk the family to leave the room