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

Ở một khoa nội hỗn hợp, điều dưỡng nên gặp người bệnh nào trước tiên?

1. ANgười bệnh đau đầu căng thẳng nhẹ đang xin acetaminophen
2. BNgười bệnh trầm cảm đã cho đi đồ đạc và có kế hoạch tự sát
3. CNgười bệnh xin thông tin bằng văn bản về việc xuất viện ngày mai
4. DNgười bệnh tăng huyết áp có huyết áp 136/84 mmHg

Một người bệnh chấn thương đầu và gãy chân đang được theo dõi. Phát hiện nào là ưu tiên?

1. AMột vết trầy nhỏ ở khuỷu tay
2. BĐiểm Glasgow (GCS) tụt từ 15 xuống 12
3. CĐau chân 6/10 dù đã dùng liều giảm đau cuối
4. DNgười bệnh xin ăn gì đó

Which information must be documented when a patient is restrained?

1. AThe reason, alternatives tried, type of restraint, times and regular assessments
2. BOnly the time the restraint was put on and the time it was taken off
3. COnly whether the family agreed to the restraint
4. DOnly the name of the nurse who applied it and the unit where it happened

A patient with dementia is often found at the exit doors trying to leave the unit. Which measure is most appropriate?

1. AUse an electronic wander alert, supervise closely and offer meaningful activity
2. BLock the patient alone in a single room so that they cannot reach the exit doors
3. CKeep the patient in a chair with a vest restraint
4. DGive a sedative each time the patient goes to the door

Trong bệnh thận mạn, phosphate huyết thanh cao thường đi kèm thay đổi nào của calci?

1. ACalci huyết thanh thấp
2. BCalci huyết thanh cao
3. CChỉ kali huyết thanh cao, calci không thay đổi
4. DCalci không thay đổi

Four patients had a thyroidectomy earlier today. Which result should the nurse act on first?

1. AGlucose 145 mg/dL (8,0 mmol/L) after surgery
2. BSodium 136 mEq/L on IV fluids after surgery
3. CCalcium 7,2 mg/dL (1,8 mmol/L) with tingling lips
4. DHemoglobin 12,1 g/dL (121 g/L) after surgery

Bệnh nhân suy tim tăng 2 kg trong hai ngày. Điều này nhiều khả năng cho thấy gì?

1. ATăng khối lượng cơ
2. BĐiều trị thành công
3. CỨ dịch
4. DMất nước

A patient with severe ulcerative colitis develops abdominal distension, fever and tachycardia, and the number of stools falls. What complication should be suspected?

1. AConstipation from dehydration
2. BCoeliac disease
3. CToxic megacolon
4. DRecovery from the colitis

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

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

An older patient with three rib fractures is breathing shallowly and refuses to cough because of pain. What is the priority intervention?

1. AEffective analgesia so they can breathe deeply and cough
2. BKeep the patient flat and still in bed until the pain settles
3. CStrap the chest tightly with bandages to stop the ribs moving
4. DWithhold analgesia to avoid depressing breathing

The day after a thyroidectomy, a patient reports tingling around the mouth and in the fingers. Why might this happen?

1. AThe thyroid hormone level has risen too high after surgery
2. BThe anaesthetic has caused an allergic reaction
3. CThe patient is breathing too slowly after the operation
4. DThe parathyroid glands may have been damaged, lowering calcium

A nurse teaches a carer to give buccal midazolam for prolonged seizures. Which statement shows a need for further teaching?

1. A"I will put something between his teeth so he does not bite his tongue."
2. B"I will give it into the space between his gum and cheek."
3. C"I will call an ambulance if the care plan tells me to."
4. D"I will write down the time the seizure started and the time I gave the dose."

Which liver function test pattern suggests bile duct obstruction?

1. AHigh bilirubin with a markedly raised ALP and GGT
2. BA low albumin with all other results normal
3. CNormal bilirubin with a low ALP and low GGT
4. DVery high ALT with a normal bilirubin only

An hour after a line flush, a patient receiving parenteral nutrition has rigors and a temperature of 39,1 °C. What should the nurse suspect and do?

1. AFluid overload; reduce the infusion rate only
2. BLine infection; escalate and take blood cultures
3. CA normal reaction; give paracetamol and continue the infusion
4. DLow blood glucose; give a sugary drink