Prioritas & Delegasi ala NCLEX: paket kilat

Which patient on an addiction unit should the nurse see first?

1. ALast drink one week ago; asking about support groups
2. BLast drink this morning; asking when lunch will arrive
3. CLast drink two days ago; now shaking, sweating, heart rate 124/min and seeing insects
4. DIn recovery for a year; came to the clinic today for a routine check and a repeat prescription

Which patient is the most appropriate to assign to an LPN/LVN?

1. AA patient who has just arrived from the emergency department with pneumonia and confusion
2. BA patient with a tracheostomy placed this morning who is coughing up blood
3. CA patient on a new IV medication that needs frequent titration
4. DA patient with a long-standing tracheostomy who needs routine suctioning and care

Kapan kewaspadaan droplet untuk pasien dengan Neisseria meningitidis biasanya dihentikan?

1. ASegera setelah dosis antibiotik pertama diberikan
2. BSetelah 24 jam pengobatan antibiotik yang efektif
3. CHanya setelah pasien dipulangkan
4. DSetelah demam hilang selama satu jam

Seorang pasien di ruang tunggu IGD mengalami batuk selama enam minggu, keringat malam, penurunan berat badan, dan darah dalam dahak. Apa yang pertama kali harus dilakukan perawat?

1. AMemulai kewaspadaan kontak dengan gaun dan sarung tangan untuk petugas
2. BMemasangkan masker pada pasien dan memindahkannya ke ruang isolasi udara
3. CMeminta pasien menunggu di ruang tunggu sampai dipanggil
4. DMenempatkan pasien di bilik bersama dengan tirai tertutup

A patient taking a statin reports new, unexplained muscle pain and weakness. Which laboratory test would the nurse expect to be ordered?

1. ASerum ammonia
2. BSerum lipase
3. CCardiac troponin
4. DCreatine kinase (CK)

In the first 24 hours after a major burn, which laboratory pattern is most expected?

1. AHigh calcium and high albumin
2. BLow potassium and low hematocrit
3. CHigh potassium and high hematocrit
4. DLow sodium and low hematocrit

Why does a patient with a suspected TIA need urgent specialist assessment?

1. AA TIA always turns into a brain tumour unless it is treated
2. BThe patient needs urgent surgery on the brain
3. CThe risk of a full stroke is highest in the days after a TIA
4. DThe symptoms will come back permanently within an hour

Which task is most appropriate for a registered nurse to delegate to a trained healthcare assistant (unlicensed assistive personnel)?

1. AAssessing a patient who has just reported new chest pain
2. BTeaching a patient to inject insulin for the first time
3. CGiving a dose of intravenous antibiotic
4. DMeasuring and recording vital signs on a stable patient

After a prescribed IV fluid bolus for hypotension, what should the nurse do next?

1. AStart a second fluid bolus straight away without checking anything
2. BWait until the next routine observations in four hours
3. CReassess heart rate, blood pressure, urine output and lung sounds
4. DStop all monitoring if the patient says they feel better

Shortly after a thoracentesis, a patient becomes breathless with sharp chest pain and reduced breath sounds on the same side. What complication is most likely?

1. APneumothorax
2. BPulmonary embolism from the leg
3. CRe-accumulation of the effusion
4. DInfection at the puncture site

During continuous bladder irrigation, 3200 mL drains out in a shift. 2500 mL of irrigation fluid was put in. What is the true urine output?

1. A700 mL
2. B5700 mL
3. C2500 mL
4. D3200 mL

A patient who has taken prednisolone daily for years is vomiting and cannot keep tablets down. What should the nurse do?

1. AGive the next dose with a glass of milk
2. BEscalate urgently for steroid by injection
3. COmit the steroid until the vomiting stops
4. DGive the tablets again after every vomit

Which early symptoms suggest local anaesthetic systemic toxicity?

1. AA red rash only at the injection site, with no other symptoms
2. BMild itching of the feet the next day
3. CIncreased hunger and thirst over several hours, with a dry mouth
4. DTingling around the mouth, a metallic taste and tinnitus

A patient with gallstones has a temperature of 39 °C with rigors, jaundice and right upper abdominal pain. What should the nurse suspect?

1. AAcute hepatitis A
2. BUncomplicated reflux
3. CSimple biliary colic
4. DAscending cholangitis