Prioritas & Delegasi ala NCLEX: paket kilat

Which patient with diabetes should the nurse see first?

1. AHbA1c result of 8,2%, asking about diet
2. BNeeds foot care teaching before discharge tomorrow
3. CGlucose 48 mg/dL (2,7 mmol/L), sweating and confused
4. DGlucose 210 mg/dL (11,7 mmol/L) after a large lunch, feels well

A day after a femur fracture, a young patient becomes confused and breathless, with small red spots on the chest. What should the nurse suspect?

1. AAlcohol withdrawal
2. BNormal pain after a fracture
3. CFat embolism syndrome
4. DAn allergic reaction to the cast

A nurse has been fit-tested for an N95 respirator. What should the nurse do each time it is put on?

1. AWear a surgical mask underneath it
2. BArrange a new fit test
3. CPerform a user seal check
4. DMoisten the edges so it seals better

A patient who speaks little English is being discharged with new medications. The patient’s 12-year-old child offers to interpret. What should the nurse do?

1. AUse a professional medical interpreter
2. BGive written instructions in English only
3. CUse simple English and many hand gestures
4. DLet the child interpret, because the family prefers it

Which finding during a transfusion suggests transfusion-associated circulatory overload (TACO)?

1. ACrackles, hypertension and a raised BNP
2. BHives and itching without other signs
3. CA low temperature and slow heart rate
4. DBack pain with dark red urine output

An 82-year-old woman without a catheter has a urine culture growing bacteria, but no fever, urinary symptoms or change in mental state. What is the best interpretation?

1. APyelonephritis, which needs admission and IV fluids today
2. BContamination, so the culture must be repeated every week
3. CA urinary tract infection that needs urgent IV antibiotics
4. DAsymptomatic bacteriuria, usually not treated with antibiotics

Why is an ankle–brachial pressure index (ABPI) measured before applying compression bandages to a leg ulcer?

1. ATo exclude significant arterial disease, as compression could cut off blood flow
2. BTo measure how deep the ulcer is and how much exudate it produces
3. CTo check for a urinary tract infection that could delay ulcer healing
4. DTo work out the patient's fluid needs

Why can sepsis be missed in older adults?

1. AOlder adults always have a very high fever
2. BThey may have no fever and present with confusion, falls or reduced mobility
3. COlder adults cannot develop sepsis because their immune system is weaker
4. DBlood tests are not useful in older people

A patient has a prosthetic heart valve. Which teaching best reduces the risk of infective endocarditis?

1. AKeep teeth and gums healthy with regular dental check-ups
2. BAvoid all physical exercise for the rest of their life
3. CTake a daily antibiotic tablet indefinitely
4. DAvoid eating dairy products and raw vegetables

Four hours after cardiac surgery, the mediastinal drain, which had been draining steadily, suddenly stops. BP falls to 84/60 mmHg, the heart rate rises and the CVP climbs. What should the nurse suspect?

1. ACardiac tamponade from a clotted drain
2. BFluid overload from intravenous fluids
3. CA tension pneumothorax on the left side
4. DNormal recovery, as the bleeding has stopped

The day after a thyroidectomy, a patient reports tingling around the mouth and in the fingers. Why might this happen?

1. AThe parathyroid glands may have been damaged, lowering calcium
2. BThe patient is breathing too slowly after the operation
3. CThe thyroid hormone level has risen too high after surgery
4. DThe anaesthetic has caused an allergic reaction

A patient on haemodialysis is on a medical ward. Which task can the registered nurse delegate to a healthcare assistant (nursing assistant)?

1. ADeciding which morning medicines to hold
2. BWeighing the patient before they go to dialysis
3. CAssessing the thrill and bruit of the fistula
4. DTeaching the patient about fluid restriction

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

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

On the day after a Hartmann's procedure, the end colostomy is dark purple to black. What should the nurse do?

1. ARecord it as normal postoperative bruising and recheck it next week
2. BRub the stoma to improve its colour
3. CCut a smaller hole in the pouch
4. DReport it urgently, as the stoma may be necrotic