NCLEX 风格的优先排序与委派：速成包

A patient has heart failure. Which instruction about daily weights is best to give the nursing assistant?

1. A“Weigh him at any time today, on whichever scale is free.”
2. B“Only weigh him if his ankles look more swollen than they did yesterday afternoon.”
3. C“Weigh him after lunch, fully dressed, with his shoes on.”
4. D“Weigh him each morning before breakfast, on the same scale, and tell me the result.”

在 START 分诊中，一名不能行走的成人每分钟呼吸 24 次，有桡动脉搏动，但不能遵从简单指令。该伤员被归入哪一类？

1. A黄色（延迟）
2. B绿色（轻伤）
3. C红色（立即）
4. D黑色（期待观察）

A patient has leftover opioid tablets after surgery. Which advice about disposal is best?

1. ALeave them in the bathroom cabinet indefinitely
2. BReturn them to a pharmacy or an approved take-back site
3. CGive them to a friend or relative who has back pain
4. DKeep them in an unlocked drawer at home in case of future pain

A nurse calls a provider using SBAR about a patient with falling blood pressure. Which statement is the “Recommendation”?

1. A“He is 72 and had a bowel resection yesterday.”
2. B“I am calling about Mr. Jansen in room 12, who is hypotensive.”
3. C“I think he needs to be assessed now. Can you come within the next 15 minutes?”
4. D“His blood pressure has fallen from 130/80 to 88/50 over the last two hours.”

Which finding during a transfusion suggests transfusion-associated circulatory overload (TACO)?

1. AHives and itching without other signs
2. BCrackles, hypertension and a raised BNP
3. CA low temperature and slow heart rate
4. DBack pain with dark red urine output

A patient with blood pressure that is hard to control has a potassium of 2.9 mEq/L, a sodium of 144 mEq/L and a raised serum bicarbonate, without taking a diuretic. Which condition is most likely?

1. APrimary adrenal insufficiency
2. BCentral diabetes insipidus
3. CSyndrome of inappropriate ADH
4. DPrimary hyperaldosteronism

Which group of symptoms suggests hypercalcaemia?

1. AWeight gain, feeling cold and a slow pulse
2. BSweating, tremor and sudden hunger
3. CTingling lips, muscle cramps and spasms of the hands and feet
4. DThirst, constipation, confusion and abdominal pain

A patient has a painful, punched-out ulcer on the toes, with a cold, pale foot and weak foot pulses. Which type of ulcer is most likely?

1. AA venous ulcer
2. BAn arterial ulcer
3. CA pressure ulcer from bed rest
4. DA burn

A young patient with hypertrophic cardiomyopathy asks why they are told to avoid dehydration. What is the best explanation?

1. ALow blood volume can worsen obstruction of blood leaving the heart
2. BDehydration is the cause of the inherited condition
3. CDehydration makes the heart muscle grow thicker within a few hours
4. DFluids dissolve the extra muscle in the heart wall

Two adults with cystic fibrosis are admitted to the same ward. What is the correct infection-control plan?

1. APut them in the same bay so they can support each other
2. BLet them share physiotherapy sessions and equipment
3. CUse standard precautions only, as CF is not infectious
4. DNurse them in separate single rooms and keep them apart

哪项尿液表现最能区分尿崩症和 SIADH？

1. A尿崩症尿中有葡萄糖；SIADH 尿中有蛋白
2. B尿崩症为稀释尿；SIADH 为浓缩尿
3. C尿崩症为浓缩尿；SIADH 为稀释尿
4. D两种疾病都排出高度浓缩的尿

A patient has erratic glucose readings. The nurse finds a soft, rubbery lump where they always inject. What is the most important teaching?

1. AKeep injecting into the lump, because it hurts less there
2. BMassage the lump firmly after every injection
3. CUse healthy sites and check glucose often, as less insulin may be needed
4. DDouble the insulin dose because the lump blocks the insulin

一名急性上消化道出血患者到院时血红蛋白正常。为什么这可能有误导性？

1. A任何失血后血红蛋白总是先升高
2. B只有在液体转移或静脉补液稀释血液后才会下降
3. C消化道出血不影响血红蛋白
4. D血红蛋白只有在持续出血整整一周后才会下降

Which preoperative task can a registered nurse usually delegate to a healthcare assistant (nursing assistant)?

1. ADeciding whether abnormal results need reporting
2. BTeaching the patient how to use a PCA pump
3. CAssessing the patient's understanding of the surgery
4. DRecording baseline vital signs