Пріоритезація та делегування у стилі NCLEX: шпаргалка-підсумок

Which action by a nursing assistant needs the nurse to step in?

1. APutting the call light within the patient’s reach
2. BTaking an oral temperature just after the patient drank cold water
3. CCleaning hands before entering the room
4. DLowering the bed to its lowest position and locking the wheels after care

Якого пацієнта медсестра має першим ескалувати до команди швидкого реагування?

1. AПацієнта з відомою гіпертензією, артеріальний тиск якого 152/94 mmHg і який почувається добре
2. BПацієнта з целюлітом, температура якого 38,1 °C, а інші життєві показники нормальні
3. CПацієнта після операції на коліні з болем 6 з 10 та нормальними життєвими показниками
4. DПацієнта з інфекцією сечовивідних шляхів, який щойно став сплутаним, з частотою дихання 26/min і систолічним тиском 94 mmHg

A visitor with a cold wants to see a patient who has severe neutropenia. What should the nurse advise?

1. AVisit only if the cold started more than a day ago
2. BPostpone the visit until the visitor is well
3. CVisit as usual after washing the hands
4. DVisit but avoid touching the patient’s bed

A child with fever, cough, red eyes and a spreading rash is in a clinic waiting room. Measles is suspected. What should the nurse do first?

1. AGive the child an antipyretic and continue triage
2. BPut a mask on the child and move them into an airborne isolation room
3. CAsk the family to wait in the main waiting room until the child is called in
4. DSend the child home to rest without an assessment

A stable adult who is not bleeding receives one unit of packed red cells. By about how much is the hemoglobin expected to rise?

1. AAbout 3 g/dL (30 g/L)
2. BAbout 0,1 g/dL (1 g/L)
3. CAbout 1 g/dL (10 g/L)
4. DAbout 5 g/dL (50 g/L)

У пацієнта на інфузії гепарину кількість тромбоцитів на 7-й день падає з 260 до 110 × 10³/µL. Яка дія найдоречніша?

1. AПродовжити інфузію й збільшити швидкість за протоколом
2. BНегайно повідомити: можлива гепарин-індукована тромбоцитопенія
3. CНе вживати дій, бо кількість ще трохи вище 100 × 10³/µL
4. DПерелити тромбоцити й продовжити гепарин

A patient on haemodialysis has an arteriovenous fistula in the left arm. Which nursing care is correct?

1. AUse the fistula arm for routine IV cannulas
2. BAvoid blood pressure readings and blood samples on that arm
3. CApply a tight bandage over the fistula at night to protect it
4. DKeep the arm raised and still at all times

A catheterised postoperative patient has passed only 10 mL of urine in the last two hours. What should the nurse check first?

1. AThat the catheter and tubing are not kinked or blocked
2. BWhether the patient has eaten breakfast
3. CThe patient's cholesterol level from the admission bloods
4. DThe patient's weight from last year

Why are IV fluids given cautiously to a patient with heart failure?

1. AIV fluids directly damage the heart valves
2. BExtra volume can quickly cause pulmonary oedema
3. CIV fluids stop diuretics from being absorbed
4. DIV fluids lower the blood pressure dangerously

A patient with a large pericardial effusion has a systolic pressure that falls by more than 10 mmHg during inspiration. What is this finding called?

1. APulsus paradoxus
2. BA pulse deficit
3. CPulsus alternans
4. DA collapsing pulse

A patient on insulin asks about drinking alcohol. Which advice is correct?

1. AAlcohol should replace a meal on the days it is drunk
2. BAlcohol raises glucose, so extra insulin should be taken first
3. CAlcohol can cause hypos, even the next day, so eat carbs with it
4. DAlcohol has no effect on blood glucose in people with diabetes

A patient with type 1 diabetes is vomiting at home. Their glucose is 12 mmol/L (216 mg/dL), and blood ketones are 3,5 mmol/L. What advice is correct?

1. ASeek urgent hospital assessment for possible DKA
2. BWait until the glucose is above 20 mmol/L (360 mg/dL)
3. CDrink less fluid to stop the vomiting
4. DStop insulin until the vomiting has settled

Why is a urinary catheter usually inserted in a patient with a major burn?

1. AThe catheter prevents wound infection
2. BIt is needed to give medicines into the bladder
3. CHourly urine output guides fluid resuscitation
4. DBurns always cause the bladder to rupture

During radiotherapy to the chest, a patient develops pain on swallowing and is eating less. What is the most likely cause and nursing focus?

1. AA stomach ulcer; give an antacid after meals only
2. BRadiation oesophagitis; analgesia, soft food and nutrition support
3. CNormal ageing; no action needed
4. DA heart attack; give aspirin and arrange an ECG