Prioritas & Delegasi ala NCLEX: paket kilat

A patient on hemodialysis has an arteriovenous fistula in the left arm. Which instruction should the nurse give the nursing assistant?

1. AKeep the left arm wrapped tightly in a bandage at night
2. BMeasure blood pressure on the left arm only, every 4 hours
3. CHelp the patient carry shopping bags on the left arm
4. DDo not measure blood pressure on the left arm

Pasien mana yang paling tepat dipindahkan keluar dari perawatan intensif untuk memberi tempat bagi pasien baru?

1. ADengan infus norepinefrin yang dosisnya dinaikkan pagi ini
2. BDiintubasi 1 jam yang lalu karena gagal napas, masih tersedasi
3. CDirawat semalam dengan perdarahan saluran cerna dan masih menerima darah
4. DDiekstubasi 2 hari yang lalu, stabil dengan oksigen nasal 2 L/menit, tanpa infus vasoaktif

Hair must be removed from a planned surgical site. Which method reduces the risk of surgical site infection?

1. AUsing wax strips on the morning of surgery
2. BShaving with a disposable razor the night before surgery
3. CClipping with electric clippers just before surgery
4. DShaving with a razor just before the incision

A handwritten order is hard to read, and the nurse is not sure of the drug name. What should the nurse do?

1. AAsk a colleague to guess what it says
2. BChoose the drug that seems most likely from the diagnosis
3. CHold the drug until the next day without telling anyone
4. DContact the prescriber to clarify before giving anything

A patient starts lisinopril (an ACE inhibitor). Which laboratory values should the nurse expect to be monitored?

1. APotassium and creatinine
2. BTSH and free T₄
3. CALT and bilirubin
4. DCalcium and phosphate

A young woman with frequent self-induced vomiting has swollen salivary glands. Which laboratory pattern is most likely?

1. AHigh potassium, low bicarbonate and low amylase
2. BLow sodium, low bicarbonate and high lipase
3. CLow potassium, high bicarbonate and high amylase
4. DHigh calcium, high phosphate and high glucose

Which measure helps prevent delirium in older inpatients?

1. AReorientation, glasses and hearing aids in use, and good sleep and hydration
2. BRestricting fluids to avoid incontinence
3. CKeeping the lights on all night
4. DMoving the patient to a different bed each night to give them a change of scene

After a viral illness, a patient has sharp chest pain that is worse lying flat and eased by sitting forward. What is the most likely cause?

1. APericarditis
2. BAortic dissection
3. CStable angina
4. DPulmonary oedema

How do clopidogrel and ticagrelor work?

1. AThey directly inhibit thrombin in the plasma
2. BThey inhibit the vitamin K-dependent clotting factors in the liver
3. CThey dissolve fibrin in existing clots
4. DThey block the platelet ADP (P2Y₁₂) receptor

A patient with severe sepsis becomes increasingly breathless over 24 hours. SpO₂ stays low despite high-flow oxygen, and the chest X-ray shows bilateral infiltrates. The heart function is normal. Which condition is most likely?

1. ASpontaneous pneumothorax
2. BAcute respiratory distress syndrome
3. CAn acute asthma attack
4. DAcute left ventricular failure after an MI

Why are tacrolimus blood levels checked regularly?

1. AThe levels show whether the patient has diabetes
2. BToo high harms the kidney; too low risks rejection
3. CThe levels show how much urine the kidney is making
4. DThe drug only works if levels are as high as possible

A patient with acromegaly snores loudly, stops breathing at times in sleep and is sleepy during the day. What is most likely?

1. ANormal snoring
2. BNarcolepsy
3. CAn anxiety disorder
4. DObstructive sleep apnoea

Which diet is usually recommended for a patient with cirrhosis and hepatic encephalopathy?

1. ANormal protein and enough calories, with a late-evening snack
2. BNo food at all until the confusion settles
3. COnly clear fluids for several weeks
4. DA very low-protein diet for the rest of their life to lower ammonia

A patient with recurrent diverticulitis reports passing air and faecal matter in the urine. What is the most likely cause?

1. ABowel preparation that was taken too quickly
2. BA simple lower urinary tract infection
3. CA fistula between the colon and the bladder
4. DA kidney stone blocking the ureter