Prioritas & Delegasi ala NCLEX: paket kilat

A nurse teaches a patient with COPD pursed-lip breathing. Which statement shows a need for further teaching?

1. A“I will breathe in through my mouth and out quickly through my nose.”
2. B“I will make my breath out about twice as long as my breath in.”
3. C“I will breathe out slowly through pursed lips.”
4. D“I will breathe in slowly through my nose.”

Which patient with cirrhosis should the nurse see first?

1. ALarge ascites that is unchanged from yesterday
2. BWants to talk about stopping drinking alcohol for good
3. CLong-standing jaundice and itchy skin, asking for cream
4. DVomiting bright red blood, heart rate 120/min

A patient with difficulty swallowing is prescribed an extended-release tablet. What should the nurse do?

1. ACrush the tablet finely and mix it into a spoonful of applesauce or yogurt
2. BDissolve the tablet in a glass of hot water
3. CAsk the prescriber or pharmacist for another form and not crush the tablet
4. DCut the tablet in half so it is easier to swallow

A patient takes medicines prescribed by several providers. Which advice best reduces the risk of medication errors at home?

1. AOnly tell each provider about the drugs they prescribed
2. BKeep one up-to-date list of all medicines and use one pharmacy where possible
3. CKeep each provider’s medicines in separate bags
4. DStop taking any medicine that seems to repeat another one, without asking anyone

A patient on warfarin has an INR of 7,8 and a nosebleed. Which medication would the nurse expect the provider to prescribe?

1. AProtamine sulfate
2. BAcetylcysteine
3. CNaloxone hydrochloride
4. DVitamin K (phytonadione)

A young man has a swollen knee after minor trauma. His aPTT is prolonged, but his PT/INR and platelet count are normal. Which condition fits best?

1. AImmune thrombocytopenia (ITP)
2. BDisseminated intravascular coagulation
3. CHemophilia A (factor VIII deficiency)
4. DVitamin K deficiency from poor diet

In suspected sepsis, what should ideally be collected before the first dose of antibiotics, as long as it does not delay treatment?

1. AA 24-hour urine collection
2. BBlood cultures
3. CA stool sample for occult blood
4. DA fasting cholesterol level

Pasien yang mendapat infus heparin mengalami penurunan trombosit mendadak lima hari setelah dimulai. Apa yang harus dicurigai?

1. ATrombositopenia akibat heparin
2. BAnemia defisiensi besi
3. CKekurangan vitamin K akibat asupan yang buruk
4. DRespons normal terhadap heparin

When should an adult with cystic fibrosis take pancreatic enzyme capsules?

1. AOnly when they have diarrhoea
2. BWith all meals and snacks that contain fat
3. COnce a day on waking, at least an hour before any food
4. DOnly at bedtime

A ventilated patient with severe ARDS is to be turned prone. What is the main reason, and the key nursing risk?

1. AIt improves oxygenation; risks are pressure injury and tube displacement
2. BIt treats infection; the risk is fever
3. CIt improves digestion and gut motility; the main risk is constipation
4. DIt lowers the blood pressure; the main risk is rebound hypertension

Which lifestyle advice best helps a patient with epilepsy reduce their seizures?

1. AAvoid all physical exercise and stay indoors
2. BSkip a dose on days without any warning signs
3. CKeep regular sleep and take every dose on time
4. DDrink coffee in the evening to stay alert

Which task for a patient with a urinary catheter can the nurse delegate to a healthcare assistant (nursing assistant)?

1. AAssessing a patient whose irrigation is not draining
2. BDeciding whether the catheter can be removed
3. CTeaching self-catheterisation for the first time
4. DEmptying the drainage bag and recording the volume

A patient with a new colostomy asks what to eat at home. Which advice is most appropriate?

1. ADrink as little fluid as possible to reduce output
2. BEat only liquids until the stoma is removed
3. CEat a normal, balanced diet and introduce foods gradually
4. DAvoid all fruit and vegetables for the rest of their life

Seorang pasien memiliki luka bakar derajat penuh sirkumferensial pada lengan atas. Pengkajian mana yang paling penting selama beberapa jam berikutnya?

1. AUkuran pupil dan reaksi terhadap cahaya
2. BBunyi usus dan lingkar perut
3. CKetajaman penglihatan kedua mata setiap hari
4. DSirkulasi dan sensasi tangan