Prioritas & Delegasi ala NCLEX: paket kilat

Seorang asisten keperawatan melaporkan bahwa tekanan darah pasien 168/98 mmHg (sebelumnya 130/80) dan pasien sakit kepala. Apa yang harus dilakukan RN?

1. AMengkaji pasien, memeriksa ulang tekanan darah, dan mencari gejala
2. BMendokumentasikan nilai tersebut dan melanjutkan putaran pemberian obat
3. CMeminta asisten memeriksa ulang tekanan darah dalam satu jam
4. DMeminta asisten memberikan obat antihipertensi bila perlu sekarang

A patient with raised intracranial pressure is being nursed on the ward. Which position is best?

1. AFlat on the back with the head turned well over to one side
2. BHead of the bed at about 30 degrees with the neck straight
3. CHead down with the legs raised above the heart
4. DSitting forward with the chin on the chest

A parent calls because a toddler has swallowed some household cleaner. The child is awake and breathing normally. What should the nurse advise first?

1. AGive syrup of ipecac from the medicine cabinet
2. BMake the child vomit, using a finger at the back of the throat
3. CContact the local poison advice service now for specific advice
4. DWait to see whether any symptoms develop over the next day

According to the “Swiss cheese” model of error, why do errors reach patients?

1. APatients often do not follow their care instructions
2. BTechnology fails more often than people do
3. COne careless person makes a mistake that no system could stop
4. DWeaknesses in several layers of defense line up at the same time

How should a blood sample for serum ammonia be handled?

1. APlaced on ice and sent to the laboratory at once
2. BShaken firmly to mix it before it is sent away
3. CKept warm and sent with the next routine batch
4. DLeft at room temperature for several hours first

A woman with preeclampsia is receiving IV magnesium sulfate. Her urine output has fallen and her creatinine is rising. Why is this a concern?

1. AMagnesium is broken down by the liver, so it will stop working soon
2. BPoor kidney function makes the magnesium level fall quickly
3. CMagnesium causes potassium loss, so the kidneys release more fluid
4. DMagnesium is excreted by the kidneys, so it can build up to toxic levels

Skor NEWS2 seorang pasien naik menjadi 7. Apa respons yang tepat?

1. AMencatat skor, meningkatkan observasi, dan menunggu visite bangsal pagi
2. BMelanjutkan observasi setiap 12 jam
3. CMemberikan sedatif dan memeriksa ulang nanti
4. DPenilaian darurat oleh tim klinis dengan keterampilan perawatan kritis

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

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

A patient with stable angina is afraid nicotine patches will harm their heart. Which reply is most accurate?

1. APeople with angina must stop smoking without any help
2. BNicotine replacement only works if smoking continues
3. CNicotine patches are much more harmful to the heart than cigarettes
4. DNicotine replacement is much safer than smoking and is recommended

During tracheal suctioning, a patient's heart rate drops from 88/min to 48/min. What should the nurse do?

1. AGive a dose of atropine without a prescription
2. BContinue suctioning until the airway is completely clear
3. CStop suctioning, give oxygen and monitor the patient
4. DIncrease the suction pressure to finish faster

A patient with Conn's syndrome starts spironolactone. Which blood test should the nurse watch most closely?

1. AGlucose
2. BCalcium
3. CAmylase
4. DPotassium

A patient with Guillain–Barré syndrome has a blood pressure that swings between 80/50 and 190/100 mmHg and a heart rate that changes suddenly. What does this suggest?

1. AAutonomic dysfunction, which needs continuous cardiac monitoring
2. BAnxiety that will settle with reassurance alone
3. CA drug reaction that means all medicines must stop
4. DA faulty blood pressure cuff that should be replaced and the readings ignored

Apa peran pembatasan natrium dan spironolakton pada sirosis?

1. AMenurunkan amonia darah dan mengobati ensefalopati
2. BMeningkatkan kehilangan kalium dan mencegah hiperkalemia
3. CMenaikkan tekanan darah dan memperbaiki aliran darah ginjal
4. DMengurangi retensi natrium dan air serta mengendalikan asites

A patient has sharp, tearing pain on passing stool, "like passing glass", with a streak of fresh blood. Which condition is most likely?

1. AUpper GI bleeding
2. BCrohn's disease of the ileum
3. CAnal fissure
4. DColorectal cancer