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

Một phụ tá điều dưỡng từ chối nhiệm vụ được ủy quyền, nói rằng chưa được đào tạo để làm. Phản hồi tốt nhất của điều dưỡng là gì?

1. ANói với phụ tá rằng nhiệm vụ nằm trong bản mô tả công việc và phải làm
2. BCảm ơn phụ tá, bảo đảm nhiệm vụ được thực hiện an toàn và sắp xếp đào tạo
3. CĐể nhiệm vụ cho ca sau, khi có người được đào tạo
4. DBáo cáo phụ tá với quản lý vì từ chối nhiệm vụ

Two call lights go on at the same time. One patient has pain of 7/10 after surgery. The other is a confused patient at high risk of falls who is climbing out of bed alone. Who does the nurse go to first?

1. AThe confused patient climbing out of bed
2. BThe patient in pain after surgery
3. CThe patient whose call light went on first
4. DWhichever patient’s room is closer to the station

A nurse gives part of a dose of an opioid from a vial and must discard the rest. What is correct?

1. AReturn the rest to the patient’s medication drawer
2. BDiscard it alone in the sink and document the amount wasted later in the shift
3. CDiscard it in front of a second licensed (registered) nurse, who witnesses and documents it
4. DKeep the rest for the patient’s next dose

A patient refuses to wear an identification wristband. What should the nurse do?

1. AExplain why it is needed, use other ID methods per policy and document
2. BStop giving the patient any care until they agree to wear the band
3. CForce the band onto the patient’s wrist
4. DAccept the refusal and identify the patient by room number and bed space instead

A patient is scheduled for a liver biopsy. Which laboratory results should the nurse check before the procedure?

1. AHbA1c and lipid panel
2. BPlatelet count and PT/INR
3. CSerum sodium and chloride
4. DTSH and free T₄

A patient with kidney stones and fatigue has a calcium of 11,6 mg/dL (2,9 mmol/L), a high parathyroid hormone (PTH) and a low phosphate. Which condition is most likely?

1. AVitamin D deficiency
2. BHypoparathyroidism
3. CPrimary hyperparathyroidism
4. DCancer-related hypercalcemia

A patient has lost more than 10% of their body weight without trying over the last few months and has a low BMI. What is the most appropriate action?

1. AWeigh the patient again in six months and review at that point
2. BRefer to the dietitian and start a nutrition care plan with food charts
3. CEncourage a low-calorie diet
4. DRestrict fluids to encourage appetite and give a low-protein diet instead

Bệnh nhân dùng bơm PCA opioid có nhịp thở 7/phút và khó đánh thức. Cần làm gì trước tiên?

1. AGhi lại các chỉ số và kiểm tra lại ở vòng theo dõi bốn giờ kế tiếp
2. BKhuyến khích bệnh nhân bấm nút PCA thường xuyên hơn cho dễ chịu
3. CTăng liều bolus PCA vì bệnh nhân có thể đang đau
4. DDừng PCA, đánh thức bệnh nhân, cho oxy và nhờ cho naloxone

Which skin changes around the ankles are typical of chronic venous insufficiency?

1. AA sharply defined red patch with fever
2. BPale, shiny, hairless skin with weak pulses
3. CBrown staining, swelling and dry, itchy skin
4. DA cold, white foot with no pulse

On the first day after abdominal surgery, a patient has a temperature of 37,8 °C, SpO₂ 93% on air and reduced breath sounds at both bases. They have stayed in bed because of pain. What is the most likely cause and response?

1. AAtelectasis: give analgesia, deep breathing and mobilisation
2. BPulmonary oedema: restrict all oral fluids and give a diuretic
3. CWound infection: open the wound fully and swab it for culture
4. DNormal recovery; no action is needed

After transsphenoidal pituitary surgery, which advice should the patient follow?

1. ALie completely flat for at least a week after surgery
2. BDrink through a straw to keep the nose clean
3. CBlow the nose often to clear any clots
4. DAvoid blowing the nose, straining and bending forward

A haemodialysis patient missed their last two sessions. They are breathless, with crackles, and the potassium is 6,9 mmol/L. What is the priority?

1. ALarge IV fluid boluses to improve the circulation
2. BUrgent dialysis, with cardiac monitoring meanwhile
3. COral potassium supplements and rest
4. DA routine dialysis session at the next planned slot

A patient received IV morphine 20 minutes ago and the surgical consent form has not been signed. What should the nurse do?

1. ASign the form on the patient's behalf as a witness
2. BTell the surgeon, as the patient may not be able to consent now
3. CAsk the patient to sign quickly before they get sleepier
4. DAsk a relative to sign instead of the patient

Six hours after surgery, a patient has not passed urine, has lower abdominal discomfort and a bladder scan shows 750 mL. What should the nurse do?

1. ACatheterise as per protocol or prescription
2. BGive a diuretic to increase urine flow
3. CWait another twelve hours before acting
4. DRestrict fluids until the urge returns