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

A patient arrives in the recovery room after general anesthesia. What does the nurse assess first?

1. AUrine output
2. BThe surgical dressing and the drains
3. CThe pain score
4. DAirway patency and breathing

A patient receiving comfort-focused end-of-life care is distressed by breathlessness. Which approach is most appropriate?

1. AStart a series of aggressive tests to find the exact cause of the breathlessness
2. BGive prescribed opioids and use positioning and a fan to relieve breathlessness
3. CWithhold all opioids because they may slow breathing
4. DLeave the patient alone so they can rest

A patient with a fentanyl skin patch wants to use a heating pad on the area. What should the nurse teach?

1. AHeat makes the patch last longer, so fewer patches are needed each month
2. BHeat only matters if the patch is on the chest
3. CAvoid heat on or near the patch, because it increases how fast the drug is absorbed
4. DHeat is fine to use, because it helps the patch stick better to the skin

A patient’s white cell differential shows a raised number of band (immature) neutrophils, called a “shift to the left”. What does this usually suggest?

1. AA typical viral infection
2. BAn acute bacterial infection
3. CA long-standing parasitic infection
4. DAn allergic reaction

The heparin infusion rate was changed according to protocol. When is the aPTT usually rechecked?

1. AAbout 6 hours after the change
2. BOnly after the infusion is stopped
3. CAbout 30 minutes after the change
4. DAbout 3 days after the change

A frail older adult in a nursing home has been drinking very little during a heat wave. She is confused, and her sodium is 158 mEq/L. Which treatment would the nurse expect?

1. AA loop diuretic to remove the extra sodium quickly
2. BStrict fluid restriction to below 800 mL a day
3. CGradual replacement of free water over many hours
4. DRapid infusion of 3% saline to raise the volume

A spontaneously breathing patient is critically ill and hypoxic. Which oxygen delivery gives the highest concentration?

1. AVenturi mask set to 24%
2. BNasal cannula at 2 L/min
3. CSimple face mask at 5 L/min with the patient sitting up
4. DNon-rebreathe mask with reservoir bag at 15 L/min

The fluid in an underwater seal chest drain has stopped swinging with breathing. What could this mean?

1. AThe drain is working perfectly and needs no checks
2. BThe water seal has been set up correctly for the first time
3. CThe patient's breathing has become normal and the drain can be pulled out by the nurse
4. DThe tube may be kinked or blocked, or the lung may have fully re-expanded

Theo hướng dẫn hiện hành, khi nào nên cho oxy ở bệnh nhân hội chứng vành cấp?

1. AKhông bao giờ, vì oxy gây hại cho cơ tim
2. BChỉ khi đã có kết quả troponin
3. CChỉ khi SpO₂ dưới khoảng mục tiêu
4. DLuôn luôn ở 15 L/phút, bất kể độ bão hòa

After chest trauma, a patient is hypotensive with reduced breath sounds on the left. Which finding suggests a haemothorax rather than a tension pneumothorax?

1. ATrachea pushed away from the affected side
2. BDistended neck veins
3. CHyper-resonance on the affected side
4. DDullness to percussion on the affected side

A patient has had a calcium oxalate kidney stone. Which advice best helps prevent another?

1. ACut all calcium out of the diet
2. BDrink plenty of fluid so the urine stays pale
3. CDrink only a little to avoid diluting the urine
4. DTake extra vitamin C supplements

A patient on insulin has worsening chronic kidney disease and is having more hypos. What is the best explanation?

1. AKidney disease makes the meter read too low
2. BThe kidneys clear less insulin, so it lasts longer
3. CKidney disease makes the body resistant to insulin
4. DThe patient is eating far more carbohydrate than before

After a spinal anaesthetic, which nursing check is particularly important?

1. ABlood glucose every 15 minutes overnight
2. BPupil reaction every five minutes for the next full day
3. CReturn of leg sensation and movement, and passing urine
4. DPeak flow before and after each meal

Ngày 3 sau phẫu thuật khớp háng, một bệnh nhân cao tuổi đột ngột lú lẫn, chú ý dao động và kích động. Điều dưỡng nên làm gì trước tiên?

1. ATìm nguyên nhân như thiếu oxy, nhiễm trùng, đau hoặc thuốc, và báo cáo lên
2. BCho rằng đó là sa sút trí tuệ và tiếp tục kế hoạch chăm sóc không đổi
3. CNhờ gia đình đưa bệnh nhân về nhà để họ yên
4. DCố định bệnh nhân và cho ngay liều lớn thuốc an thần