Prioritas & Delegasi ala NCLEX: paket kilat

Using the Emergency Severity Index, which level fits a 70-year-old with chest pressure that suggests a heart attack, but normal vital signs?

1. ALevel 5
2. BLevel 2
3. CLevel 1
4. DLevel 4

A patient with MRSA in a wound is on contact precautions. Which instruction to the nursing assistant is correct?

1. AWear a respirator mask in the room, because MRSA in a wound spreads through the air to others
2. BNo special precautions are needed if the wound is covered with a dressing
3. CWear a gown and gloves for contact with the patient or the room, and use dedicated equipment
4. DOnly wear gloves when touching the wound itself; skin and bedding are safe

A patient is admitted to an inpatient mental health unit. Why are personal belongings checked?

1. ATo decide which family members may visit
2. BTo find out what the patient likes to wear during the hospital stay
3. CTo remove items that could be used to harm self or others
4. DTo make a list of valuable items for insurance

A 2-year-old living in a house built many decades ago has anemia, irritability and poor appetite. Which cause should the nurse suspect?

1. ACarbon dioxide from a gas cooker
2. BIron overload from eating too much red meat
3. CA food allergy to cow’s milk proteins
4. DLead poisoning from old paint dust or chips

A patient with recurrent gout starts allopurinol. Which laboratory result shows that the treatment is achieving its goal?

1. AA falling serum uric acid
2. BA falling serum potassium
3. CA rising white cell count
4. DA rising serum calcium

A patient with a serum albumin of 1,9 g/dL (19 g/L) has signs of phenytoin toxicity, although the total phenytoin level is in the usual range. What is the most likely explanation?

1. ALow albumin makes the total level falsely high in all cases
2. BLow albumin makes the liver clear phenytoin much faster
3. CLow albumin stops phenytoin from crossing into the brain
4. DLow albumin raises the free (active) fraction of phenytoin

Which is a major risk factor for Clostridioides difficile infection?

1. AA diet high in fibre and fresh fruit
2. BTaking regular paracetamol
3. CRegular exercise
4. DRecent broad-spectrum antibiotic use

An older man has sudden severe abdominal and back pain, is hypotensive and has a pulsating mass in the abdomen. What should be suspected?

1. AMusculoskeletal back pain
2. BA ruptured abdominal aortic aneurysm
3. CRenal colic from a kidney stone
4. DAcute gastritis from anti-inflammatory drugs

Why is a beta-blocker started at a low dose and increased slowly in heart failure?

1. AIt is safe only at the highest possible dose from the very start
2. BIt must be stopped as soon as symptoms improve
3. CIt works only if the dose is never changed after the first day
4. DIt can briefly worsen symptoms before long-term benefit appears

An 84-year-old with heart failure becomes breathless with new crackles and a rising blood pressure during a blood transfusion. What should the nurse suspect?

1. AAn acute haemolytic reaction from wrong blood
2. BNormal effects of the transfusion
3. CA mild febrile reaction
4. DTransfusion-associated circulatory overload

A patient with Conn's syndrome starts spironolactone. Which blood test should the nurse watch most closely?

1. AAmylase
2. BCalcium
3. CPotassium
4. DGlucose

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

1. AUnderdrainage, so the drain should be lowered further
2. BNo concern, because more drainage always lowers the ICP safely
3. CAn infected drain, so the dressing should be removed
4. DOverdrainage of CSF, so act per protocol and inform the team

Which instruction is important during bowel preparation for colonoscopy?

1. ATake the preparation only if the bowels have not opened
2. BAvoid all fluids for 24 hours before the test
3. CDrink plenty of clear fluids while taking the preparation
4. DEat a high-fibre meal the evening before the test

A patient with diabetes has a foot ulcer. A sterile probe touches bone at the base of the ulcer. What should the nurse suspect?

1. ASimple dry skin
2. BVenous insufficiency
3. CA healing category 1 ulcer
4. DOsteomyelitis