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

A patient has a reddened area on the sacrum that does not blanch when pressed. What is the priority action?

1. AKeep the patient lying on the back to protect the area
2. BMassage the area firmly to improve the blood flow to the skin
3. CRelieve pressure on the area by changing position regularly
4. DApply a heat pad to the area to increase circulation

A patient with suspected sepsis has four prescribed orders. Which should usually be done first?

1. AArrange a chest X-ray for later today
2. BGive the IV antibiotic
3. CRepeat the lactate in six hours
4. DTake blood cultures

Why can side rails be dangerous for a confused, restless patient?

1. ASide rails always cause pressure injuries
2. BThe patient may climb over them or get trapped in gaps
3. CSide rails stop staff from reaching the patient in an emergency
4. DSide rails make the bed move by itself

A patient’s allergy band says “penicillin”, and an order has been written for amoxicillin. What should the nurse do?

1. AGive an antihistamine first and then the drug
2. BHold the drug and contact the prescriber
3. CGive the drug and watch the patient closely
4. DAsk the patient whether they would like to take it anyway

Một người bệnh dùng phenytoin có nồng độ 28 mcg/mL (khoảng thông thường khoảng 10–20 mcg/mL). Điều dưỡng mong đợi những phát hiện nào?

1. ARung giật nhãn cầu, đi loạng choạng và nói lắp
2. BChỉ hành vi tăng động và mất ngủ
3. CSóng T cao, nhọn
4. DĐói và tăng cân

A patient's bedside glucose meter shows "HI" (above its measuring range). The patient is drowsy. What should the nurse do?

1. AGive oral glucose in case the reading is wrong and the patient is low
2. BAssume the meter is broken and give the usual insulin dose
3. CRecord "HI" and repeat the meter test at the next scheduled time
4. DSend a venous sample to the lab and inform the provider at once

Why are people with diabetes advised to have regular eye screening?

1. ATo measure their blood glucose through the eye
2. BTo prevent conjunctivitis
3. CTo detect diabetic retinopathy early, before sight is lost
4. DTo check whether they need reading glasses for close work

A hypotensive postoperative patient is given a fluid bolus. Which findings suggest a good response?

1. AThe respiratory rate rises and new lung crackles appear
2. BThe capillary refill time becomes longer
3. CThe heart rate falls, blood pressure rises and urine output improves
4. DThe heart rate rises further and the patient becomes more confused

A woman with hypertension who takes lisinopril says she is planning a pregnancy. What should the nurse advise?

1. ADiscuss switching medicine with the prescriber before trying to conceive
2. BContinue lisinopril, as it is the safest blood pressure drug in pregnancy
3. CStop all blood pressure treatment straight away without telling anyone
4. DDouble the dose to protect the baby from high blood pressure

Which task for a stable patient with heart failure can the registered nurse most appropriately delegate to a healthcare assistant (unlicensed assistive personnel)?

1. ADeciding whether to give the furosemide dose
2. BAssessing lung sounds for new crackles
3. CTeaching the patient about a low-salt diet
4. DMeasuring and recording the morning weight

Several hours after a carotid endarterectomy, which finding needs the most urgent action?

1. AAn expanding neck swelling with noisy breathing
2. BA blood pressure slightly above the baseline
3. CMild pain at the incision site
4. DA small amount of dried blood on the dressing

A patient with a brain tumour on high-dose dexamethasone has a capillary glucose of 16 mmol/L (288 mg/dL). They have no history of diabetes. What is the best explanation?

1. ANormal for this patient, so no action is needed
2. BA lab error, because steroids lower blood glucose
3. CA sign that the brain tumour has now spread to the pancreas
4. DSteroid-induced hyperglycaemia, which needs monitoring and treatment

Mục đích của khoảng thời gian khóa (lockout) trên bơm PCA là gì?

1. ABắt bệnh nhân chờ một ngày giữa các liều lớn
2. BNgăn một liều mới trước khi liều trước phát huy tác dụng
3. CNgăn bệnh nhân nhận bất kỳ liều nào vào ban đêm
4. DKhóa bơm để không thay được ống tiêm

Just after extubation in recovery, a patient develops a high-pitched noise on breathing in, with falling SpO₂. What should the nurse do first?

1. ASit the patient up and give a drink of water
2. BCall for help, give 100% oxygen and use a jaw thrust
3. CWait a few minutes to see if it passes
4. DGive an opioid to calm the patient's breathing and reduce anxiety