Prioritas & Delegasi ala NCLEX: paket kilat

A patient with heart failure gained 2 kg (about 4 lb) since yesterday and is more breathless when lying down. What should the nurse do first?

1. AAssess the lungs, oxygen saturation and swelling, then inform the provider
2. BRecord the weight on the chart and recheck it at the next weekly weigh-in
3. CEncourage extra fluids to correct the weight change
4. DLay the patient flat to help them breathe more easily

During surgery under general anesthesia, a patient develops rising end-tidal carbon dioxide, muscle rigidity and a rapidly increasing temperature. Which drug should the nurse anticipate?

1. AFlumazenil
2. BAtropine
3. CNaloxone
4. DDantrolene

Saat memakai sarung tangan steril, bagaimana perawat memakai sarung tangan kedua?

1. AMenggunakan tangan telanjang untuk merapikan sisi luar sarung tangan pertama
2. BMemegang sisi dalam sarung tangan kedua dengan tangan bersarung tangan
3. CMenarik sarung tangan kedua pada ujung jarinya dengan tangan telanjang
4. DMenyelipkan jari bersarung tangan di bawah manset sarung tangan kedua dan menariknya

In a US hospital (CMS rules), a patient keeps pulling at an endotracheal tube, and alternatives have failed. The nurse applies wrist restraints in an emergency. What must happen next?

1. AKeep the restraints on without an order until the patient is calm
2. BObtain a time-limited order for the restraint promptly, following policy
3. CAsk the provider for a PRN restraint order to use as needed
4. DAsk the family to sign a consent form instead of an order

A patient who is breathless during a transfusion has hypotension, fever and bilateral lung infiltrates, with no signs of fluid overload. Which complication is most likely?

1. AA simple allergic reaction with hives
2. BA mild febrile nonhemolytic reaction
3. CTransfusion-associated circulatory overload
4. DTransfusion-related acute lung injury (TRALI)

Seorang pasien dengan gangguan penggunaan alkohol memiliki kalium 3,0 mEq/L meskipun telah mendapat penggantian selama dua hari. Magnesiumnya 0,9 mEq/L. Langkah berikutnya yang paling tepat?

1. AMengganti magnesium; magnesium rendah membuat ginjal terus kehilangan kalium
2. BMenghentikan semua penggantian elektrolit selama 24 jam lalu memeriksa ulang
3. CMenggandakan dosis kalium dan menunda magnesium
4. DMemberikan diuretik untuk membuang kelebihan magnesium

Which group of features is typical of nephrotic syndrome?

1. ABlood in the urine, high blood pressure and reduced urine output only
2. BSevere loin pain and fever
3. CPolyuria, thirst and weight loss
4. DHeavy proteinuria, low serum albumin and oedema

A patient going home with a leg cast is taught about cast care. Which statement shows a need for further teaching?

1. A"I will keep my leg raised on pillows for the first few days."
2. B"I will keep the cast dry."
3. C"I will come back if my toes go numb or turn blue."
4. D"I can push a knitting needle down the cast to scratch an itch."

A patient is starting long-term amiodarone. Which teaching and monitoring are most important?

1. AAvoid dairy products and have the INR checked once at the start
2. BEat extra salt and stop the drug as soon as the pulse is regular
3. CProtect skin from sunlight and have thyroid, liver and lung checks
4. DExpect orange urine and no need for blood tests

Ten days after cardiac surgery, a patient has a fever, a red sternal wound with discharge and a clicking feeling in the chest when coughing. What should the nurse suspect?

1. ASternal wound infection with an unstable sternum
2. BNormal wound healing with some expected discharge
3. CCostochondritis caused by forceful coughing
4. DPericarditis from the operation

A patient has a nephrostomy tube. Which finding needs urgent action?

1. AA dry, intact dressing at the site
2. BDrainage that stops suddenly with new loin pain
3. CLight pink urine on the first day after insertion
4. DSteady urine drainage into the bag

A patient with a long-term catheter has fever and rigors, and a catheter UTI is suspected. Which action is recommended before starting antibiotics?

1. ARemove the catheter and leave it out permanently
2. BFlush the catheter with saline and continue
3. CReplace the catheter and take a sample from the new one
4. DTake a sample from the drainage bag and send it to the lab

Which patient is at highest risk of refeeding syndrome?

1. AA patient with a normal BMI eating three meals a day
2. BA healthy adult after an overnight fast for minor surgery
3. CAn underweight patient who has eaten very little for 10 days
4. DA patient who missed one lunch because of a scan

On day 5 after a major burn, a patient is confused, with a temperature of 39,2 °C, tachycardia, and an offensive, discoloured wound. What should the nurse suspect?

1. ABurn wound infection with sepsis
2. BDelirium from boredom on the ward
3. CThe normal hypermetabolic response alone
4. DAn allergy to the dressing only