Prioritas & Delegasi ala NCLEX: paket kilat

Pernyataan mana yang menunjukkan pemahaman yang benar tentang akuntabilitas dalam pendelegasian?

1. A"Begitu saya mendelegasikan suatu tugas, itu bukan lagi urusan saya."
2. B"Saya tetap bertanggung jawab atas keputusan mendelegasikan dan menindaklanjuti hasilnya."
3. C"Asisten keperawatan bertanggung jawab atas apakah tugas itu tepat didelegasikan."
4. D"Jika tugas itu salah, hanya asistennya yang bertanggung jawab."

Seorang pasien dengan perdarahan saluran cerna atas memiliki denyut jantung 128/menit dan tekanan darah 84/50 mmHg. Semua ini diresepkan. Mana yang dimulai perawat lebih dulu?

1. AMemesan endoskopi diagnostik untuk pagi berikutnya
2. BInfus penghambat pompa proton IV
3. CCairan IV atau darah melalui kanula berukuran besar
4. DTablet zat besi oral

Salin steril tumpah pada duk steril yang terletak di atas meja tidak steril. Apa artinya?

1. AHanya bagian yang basah yang terkontaminasi, sehingga alat dapat dipindahkan ke bagian yang kering
2. BArea terkontaminasi, karena cairan dapat membawa mikroorganisme menembus duk
3. CArea menjadi steril lagi saat kering
4. DArea tetap steril, karena salin itu steril

While preparing an IV medication, a nurse sees that the syringe tip touched the medication tray after the cap came off. What should the nurse do?

1. ADiscard the syringe and prepare the dose again with new equipment
2. BGive the dose anyway, because the medication tray was cleaned this morning
3. CBlow on the tip to remove any dust
4. DWipe the tip with an alcohol swab and give the dose

When blood is drawn from a central venous catheter, why is a small volume of blood usually discarded first, according to policy?

1. ATo remove blood clots that form in all central lines
2. BTo lower the patient's hemoglobin for a blood transfusion
3. CTo check that the catheter tip is still in the right vein
4. DTo avoid diluting the sample with flush or infusion fluid

A frail older adult in a nursing home has been drinking very little during a heat wave. She is confused, and her sodium is 158 mEq/L. Which treatment would the nurse expect?

1. AA loop diuretic to remove the extra sodium quickly
2. BStrict fluid restriction to below 800 mL a day
3. CRapid infusion of 3% saline to raise the volume
4. DGradual replacement of free water over many hours

A patient with sickle cell disease is admitted with a painful crisis. What is a key early nursing priority?

1. AGiving prompt, effective analgesia
2. BDelaying pain relief until a diagnosis is confirmed
3. CRestricting oral fluids
4. DApplying cold packs to the painful areas

A patient with myasthenia gravis develops increasing difficulty swallowing and weak, shallow breathing. What is the main danger?

1. ARespiratory failure from a myasthenic crisis
2. BSevere hypertension from anxiety
3. CA urinary tract infection
4. DA sudden rise in blood glucose from the stress

Seorang pasien dengan stroke baru dan kesulitan menelan mengalami demam dan krepitasi lobus bawah kanan. Apa penyebab yang paling mungkin?

1. AEmboli paru
2. BPneumonia aspirasi
3. CAsma akut
4. DGagal ventrikel kiri

A patient with severe chronic kidney disease needs therapeutic anticoagulation for a DVT. Why might unfractionated heparin be chosen instead of a low-molecular-weight heparin?

1. ALMWH cannot be given to anyone over 60
2. BLMWH is cleared by the kidneys and can accumulate
3. CUnfractionated heparin has no bleeding risk at all
4. DUnfractionated heparin is taken by mouth

Pasien yang menggunakan fenitoin jangka panjang harus diedukasi tentang efek samping mana?

1. APertumbuhan berlebih gusi, sehingga kebersihan mulut yang baik penting
2. BGangguan pendengaran bertahap dan permanen
3. CPenurunan berat badan dan tidak tahan panas
4. DRambut rontok di kulit kepala pada hampir semua pasien

A patient with a known ureteric stone develops a fever of 39 °C (102,2 °F) and rigors. Scanning shows a blocked, swollen kidney. What is needed?

1. AA fluid restriction to reduce the swelling
2. BStrong pain relief alone, then discharge
3. CUrgent drainage of the kidney plus IV antibiotics
4. DOral antibiotics and waiting for the stone to pass

Why are patients with diabetes often placed early on the operating list?

1. ABecause their surgery always takes longer than others
2. BBecause they need to go home before midday
3. CTo shorten fasting and reduce swings in blood glucose
4. DBecause their wounds heal faster in the morning

Selama resusitasi luka bakar, keluaran urine seorang dewasa 80 kg adalah 15 mL/jam selama 2 jam. Apa yang ditunjukkan hal ini?

1. AKelebihan cairan; semua cairan IV harus dihentikan sekarang
2. BResusitasi kurang; laju cairan biasanya perlu dinaikkan
3. CKeluaran urine normal untuk pasien luka bakar
4. DKateter tersumbat yang cukup dilepas saja