NCLEX-style Prioritization & Delegation: cram pack

A patient is raising his voice, pacing and clenching his fists. What should the nurse do first?

1. AApply physical restraints at once
2. BTurn away and ignore the behavior
3. CSpeak calmly, keep a safe distance and invite him to talk about what is wrong
4. DStand very close to him and tell him firmly and loudly to sit down and be quiet

Which nursing approach may raise intracranial pressure in a patient with a head injury?

1. ADoing suctioning, turning and bathing all at the same time
2. BKeeping the head in line with the body
3. CSpacing out care with rest periods in between activities
4. DKeeping the room calm and quiet

Which assessment is most important while a patient is in wrist restraints?

1. AThe patient’s height and weight
2. BCirculation, sensation and skin beyond the restraint
3. CThe patient’s hearing in both ears with a watch test
4. DThe patient’s food and drink preferences for the day

In US nursing practice, which task should the RN not assign to an LPN/LVN?

1. AReinforcing hand hygiene teaching that the RN has already given
2. BGiving scheduled oral antibiotics to a stable patient
3. CThe initial admission assessment of a new patient with suspected sepsis
4. DA dressing change on a healing surgical wound that has no signs of infection

In chronic kidney disease, a high serum phosphate is usually accompanied by which change in calcium?

1. ANo change in calcium
2. BA low serum calcium
3. CA high serum calcium
4. DA high serum potassium only, with no calcium change

A patient with advanced chronic kidney disease has a mildly raised troponin that has stayed the same on several tests over months. There is no chest pain and the ECG is unchanged. What is the best interpretation?

1. AA laboratory error, because troponin is never raised in kidney disease
2. BA sign of skeletal muscle injury, because troponin comes from all muscles
3. CA chronic stable rise; infarction needs a rising or falling pattern
4. DProof of an acute myocardial infarction that needs emergency treatment now

What is the recommended first aid for a thermal burn?

1. ACool it under cool running water for about 20 minutes
2. BBurst any blisters to release the fluid
3. CSpread butter or oil over the burn
4. DApply ice directly to the burn until the pain stops completely

How should pain be assessed in a patient with advanced dementia who cannot describe it?

1. ABy assuming the patient has no pain unless they are crying out or calling for help
2. BWith an observational pain tool that scores facial expression, behaviour and body language
3. CBy asking the patient to rate their pain on a numerical scale from 0 to 10
4. DBy checking the blood pressure only

A patient has episodes of severe headache, sweating and palpitations with very high blood pressure. Which rare cause should be considered?

1. AStable angina
2. BAortic stenosis
3. CAsthma
4. DPhaeochromocytoma

A ventilated patient suddenly desaturates to 82%. The cause is not obvious and the ventilator alarms are sounding. What should the nurse do first?

1. AIncrease the sedation and watch the monitor for the next half hour
2. BSilence the alarm and wait for the result of the next routine blood gas
3. CChange the ventilator settings to a higher rate
4. DDisconnect and hand-ventilate with 100% oxygen while calling for help

A patient's fistula starts to bleed at home after the needles were removed. What should they do first?

1. APress firmly on the site with clean gauze
2. BRaise the arm and let it bleed freely
3. CApply a tight tourniquet above the fistula
4. DWait for the next dialysis session

Which nursing care is important for a patient receiving mannitol for raised intracranial pressure?

1. AGiving the drug orally with meals to reduce nausea
2. BStopping the fluid balance chart during treatment
3. CClose monitoring of urine output, sodium and osmolality
4. DClamping the catheter to keep fluid in the body

During the first infusion of a monoclonal antibody such as rituximab, which problem is most important to watch for?

1. ASevere constipation within the first hour of starting the infusion
2. BAn infusion reaction, such as fever, rigors or breathlessness
3. CSudden hair loss during the infusion
4. DA rise in platelet count above normal

A patient with cirrhosis and ascites has a new fever, abdominal tenderness and worsening confusion. Which complication should be suspected?

1. ASpontaneous bacterial peritonitis
2. BNormal progression of ascites
3. CAcute pancreatitis
4. DSimple constipation