NCLEX-style Prioritization & Delegation: cram pack

Which task should the nurse delegate to a nursing assistant for a patient on fall precautions?

1. AAssessing and recording the patient’s fall risk score each morning
2. BHelping the patient to the toilet every 2 hours as planned
3. CDeciding whether the bed alarm is still needed
4. DTeaching the family how to prevent falls at home

A patient has full-thickness burns all the way around the chest and is finding it harder to breathe, although the airway is clear. What does this suggest?

1. AThe burns are healing and the skin is tightening normally
2. BThe patient has had too little IV fluid and needs a fast bolus to improve the breathing
3. CThe patient is anxious and only needs reassurance
4. DThe tight burned skin is restricting chest movement, so an escharotomy may be needed

An alcohol-based skin prep has been used before surgery with electrosurgery. What must happen before the drapes are placed?

1. AThe prep must be warmed with a hair dryer
2. BThe prep must be covered with the drapes while it is still wet
3. CThe prep must be wiped off with saline
4. DThe prep must be fully dry and any pooled liquid removed

During an oral drug round, a patient asks to take a tablet later. The nurse leaves it on the bedside table. What is the main safety problem?

1. AThere is no safety problem if the patient is alert
2. BTablets dissolve quickly when left in the open air
3. CThe tablet may lose its color and become hard to identify later
4. DThe nurse cannot confirm it was taken, and another person could take it

A patient on warfarin has an INR of 7.8 and a nosebleed. Which medication would the nurse expect the provider to prescribe?

1. AAcetylcysteine
2. BProtamine sulfate
3. CVitamin K (phytonadione)
4. DNaloxone hydrochloride

A patient receiving IV magnesium sulfate has a respiratory rate of 9/min and absent patellar reflexes. After stopping the infusion, which medication should the nurse expect to give?

1. AProtamine sulfate
2. BPotassium chloride
3. CCalcium gluconate
4. DSodium bicarbonate

What should a patient be told before using sublingual glyceryl trinitrate (GTN, nitroglycerin) spray for angina?

1. ATake it with a large glass of milk to protect the stomach lining
2. BSit down before using it, as it can cause dizziness and low blood pressure
3. CUse it only after the pain has lasted over an hour, with the patient lying flat
4. DSwallow the spray rather than leaving it under the tongue

A nurse realises she has given a patient a medicine prescribed for another patient. What should she do first?

1. ACheck the patient's condition and inform the doctor
2. BAsk a colleague not to mention it
3. CGive the patient's own medicine as well to balance it
4. DWait to see whether any side effects develop

A patient has a heart rate of 36/min with hypotension and dizziness. Which drug is usually the first choice?

1. AOral bisoprolol
2. BIntravenous amiodarone
3. CIntravenous atropine
4. DIntravenous adenosine

The monitor shows a regular broad-complex tachycardia at 180/min. The patient is alert with BP 126/78 mmHg and no chest pain. What is the most appropriate plan?

1. ARecord a 12-lead ECG, call senior help and anticipate an antiarrhythmic
2. BDeliver an unsynchronised shock immediately, before any other assessment
3. CReassure the patient, as this is a normal rhythm
4. DStart chest compressions straight away and give a dose of IV adrenaline

Which finding most suggests fluid overload in a patient with chronic kidney disease?

1. AA weight gain of 2 kg (4.4 lb) in two days with ankle swelling
2. BA weight loss of 1 kg (2.2 lb) after a hot day
3. CA dry mouth and a low blood pressure when standing
4. DDark yellow urine and thirst

A patient with type 1 diabetes is nil by mouth before surgery tomorrow. Which plan is safest?

1. AStop all insulin until the patient is eating and drinking normally again
2. BGive insulin only if the urine ketones become strongly positive overnight
3. CContinue some insulin (basal or a variable-rate IV infusion) with glucose checks
4. DGive the usual meal-time insulin, even though no meals will be eaten

Which infection control measure is correct for a patient with C. difficile diarrhoea?

1. AA single room with its own toilet, and soap-and-water handwashing
2. BA shared bay, as long as alcohol gel is used after every contact
3. CA face mask for the patient and visitors only
4. DNo special measures once antibiotics have started

A nurse teaches a carer about overnight tube feeding at home. Which statement shows a need for further teaching?

1. A"I'll let him lie flat so he sleeps better while the feed runs."
2. B"I'll stop the feed and call if he coughs or struggles to breathe."
3. C"I'll check the external length mark on the tube every day."
4. D"I'll flush the tube with water before and after his medicines."