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

One day after surgery, a patient walked safely with the RN this morning. The RN now asks a nursing assistant to walk her again. Which instruction is most important?

1. A“Try to finish the walk before the lunch trays arrive.”
2. B“Make sure she wears her own slippers if she has them.”
3. C“Walk her to the end of the corridor and back twice before lunch.”
4. D“Stop and call me at once if she feels dizzy or short of breath.”

Which finding most suggests a tension pneumothorax rather than a simple pneumothorax?

1. ASharp chest pain that is worse on deep breathing
2. BA small air leak seen on a routine chest X-ray
3. CMild breathlessness with reduced breath sounds on one side of the chest only
4. DTrachea shifted away from the affected side, with low blood pressure

Khi mang găng vô khuẩn, điều dưỡng mang chiếc găng thứ hai như thế nào?

1. AKéo găng thứ hai lên bằng đầu ngón tay, dùng tay trần
2. BLuồn các ngón tay đã đeo găng vào dưới nếp gấp cổ của găng thứ hai và kéo lên
3. CCầm mặt trong của găng thứ hai bằng tay đã đeo găng
4. DDùng tay trần chỉnh mặt ngoài của găng thứ nhất

A nurse has just started a unit of red blood cells when a colleague asks for urgent help with another patient. What is the best action?

1. APause the transfusion until the nurse is free again
2. BStay with the transfusing patient for the first 15 minutes and ask another nurse to help
3. CSpeed up the transfusion so it finishes sooner
4. DLeave to help the other patient, and check the transfusion again in about an hour

An older adult takes lisinopril and furosemide and recently started daily ibuprofen for knee pain. The creatinine has risen from 1,0 to 1,8 mg/dL (88 to 159 µmol/L). What is the most likely cause?

1. ANormal aging of the kidneys over a period of a few weeks
2. BA laboratory error, since ibuprofen has no effect on the kidney
3. CThe NSAID reduces kidney blood flow on top of the other two drugs
4. DMore activity has increased the patient's muscle mass quickly

A patient with cirrhosis and ascites has fever and abdominal tenderness. The ascitic fluid neutrophil count is 400 cells/mm³. What does this indicate?

1. ANormal ascitic fluid in cirrhosis
2. BSpontaneous bacterial peritonitis
3. CBleeding into the abdominal cavity
4. DMalignant ascites from cancer

Why are patients with atrial fibrillation often given anticoagulants?

1. ATo reduce the risk of stroke from clots in the atria
2. BTo convert the rhythm back to normal
3. CTo slow the heart rate directly and prevent palpitations
4. DTo lower the blood pressure

A nurse is teaching a patient who is starting warfarin. Which statement shows a need for further teaching?

1. A"I will report black stools or unusual bruising."
2. B"I can take aspirin if I get a headache."
3. C"I will keep my INR blood test appointments."
4. D"I will tell my dentist that I take warfarin."

A patient's ankle–brachial pressure index (ABPI) is 0,6. What does this suggest?

1. AA deep vein thrombosis
2. BStiff, calcified arteries that read falsely high
3. CSignificant peripheral arterial disease
4. DNormal leg circulation

A 74-year-old with atrial fibrillation, hypertension and diabetes asks why she needs an anticoagulant when she feels well. Which reply is best?

1. AThe anticoagulant will stop the irregular heartbeat for good
2. BHer risk of stroke is high, and an anticoagulant lowers it
3. CIt is given to lower her blood pressure
4. DIt is needed only while she has palpitations

A patient with diabetic neuropathy has an ulcer on the ball of the foot. Which measure is most important for healing?

1. ACovering it and checking it in a month
2. BWalking more to improve blood flow
3. CSoaking the foot in hot water daily
4. DTaking pressure off the ulcer

The nurse has four patients. Which one needs to be seen first?

1. AA patient with hypothyroidism asking when to take levothyroxine
2. BA patient on insulin for DKA whose potassium is now 2,9 mmol/L
3. CA patient with stable CKD waiting for a renal diet review
4. DA patient with Parkinson's disease whose next dose is due in two hours

Which patient is at highest risk of refeeding syndrome?

1. AA patient with a normal BMI eating three meals a day
2. BAn underweight patient who has eaten very little for 10 days
3. CA healthy adult after an overnight fast for minor surgery
4. DA patient who missed one lunch because of a scan

A nurse teaches a patient to self-inject low molecular weight heparin at home. Which statement shows a need for further teaching?

1. A"I'll put the used syringe in the sharps bin."
2. B"I'll rub the area afterwards to spread the medicine."
3. C"I'll report any unusual bruising or bleeding."
4. D"I'll change the injection site each day."