Prioritas & Delegasi ala NCLEX: paket kilat

A patient on a continuous IV heparin infusion has new black, tarry stools and an aPTT well above the target range. What should the nurse do first?

1. AGive a dose of vitamin K by mouth
2. BOffer an iron-rich meal to replace the lost blood
3. CCheck the pump rate and leave the infusion running
4. DStop the heparin infusion and inform the provider

Two days after starting haloperidol, a patient suddenly develops painful neck twisting and the eyes roll upwards. What should the nurse anticipate?

1. APhysical restraint until the spasm passes
2. BNo action, because the spasm is a sign of improvement
3. CA higher dose of haloperidol to calm the patient and stop the movements quickly
4. DAn anticholinergic drug, such as benztropine or procyclidine, as prescribed

A woman who is pregnant asks for the MMR vaccine because she is not immune to rubella. What is correct?

1. AMMR should be given as soon as possible in the first trimester to protect the baby
2. BMMR is only given to pregnant women who work in hospitals
3. CMMR is a live vaccine and is not given during pregnancy, but can be given after delivery
4. DMMR is safe at any stage of pregnancy

A nurse has a needlestick from a patient known to have hepatitis C. Which statement about management is correct?

1. AHepatitis C immune globulin is given within 24 hours, followed by a booster dose
2. BThere is no preventive drug, so baseline and follow-up testing are done to detect infection early
3. CNo follow-up is needed because hepatitis C does not spread by needles
4. DThe hepatitis C vaccine series is started at once, with a booster dose six months later

A patient without symptoms has a fasting plasma glucose of 132 mg/dL (7,3 mmol/L) on Monday and 138 mg/dL (7,7 mmol/L) on Thursday. What does this show?

1. AThe results are within the normal fasting range
2. BThe results show prediabetes only
3. CThe results show reactive hypoglycemia
4. DThe results meet the criteria for diabetes

A patient has painless jaundice, itching, dark urine and pale stools. ALP is markedly raised, conjugated (direct) bilirubin is high and ALT is only mildly raised. What is the most likely cause?

1. AIncreased breakdown of red blood cells (hemolytic anemia)
2. BAcute viral hepatitis with widespread liver cell damage
3. CGilbert syndrome, a harmless inherited bilirubin disorder
4. DBlockage of bile flow, for example by a tumor in the bile duct

Why are patients asked to fast before a general anaesthetic?

1. ATo reduce the risk of aspirating stomach contents
2. BTo make the surgery shorter
3. CTo lower the blood glucose before surgery
4. DTo prevent postoperative constipation and abdominal bloating

A patient with poorly controlled hyperthyroidism develops a high fever, very fast heart rate, agitation and vomiting during an infection. What is likely?

1. AThyroid storm
2. BAddisonian crisis
3. CHypoglycaemia
4. DMyxoedema coma

A patient taking simvastatin drinks a large glass of grapefruit juice every morning. Why is this a concern?

1. AIt causes the cholesterol level to rise sharply
2. BIt turns the statin into a blood thinner
3. CIt raises statin levels and the risk of muscle damage
4. DIt stops the statin from being absorbed from the gut at all

A nurse looked after a patient for a shift before smear-positive pulmonary TB was diagnosed, without wearing a respirator. What should happen?

1. AReport it so occupational health can arrange follow-up screening
2. BStart a full six-month course of TB drugs at once without any tests
3. CTake no action, as healthcare workers are immune to TB
4. DStay off work for six months in case symptoms develop

Before checking a capillary glucose, why should the patient wash their hands with soap and water?

1. ASugar on the skin can give a falsely high reading
2. BWashing lowers the glucose in the blood
3. CSoap makes the blood flow faster from the finger
4. DWashing prevents all infection from the lancet

A nurse teaches a patient with CKD and a high potassium about diet. Which statement shows a need for further teaching?

1. A"I will check food labels for added salt when I go shopping."
2. B"I will use a salt substitute instead of ordinary salt."
3. C"I will keep bananas and dried fruit to a minimum."
4. D"I will boil my potatoes and throw away the water."

When is cold therapy most useful for pain?

1. AOver numb areas where sensation is lost
2. BFor long-term muscle stiffness, applied continuously for several hours
3. CSoon after an acute soft tissue injury, to reduce swelling
4. DDirectly on skin with poor circulation

Which patient has the highest risk of postoperative nausea and vomiting?

1. AA man with no history of nausea having local anaesthetic only
2. BA non-smoking woman with motion sickness who will need opioids
3. CA smoker who has never had nausea after surgery
4. DA male smoker having a short procedure without opioids