Prioritas & Delegasi ala NCLEX: paket kilat

A patient’s peripheral IV site is swollen, pale and cool, and the infusion has slowed. What should the nurse do first?

1. AFlush the cannula hard to clear the blockage
2. BStop the infusion and remove the cannula
3. CIncrease the infusion rate to overcome the resistance
4. DApply a tight bandage over the site to reduce swelling

A patient has peripheral arterial disease with a non-healing ulcer on the toe. Which advice about leg position is correct?

1. AKeep the legs raised above the heart as much as possible
2. BSit with the legs crossed to improve blood flow
3. CWrap the legs tightly with compression bandages
4. DKeep the legs level or slightly lowered, not raised

What is the main aim of purposeful hourly rounding?

1. ATo wake the patient every hour to check orientation
2. BTo count the patient’s medications every hour and check that none are missing
3. CTo replace the need for a call light
4. DTo check pain, toileting, position and personal items before the patient needs to ask

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. AMeminta pasien menunggu di ruang tunggu sampai dipanggil
2. BMemulai kewaspadaan kontak dengan gaun dan sarung tangan untuk petugas
3. CMenempatkan pasien di bilik bersama dengan tirai tertutup
4. DMemasangkan masker pada pasien dan memindahkannya ke ruang isolasi udara

Seorang pasien sadar dengan glukosa darah 54 mg/dL (3,0 mmol/L) telah mengonsumsi 15 g karbohidrat kerja cepat. Kapan glukosa harus diperiksa ulang?

1. AKeesokan paginya
2. BPada waktu makan berikutnya
3. CSetelah sekitar 2 jam
4. DSetelah sekitar 15 menit

A nursing student has a positive interferon-gamma release assay (IGRA) for tuberculosis, no symptoms and a normal chest X-ray. What does this most likely mean?

1. AA false result, as the test does not detect TB
2. BLatent TB infection, which is not contagious
3. CPast BCG vaccination only, with no infection
4. DActive pulmonary TB, which is contagious

A patient has a fentanyl patch for chronic pain. Which advice is correct?

1. AApply the patch to broken skin for faster effect
2. BAvoid heat sources such as hot water bottles over the patch
3. CKeep using the old patch with the new one
4. DCut the patch in half if the pain improves, to lower the dose

A patient with diabetes is found confused with slurred speech and weakness on one side. What should the nurse check first?

1. ASerum cholesterol
2. BUrine output for the last day
3. CBody mass index
4. DCapillary blood glucose

A patient with heart failure starts dapagliflozin, an SGLT2 inhibitor. Which teaching is most relevant?

1. ATake an extra dose if the ankles swell
2. BExpect the urine to turn bright orange and stain underwear and clothes
3. CKeep the genital area clean, as fungal infections are more common
4. DAvoid drinking any fluids at all for the first week of treatment

Seorang pasien gagal jantung dengan pembatasan cairan 1,5 L/hari mengeluh sangat haus. Tindakan mana yang paling tepat?

1. AAir tanpa batas, karena rasa haus harus selalu dipuaskan
2. BCamilan asin untuk merangsang air liur dan meredakan kekeringan
3. CPerawatan mulut, es batu yang dihitung, dan cairan yang disebar sepanjang hari
4. DTidak ada cairan sama sekali sampai penimbangan besok pagi

A patient taking warfarin is diagnosed with an intracerebral haemorrhage. What is the priority treatment?

1. AStarting aspirin to prevent further clots
2. BDoubling the warfarin dose to stabilise the INR
3. CIV thrombolysis within 4,5 hours
4. DUrgent reversal of the anticoagulant effect

The nurse has four patients with diabetes. Which one needs to be seen first?

1. AA patient with a glucose of 14 mmol/L (252 mg/dL) who feels well and is eating
2. BA patient waiting for a routine HbA1c test
3. CA newly diagnosed patient asking about which foods to eat
4. DA patient with a glucose of 2,8 mmol/L (50 mg/dL) who is sweaty and confused

What is achalasia?

1. AFailure of the lower oesophageal sphincter to relax on swallowing
2. BA tear at the junction of the oesophagus and the stomach
3. CWeakness of the lower oesophageal sphincter that allows reflux
4. DInflammation of the oesophagus caused by a fungal infection

A patient with cirrhosis and ascites has a falling urine output and a rising creatinine. They have not received nephrotoxic drugs and are not dehydrated. Which complication is likely?

1. AHepatorenal syndrome
2. BUrinary tract infection
3. CPolycystic kidney disease
4. DNephrotic syndrome