Prioritas & Delegasi ala NCLEX: paket kilat

A patient taking warfarin has an INR of 5,2 and no signs of bleeding. What should the nurse do?

1. AEncourage the patient to take aspirin for pain
2. BGive the usual dose and recheck the INR next month
3. CHold the warfarin dose and inform the provider
4. DGive a double dose to correct the result

Seorang pasien yang diselamatkan dari kebakaran rumah mengalami luka bakar pada wajah, rambut hidung hangus, dan suara serak. Apa prioritasnya?

1. AMelindungi jalan napas, bersiap untuk bantuan jalan napas dini
2. BMemulai resusitasi cairan IV yang dihitung dari luas luka bakar
3. CMemberikan pereda nyeri
4. DMembersihkan dan membalut luka bakar wajah

Which practice reduces back strain when a nurse moves a patient or heavy object?

1. ABend at the waist and keep both knees straight
2. BKeep the load close to the body and avoid twisting
3. CHold the load at arm’s length to keep it steady
4. DStand with the feet close together for balance

In START triage at a mass-casualty incident, a casualty cannot walk, breathes 20 times a minute, has a radial pulse and follows simple commands. Which category applies?

1. ARed (immediate)
2. BBlack (expectant or dead)
3. CYellow (delayed)
4. DGreen (minor)

A patient with type 2 diabetes starts prednisone each morning. When is the glucose most likely to be highest?

1. AThe glucose will not change
2. BIn the afternoon and evening
3. CIn the early morning, before the dose
4. DAt midnight only

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. BMagnesium causes potassium loss, so the kidneys release more fluid
3. CPoor kidney function makes the magnesium level fall quickly
4. DMagnesium is excreted by the kidneys, so it can build up to toxic levels

Which advice should be given to a patient with a new permanent pacemaker?

1. AStop all heart medicines straight away
2. BTell staff about the pacemaker before any MRI scan or procedure
3. CAvoid using all household electrical appliances such as kettles
4. DNever raise the arm on that side again

A patient with lung cancer develops swelling of the face and arms, distended neck veins and breathlessness that is worse lying down. What should be suspected?

1. AHypothyroidism
2. BSuperior vena cava obstruction
3. CAn allergic reaction to food
4. DRight-sided heart failure from valve disease

Why is active tuberculosis treated with several drugs for at least six months?

1. ABecause each drug works on a different organ only
2. BTo reduce the number of side effects compared with one drug
3. CTo kill slow-growing bacteria and prevent drug resistance
4. DBecause the bacteria are resistant to all drugs at first

On day 2 after a surgical tracheostomy, the tube falls out. The patient is breathing but distressed. What should the nurse do first?

1. ALeave the patient alone while fetching a new tube
2. BCall for expert help and give oxygen to both the face and the stoma
3. CForce the tube back through the stoma immediately with firm pressure
4. DCover the stoma completely with a sealed dressing and wait for help

A routine blood test shows a potassium of 6,4 mmol/L. The lab reports that the sample was haemolysed. The patient feels well. What should the nurse do?

1. AStart dialysis as soon as possible
2. BIgnore it, because haemolysis always gives a normal result
3. CGive oral potassium supplements straight away
4. DInform the doctor and arrange an urgent repeat sample

A patient with untreated end-stage kidney disease has chest pain that is worse lying flat and better sitting forward. A rub is heard over the heart. What is most likely?

1. AIndigestion from phosphate binders
2. BUraemic pericarditis, which usually needs urgent dialysis
3. CA rib fracture from coughing
4. DA stable angina attack, which needs only a nitrate spray and rest

Why is an ankle-brachial pressure index (ABPI) measured before compression bandaging for a leg ulcer?

1. ATo find the bacteria in the wound
2. BTo check for a leg bone fracture
3. CTo exclude significant arterial disease
4. DTo find out how deep the ulcer is

Seorang pasien kanker paru mengalami pembengkakan wajah, vena leher distensi, dan sesak napas yang memburuk saat berbaring. Kegawatan mana yang mungkin?

1. AEmboli paru masif
2. BHiperkalsemia akibat keganasan
3. CKompresi medula spinalis
4. DObstruksi vena kava superior