Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

An older patient who has been constipated for days now has small amounts of liquid stool leaking. What should the nurse suspect?

1. AA new bowel infection that has caused the diarrhea
2. BA side effect of drinking too much water
3. CThe constipation has fully resolved
4. DFecal impaction with liquid stool passing around it

A patient with anorexia nervosa is admitted. Which finding is the priority?

1. ASays she feels fat although she is very thin
2. BRefuses to eat in front of other people
3. CHas fine, downy hair on her arms
4. DHeart rate 38/min and potassium 2,8 mEq/L

Що має зробити медсестра після випадкового потрапляння крові пацієнта в очі?

1. AСпершу обережно протерти очі чистою сухою серветкою, щоб прибрати кров
2. BЗакапати антибактеріальні краплі й нікому не казати
3. CОдразу промити очі великою кількістю води чи фізрозчину, а потім повідомити
4. DЗакінчити маніпуляцію й повідомити наступного дня

A nurse calculates a child’s prescribed dose and finds it is ten times higher than the usual dose for the child’s weight. What should the nurse do?

1. AGive it, because the prescriber must have a reason
2. BHold the dose and verify it with the prescriber and pharmacist
3. CGive one-tenth of the dose without telling anyone about it
4. DGive half the dose and watch the child closely

Which finding during a transfusion suggests transfusion-associated circulatory overload (TACO)?

1. ABack pain with dark red urine output
2. BCrackles, hypertension and a raised BNP
3. CHives and itching without other signs
4. DA low temperature and slow heart rate

After lying on the floor for many hours, a patient has a CK of 40,000 U/L, a potassium of 6,1 mEq/L and dark urine. Which prescribed treatment is the priority?

1. AFluid restriction to protect the heart from overload
2. BLarge-volume IV fluids with cardiac monitoring
3. CAn oral potassium supplement with each meal
4. DHigh-dose NSAIDs for the muscle pain

Which ECG change is typical of hypokalaemia?

1. AFlattened T waves and prominent U waves
2. BTall, peaked T waves
3. CA very short PR interval with a delta wave
4. DST elevation in leads II, III and aVF

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. A15 L/min oxygen via a non-rebreathe mask
2. BNon-invasive ventilation
3. CStopping all oxygen therapy
4. DSedation to slow the breathing

How should a patient with asthma record their peak flow at home?

1. ABlow only during an asthma attack, never when well
2. BTake the best of three blows, ideally morning and evening
3. CTake one gentle blow once a week, at any time of day
4. DTake the average of ten blows after exercise

A nurse teaches a patient how to measure blood pressure at home. Which statement shows a need for further teaching?

1. A"I will take two readings and write them both down."
2. B"I will measure it straight after my morning jog."
3. C"I will sit with my back supported and my arm at heart level."
4. D"I will rest quietly for five minutes before measuring."

Which nursing care is most important for a patient with diabetes insipidus?

1. AStrict fluid balance, daily weight and free access to water
2. BA strict fluid restriction to reduce the amount of urine passed
3. CGiving a loop diuretic to clear extra fluid
4. DWeighing the patient once a month

A patient has erratic glucose readings. The nurse finds a soft, rubbery lump where they always inject. What is the most important teaching?

1. AUse healthy sites and check glucose often, as less insulin may be needed
2. BMassage the lump firmly after every injection
3. CKeep injecting into the lump, because it hurts less there
4. DDouble the insulin dose because the lump blocks the insulin

A patient with a new colostomy asks what to eat at home. Which advice is most appropriate?

1. AEat a normal, balanced diet and introduce foods gradually
2. BAvoid all fruit and vegetables for the rest of their life
3. CDrink as little fluid as possible to reduce output
4. DEat only liquids until the stoma is removed

Which history should most alert the nurse to a possible latex allergy before surgery?

1. AFeeling sick after eating shellfish once
2. BItching with bananas, avocado and kiwi, and many operations
3. CA rash after taking amoxicillin as a child, with a family history of asthma
4. DHay fever every spring since childhood