Prioritas & Delegasi ala NCLEX: paket kilat

A patient is in skeletal traction. Which finding needs the nurse to act?

1. AThe weights are resting on the floor
2. BThe patient’s body is in line with the traction
3. CThe weights are hanging freely
4. DThe ropes are in the pulleys

A victim heavily contaminated with an industrial chemical arrives at the emergency department with stable vital signs. What should happen first?

1. ADecontamination before the victim enters the treatment area
2. BPlacing the victim in the waiting room until a doctor is free
3. CTaking the victim straight to the X-ray department
4. DFull assessment inside the main department straight away

Seorang pasien yang menggunakan diuretik berisiko jatuh tinggi dan sering bangun pada malam hari. Tindakan mana yang paling membantu?

1. AMenyuruh pasien tidak minum apa pun setelah makan siang
2. BMenjaga ruangan benar-benar gelap pada malam hari agar pasien tidur
3. CMemberikan diuretik saat menjelang tidur agar bekerja semalaman
4. DJadwal ke toilet, dengan bel panggil dan alat bantu jalan dalam jangkauan

The laboratory reports that a blood sample labeled with one patient’s name has a blood group different from that patient’s previous result. What is the most likely problem and response?

1. AThe previous result was wrong, so it is deleted
2. BA wrong-patient sample, so the test is repeated and the event reported
3. CA normal change in the patient’s blood group over the years since the last test
4. DA laboratory machine fault, so no action is needed

Faktor mana yang paling mungkin meningkatkan kadar litium pasien?

1. AMinum lebih banyak cairan daripada biasanya saat cuaca panas
2. BDehidrasi atau penurunan mendadak asupan natrium
3. CMakan lebih banyak garam daripada biasanya selama beberapa hari
4. DMeminum setiap dosis bersama makan, bukan sebelumnya

A patient with diabetes had a glucose of 58 mg/dL (3,2 mmol/L), took 15 g of fast-acting carbohydrate and, 15 minutes later, the glucose is 64 mg/dL (3,6 mmol/L). The patient is alert. What should the nurse do next?

1. AGive a protein snack only and recheck tomorrow
2. BGive another 15 g of fast carbohydrate and recheck
3. CWait until the next meal before giving anything
4. DGive a long-acting insulin dose to stabilize it

Why are alternate sutures sometimes removed first when taking out stitches?

1. ATo make the procedure faster
2. BTo check the wound stays closed before removing the rest
3. CBecause the remaining sutures dissolve on their own within a day
4. DTo reduce the cost of dressings

A few hours after cardiac surgery, a patient has low blood pressure, a raised jugular venous pressure and quiet, muffled heart sounds. What should be suspected?

1. ACardiac tamponade
2. BHypovolaemia from dehydration
3. CPneumonia
4. DHyperkalaemia

Seorang pasien gagal jantung memulai spironolakton selain penghambat ACE. Hasil darah mana yang memerlukan pemantauan ketat?

1. AGlukosa, karena kedua obat dapat menyebabkan hipoglikemia
2. BHemoglobin, karena kedua obat dapat menyebabkan perdarahan
3. CKalium, karena kedua obat dapat meningkatkannya
4. DKalsium, karena kedua obat dapat menurunkannya

A conscious adult in the dining room is suddenly unable to speak, cough or breathe after a mouthful of food. What should the nurse do first?

1. AEncourage them to drink a glass of water to wash the food down
2. BLie them down on the floor and start chest compressions immediately
3. CSweep blindly in the mouth with a finger
4. DUp to five back blows, then up to five abdominal thrusts if needed

Why might a patient taking a beta-blocker not notice a hypoglycaemic episode?

1. ABeta-blockers block the effect of all diabetes medicines
2. BBeta-blockers can mask the tremor and racing heart of a hypo
3. CBeta-blockers raise blood glucose, so hypos cannot happen
4. DBeta-blockers make the patient sleep through every hypo

Why might a frail 88-year-old with type 2 diabetes have a less strict HbA1c target?

1. ATo save money on blood tests and drugs
2. BBecause diabetes cannot damage older people
3. CBecause older people cannot use any glucose medicines
4. DTo reduce the risk of hypos, falls and confusion

In the SBAR communication tool, what belongs under "A"?

1. AThe patient's admission date only
2. BThe address and phone number of the patient's next of kin
3. CA list of the patient's allergies only
4. DThe nurse's assessment of what the problem is

After signing the consent form, a patient tells the nurse, "I don't really understand what they are going to do." What should the nurse do?

1. AExplain the surgical risks in detail without involving the surgeon
2. BReassure the patient that the surgeon knows best
3. CInform the surgeon so that the procedure can be explained again
4. DIgnore the comment because the form is already signed