Prioritas & Delegasi ala NCLEX: paket kilat

A patient on a nasal cannula at 6 L/min still has a low SpO₂. What should the nurse do?

1. ATurn the nasal cannula up to 15 L/min
2. BRemove the oxygen to see if the SpO₂ changes
3. CRecheck the SpO₂ at the next routine set of observations in four hours
4. DReport it, because a different oxygen device is likely to be needed

Seorang pasien menerima nutrisi parenteral melalui jalur sentral. Temuan mana yang memerlukan tindakan segera?

1. ABerkeringat, gemetar, dan glukosa 62 mg/dL (3,4 mmol/L) setelah infus berhenti tak terduga
2. BGlukosa 150 mg/dL (8,3 mmol/L) selama infus berjalan
3. CBalutan kering dan utuh di atas jalur
4. DKenaikan berat badan 0,2 kg sejak kemarin

A patient has botulism after eating contaminated food. Which precautions are needed?

1. AStandard precautions
2. BAirborne precautions
3. CDroplet precautions
4. DContact precautions

A nurse caring for a patient with influenza on droplet precautions will assist with an aerosol-generating procedure, such as bronchoscopy. What change in PPE is needed?

1. AWear two surgical masks, one on top of the other, for the length of the procedure
2. BNo change, because influenza only needs droplet precautions
3. CWear a fit-tested respirator (N95 or FFP3) and eye protection instead of a surgical mask
4. DWear gloves only, because the procedure is short

A patient had a total gastrectomy. Which long-term therapy is needed to prevent anemia?

1. ALifelong oral folic acid tablets only
2. BMonthly transfusions of red blood cells
3. CWeekly doses of oral vitamin K tablets
4. DLifelong vitamin B₁₂ replacement

A 68-year-old man has fatigue, a hemoglobin of 9,8 g/dL (98 g/L), an MCV of 72 fL and a low ferritin. He eats a normal diet. What is the most important next step?

1. AGive iron and do no further tests at all
2. BLook for a source of blood loss in the gut
3. CRepeat the blood count in one year
4. DStart vitamin B₁₂ injections

A patient is prescribed two different eye drops at the same time. What is correct?

1. AGive one drop now and the other the next day
2. BWait about five minutes between the two drops
3. CMix the two drops in one bottle
4. DGive both drops at once into the same eye

A conscious patient with hypoglycaemia was given fast-acting carbohydrate. On re-check 15 minutes later the blood glucose is 3,6 mmol/L (65 mg/dL). What should the nurse do next?

1. ATake no action because the level is rising
2. BGive another dose of fast-acting carbohydrate and recheck
3. CGive a long-acting carbohydrate snack only and recheck tomorrow
4. DGive a dose of subcutaneous insulin

Why is a shock for cardioversion synchronised with the QRS complex?

1. ATo make the shock less painful for the patient
2. BTo allow the use of a lower battery charge
3. CTo avoid delivering the shock during the T wave
4. DTo keep the pads from burning the skin

A nurse teaches a patient how to measure blood pressure at home. Which statement shows a need for further teaching?

1. A"I will take two readings and write them both down."
2. B"I will measure it straight after my morning jog."
3. C"I will sit with my back supported and my arm at heart level."
4. D"I will rest quietly for five minutes before measuring."

Which statement about giving IV potassium is correct?

1. AIt needs no monitoring at all once the infusion is running
2. BIt is diluted and given through an infusion pump, never as a bolus
3. CIt is safest given through a small vein in the hand at a fast rate
4. DIt can be given quickly as a push to correct the level fast

A patient had a witnessed tonic-clonic seizure. Afterwards their left arm is weak, and the weakness improves over the next few hours. What is the best interpretation?

1. ANormal postictal tiredness that needs no further assessment or imaging at all
2. BA sign that the patient is pretending to be weak
3. CCertainly a stroke, so the seizure can be ignored
4. DPossible postictal (Todd's) paresis, but a stroke must still be excluded

How is the height of an epidural sensory block usually checked?

1. ATesting sensation to cold with ice or a cold spray
2. BMeasuring the patient's blood glucose level
3. CChecking the colour of the patient's urine
4. DTapping the knee with a reflex hammer and recording the score

On day 5 after hip surgery, a patient suddenly becomes breathless, with sharp chest pain on breathing in, a pulse of 120/min and SpO₂ 89%. What should the nurse suspect and do first?

1. APulmonary embolism; sit up, give oxygen and call for urgent help
2. BAnxiety; give reassurance and repeat the observations in an hour's time
3. CSimple atelectasis; encourage walking around the ward
4. DWound infection; take a wound swab and wait for results