Prioritas & Delegasi ala NCLEX: paket kilat

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

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

A trauma patient has an open leg fracture, absent breath sounds on one side, a trachea shifted to the other side and a falling blood pressure. Which problem is the priority?

1. AThe risk of wound infection
2. BThe open fracture of the leg
3. CThe suspected tension pneumothorax
4. DThe pain from the fracture

Seorang pasien dengan dugaan tuberkulosis berada di ruang bertekanan negatif. Praktik mana yang benar?

1. AMembiarkan pintu terbuka agar petugas dapat melihat pasien setiap saat
2. BMembiarkan pengunjung masuk tanpa perlindungan apa pun
3. CMenjaga pintu tetap tertutup kecuali saat masuk atau keluar
4. DMematikan ventilasi ruangan pada malam hari

Seorang pasien bingung dengan restrain pergelangan tangan memiliki jari yang dingin dan pucat pada satu tangan dan nadi radialis lemah pada sisi tersebut. Apa yang pertama kali harus dilakukan perawat?

1. AMengencangkan restrain yang lain agar pasien berhenti menarik
2. BMelonggarkan restrain tersebut dan mengkaji sirkulasi tangan
3. CMengangkat tangan di atas bantal, membiarkan restrain apa adanya
4. DMendokumentasikan temuan dengan cermat dan memeriksa ulang dalam dua jam

A patient has a calcium of 11,8 mg/dL (2,95 mmol/L) from bone metastases. Which nursing measure is appropriate?

1. AEncourage bed rest and limit oral fluids
2. BGive calcium carbonate antacids for nausea
3. CEncourage fluids and mobility as tolerated
4. DOffer extra milk and cheese at each meal

The nurse teaches a patient who is starting warfarin. Which statement shows a need for further teaching?

1. A"If I miss a dose, I will take two tablets the next day"
2. B"I will tell my dentist and pharmacist that I take warfarin"
3. C"I will keep my intake of green leafy vegetables about the same"
4. D"I will have my INR checked as often as I am told to"

What is the recommended first aid for a thermal burn?

1. ACool it under cool running water for about 20 minutes
2. BApply ice directly to the burn until the pain stops completely
3. CSpread butter or oil over the burn
4. DBurst any blisters to release the fluid

An older patient's blood pressure is 142/80 mmHg lying and 116/72 mmHg after standing for three minutes, and they feel dizzy. What does this show?

1. AHypertensive emergency
2. BNormal blood pressure variation
3. CWhite coat hypertension
4. DPostural hypotension

Bilik segel air drainase dada menggelembung terus-menerus, bahkan saat pasien tidak batuk. Apa yang ditunjukkan hal ini?

1. ADrain tersumbat bekuan di selang
2. BKebocoran udara dari paru atau dari sistem drainase
3. CSumber hisapan telah dimatikan
4. DParu telah mengembang penuh dan drain siap dilepas

A 70-year-old man has a small abdominal aortic aneurysm found on screening and is placed under surveillance. Which advice is most important?

1. AAvoid all exercise and lifting for the rest of his life to protect the aorta
2. BHave the aneurysm repaired immediately, whatever its size or growth rate
3. CStop smoking, control BP and seek help at once for sudden back pain
4. DStop all blood pressure medicines to avoid low pressure

Mengapa pasien ditimbang sebelum dan sesudah setiap sesi hemodialisis?

1. AUntuk menghitung dosis setiap obat untuk minggu berikutnya
2. BUntuk memeriksa penurunan berat badan akibat malnutrisi
3. CKarena mesin tidak dapat dimulai tanpa berat badan
4. DUntuk melihat berapa banyak cairan yang dikeluarkan dan memandu berat kering

A haemodialysis patient missed their last two sessions. They are breathless, with crackles, and the potassium is 6,9 mmol/L. What is the priority?

1. ALarge IV fluid boluses to improve the circulation
2. BOral potassium supplements and rest
3. CUrgent dialysis, with cardiac monitoring meanwhile
4. DA routine dialysis session at the next planned slot

Why is IV albumin often given after a large-volume paracentesis?

1. ATo treat infection in the ascitic fluid
2. BTo raise the blood glucose after the procedure
3. CTo prevent low blood pressure and kidney injury from fluid shifts
4. DTo replace the clotting factors and platelets lost in the drained fluid

Two days after surgery, a patient on regular ibuprofen has a low urine output and a rising creatinine, and intake has been poor. What should the nurse do?

1. AWithhold the next dose and report to the prescriber
2. BChange to a higher-strength NSAID tablet
3. CIncrease the dose to treat the pain better and encourage fluids
4. DGive the next dose with extra food