Ưu tiên và ủy quyền kiểu NCLEX: gói ôn nước rút

A swimmer is found unresponsive after diving into shallow water. Which method should the nurse use to open the airway?

1. ARaising the chin while bending the neck forward
2. BJaw thrust, keeping the head and neck in line
3. CHead-tilt, chin-lift with full neck extension
4. DTurning the head to the side to drain water

Which finding after a laparoscopic cholecystectomy is expected and needs only reassurance and comfort measures?

1. ARight shoulder pain from the gas used during surgery
2. BA heart rate of 125/min with a falling blood pressure
3. CIncreasing abdominal pain with a temperature of 39 °C
4. DYellow skin with dark urine on the second day

Một điều dưỡng bị kim đâm từ bệnh nhân đã biết nhiễm HIV. Vì sao cần báo cáo ngay lập tức?

1. ADự phòng sau phơi nhiễm có hiệu quả nhất khi bắt đầu trong vòng vài giờ
2. BCó thể báo cáo bất cứ lúc nào trong vòng một tháng mà không đổi nguy cơ
3. CChỉ cần báo cáo với các tổn thương do kim tiêm tĩnh mạch
4. DChỉ cần báo cáo nếu vết thương chảy máu hoặc sâu

Một bệnh nhân lú lẫn liên tục giật ống thông mũi–dạ dày. Nên thử cách tiếp cận nào trước?

1. ACác biện pháp ít hạn chế hơn, như định hướng lại và người trông
2. BCố định cổ tay ngay lập tức để bảo vệ ống
3. CRút ống mà không hỏi ý kiến cả kíp
4. DMột thuốc an thần để bệnh nhân ngủ yên cả đêm

A patient's potassium is 7,0 mEq/L. Which ECG change would the nurse expect?

1. ATall, peaked T waves
2. BFlattened T waves
3. CProminent U waves
4. DDelta waves before the QRS

Một người bệnh huyết khối tĩnh mạch sâu mới đang truyền heparin, và warfarin vừa được bắt đầu. Vì sao heparin được tiếp tục vài ngày?

1. AHeparin tăng hấp thu warfarin từ ruột
2. BHeparin ngăn các tác dụng phụ của warfarin
3. CWarfarin chỉ có tác dụng khi dùng heparin cùng lúc
4. DWarfarin cần vài ngày để đạt tác dụng chống đông đầy đủ

A patient taking a statin reports unexplained muscle pain and weakness. What should the nurse do?

1. AAdvise more vigorous exercise to work through it
2. BReassure them that this is a sign the drug is working
3. CReport it, as statins can cause muscle damage
4. DTell them to double the dose

A patient with back pain develops numbness around the anus and genitals and new difficulty passing urine. Which condition should be suspected?

1. ASimple muscle strain
2. BCauda equina syndrome
3. CKidney stones
4. DConstipation

Virchow's triad describes three factors that promote venous thrombosis. Which patient factor represents venous stasis?

1. AImmobility after major surgery
2. BDamage to a vein during hip surgery
3. CAn inherited clotting disorder
4. DTaking an oestrogen-containing pill

During tracheal suctioning, a patient's heart rate drops from 88/min to 48/min. What should the nurse do?

1. AGive a dose of atropine without a prescription
2. BStop suctioning, give oxygen and monitor the patient
3. CContinue suctioning until the airway is completely clear
4. DIncrease the suction pressure to finish faster

Which approach helps most when talking to a patient with expressive aphasia?

1. AAvoid talking to them until their speech has recovered
2. BSpeak louder, because the patient cannot hear well
3. CFinish their sentences quickly to save them effort
4. DAsk questions that can be answered with yes, no or a gesture

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

Which description fits a category (stage) 4 pressure ulcer?

1. AFull-thickness loss with exposed bone, tendon or muscle
2. BA blister filled with clear fluid over the heel or sacrum
3. CIntact skin with redness that does not blanch
4. DA shallow wound into the dermis only

On day 5 after hip surgery, a patient suddenly becomes breathless, with sharp chest pain on breathing in, a pulse of 120/min and SpO₂ 89%. What should the nurse suspect and do first?

1. AWound infection; take a wound swab and wait for results
2. BPulmonary embolism; sit up, give oxygen and call for urgent help
3. CSimple atelectasis; encourage walking around the ward
4. DAnxiety; give reassurance and repeat the observations in an hour's time