Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

A patient at 35 weeks of pregnancy with high blood pressure calls the clinic. Which symptom needs urgent assessment?

1. ABackache after a long walk
2. BNeeding to pass urine more often
3. CMild ankle swelling at the end of the day
4. DA severe headache with blurred vision

A patient with a severe asthma attack had a PaCO₂ of 32 mmHg (4,3 kPa) on arrival. An hour later it is 46 mmHg (6,1 kPa), and the patient seems tired. What does this suggest?

1. ARespiratory muscle fatigue with possible impending respiratory failure
2. BThe patient is hyperventilating even more than before and needs calming
3. CThe asthma is improving, because the PaCO₂ is now near normal
4. DA laboratory error that should be ignored

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

1. ARegular oral care to reduce bacteria in the mouth
2. BChanging the ventilator circuit every few hours
3. CLeaving secretions in the mouth to protect the airway
4. DLying the patient flat for most of the day

While preparing an IV medication, a nurse sees that the syringe tip touched the medication tray after the cap came off. What should the nurse do?

1. AGive the dose anyway, because the medication tray was cleaned this morning
2. BDiscard the syringe and prepare the dose again with new equipment
3. CBlow on the tip to remove any dust
4. DWipe the tip with an alcohol swab and give the dose

A patient has a hot, swollen big toe. The serum uric acid is normal. Which statement is correct?

1. AGout is still possible, as urate can be normal in an attack
2. BGout is certain, as a normal urate proves the diagnosis
3. CGout is ruled out, as uric acid is always high in an attack
4. DGout can only be diagnosed with a CT scan of the foot

The nurse teaches a patient with severe neutropenia after chemotherapy. Which statement shows a need for further teaching?

1. A"I'll check my temperature rectally to be accurate"
2. B"I'll avoid people who have a cold or the flu"
3. C"I'll call the clinic if my temperature rises"
4. D"I'll wash my hands before eating and after the toilet"

What should a patient be told before using sublingual glyceryl trinitrate (GTN, nitroglycerin) spray for angina?

1. ASwallow the spray rather than leaving it under the tongue
2. BSit down before using it, as it can cause dizziness and low blood pressure
3. CTake it with a large glass of milk to protect the stomach lining
4. DUse it only after the pain has lasted over an hour, with the patient lying flat

A patient with suspected appendicitis says the pain suddenly eased, but an hour later has pain all over the abdomen, a rigid abdomen and a fever. What is most likely?

1. AThe patient has developed gastroenteritis
2. BThe appendix has perforated, causing peritonitis
3. CThe appendicitis has resolved without treatment
4. DThe analgesia has started working

У пацієнта з нещодавнім інсультом і утрудненим ковтанням з'являються гарячка й хрипи в нижній частці правої легені. Яка найімовірніша причина?

1. AГострий напад астми
2. BАспіраційна пневмонія
3. CЛівошлуночкова недостатність
4. DТромбоемболія легеневої артерії

A one-way speaking valve is fitted to a patient's tracheostomy tube while the cuff is still inflated. What is the danger?

1. AThe valve will humidify the air too much
2. BThe patient cannot breathe out and may suffocate
3. CThe patient will speak too loudly
4. DThere is no danger, as the valve works with any cuff

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

1. AWeighing the patient once a month
2. BGiving a loop diuretic to clear extra fluid
3. CStrict fluid balance, daily weight and free access to water
4. DA strict fluid restriction to reduce the amount of urine passed

A patient had a witnessed tonic-clonic seizure. Afterwards their left arm is weak, and the weakness improves over the next few hours. What is the best interpretation?

1. ACertainly a stroke, so the seizure can be ignored
2. BA sign that the patient is pretending to be weak
3. CNormal postictal tiredness that needs no further assessment or imaging at all
4. DPossible postictal (Todd's) paresis, but a stroke must still be excluded

Dysphagia that started with solids and now includes liquids, with weight loss, most suggests which cause?

1. AA dry mouth from drinking too little water
2. BSimple anxiety about swallowing tablets
3. CA narrowing such as an oesophageal tumour
4. DNormal ageing of the swallowing muscles

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

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