Prioritas & Delegasi ala NCLEX: paket kilat

After a hip replacement using a posterior approach, which statement shows a need for further teaching?

1. A“I will cross my legs when I sit, so I am more comfortable.”
2. B“I will keep a pillow between my knees when I lie on my side in bed.”
3. C“I will use a raised toilet seat at home.”
4. D“I will not bend my hip past 90 degrees.”

A patient’s serum potassium is 6,1 mEq/L. Which of the patient’s medications should the nurse question first?

1. ASpironolactone
2. BHydrochlorothiazide
3. CFurosemide
4. DOmeprazole

A small spill of blood is found on the floor. How should it be cleaned?

1. AWear gloves, absorb the blood, then clean the area with an approved disinfectant
2. BCover it with a clean sheet and keep working
3. CLeave it until housekeeping arrives the next morning
4. DWipe it up quickly with a dry cloth using bare hands, then wash the hands well

A patient on airborne precautions for tuberculosis wants to walk in the hallway. What is the best response?

1. AAllow it, as long as the patient wears an N95 respirator in the corridor
2. BExplain that they must stay in the room, and offer ways to stay active inside it
3. CAllow it, if they avoid the nurses’ station
4. DAllow it, as long as they walk quickly

A patient receives repeated nebulized albuterol (salbutamol) for severe asthma. Which laboratory change should the nurse watch for?

1. AA fall in serum potassium
2. BA rise in serum calcium
3. CA rise in serum sodium
4. DA fall in blood glucose

A patient on warfarin with an INR of 3,6 fell and hit their head an hour ago. They now report a worsening headache and drowsiness. What is the priority?

1. AReport urgently for imaging and possible reversal
2. BGive acetaminophen (paracetamol) and recheck the INR tomorrow
3. CEncourage rest in a dark room to settle the pain
4. DHold warfarin for one dose and observe at home

During a red cell transfusion, when are serious acute reactions most likely to start?

1. AAbout 24 hours later
2. BIn the first 15 minutes
3. COnly after the unit has finished
4. DAfter the third unit only

A patient took a large paracetamol (acetaminophen) overdose six hours ago and says they feel well. Why is treatment still urgent?

1. AParacetamol damage only shows up in the kidneys, many weeks later
2. BLiver damage develops later, and the antidote works best when given early
3. CParacetamol overdose causes immediate breathing problems
4. DPatients who feel well after six hours never need any treatment at all

The telemetry monitor suddenly shows a chaotic waveform resembling ventricular fibrillation, but the patient is talking and brushing their teeth. What should the nurse do first?

1. AStart chest compressions straight away and call the arrest team
2. BDeliver an immediate defibrillation shock before checking anything
3. CCheck the patient and the electrodes, as this is likely artefact
4. DGive IV amiodarone as a bolus

A patient with pneumonia has a temperature of 39 °C, pain and a sinus tachycardia of 122/min. BP is normal. What is the best way to manage the heart rate?

1. AGive IV adenosine
2. BArrange urgent electrical cardioversion to restore a normal rate
3. CTreat the fever, pain and possible dehydration, then reassess
4. DGive a beta-blocker to bring the heart rate below 100/min

Which approach helps most when talking to a patient with expressive aphasia?

1. AFinish their sentences quickly to save them effort
2. BSpeak louder, because the patient cannot hear well
3. CAsk questions that can be answered with yes, no or a gesture
4. DAvoid talking to them until their speech has recovered

A patient's potassium is 7,1 mmol/L, and the ECG shows peaked T waves and broad QRS complexes. What is the first treatment?

1. AIV furosemide
2. BIV calcium gluconate
3. COral sodium bicarbonate
4. DOral potassium binder

A dying patient can no longer drink. Which mouth care is most appropriate?

1. AFrequent, gentle moistening of the mouth and lips
2. BNo mouth care, to avoid disturbing the patient
3. CBrushing hard with a stiff toothbrush twice a day
4. DLemon and glycerine swabs every hour to stimulate saliva

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. BInform the surgeon so that the procedure can be explained again
3. CReassure the patient that the surgeon knows best
4. DIgnore the comment because the form is already signed