Prioritas & Delegasi ala NCLEX: paket kilat

A patient receives hemodialysis this morning. Which type of medication is often held before dialysis, as prescribed?

1. AAntihypertensive drugs
2. BInhaled bronchodilators
3. CTopical skin creams
4. DEye drops for glaucoma

A patient with SIADH has a serum sodium of 120 mEq/L and is newly confused. Which nursing action has priority?

1. AHelping the patient to walk in the corridor alone
2. BEncouraging the patient to drink plenty of water
3. CSeizure precautions and close neurological checks
4. DTeaching the patient about a low-sodium diet at home

A patient receiving continuous nasogastric feeding has pulled the tube partly out. What should the nurse do first?

1. AStop the feeding until the tube position is checked
2. BIncrease the feed rate to make up for the lost time
3. CPush the tube back in and restart the feed
4. DTape the tube in its new position and continue

A nurse has weeping dermatitis on both hands. What is the most appropriate action?

1. AAvoid direct patient care and handling of equipment until it heals, and see occupational health
2. BContinue care as usual and wear one pair of gloves
3. CCover the lesions with a waterproof bandage and keep working with patients as usual
4. DUse extra alcohol hand rub on the lesions

A tired patient with heavy menstrual periods has a normal hemoglobin and MCV but a ferritin of 8 ng/mL. What does this show?

1. AIron overload from too much iron
2. BIron deficiency without anemia yet
3. CVitamin B₁₂ deficiency anemia
4. DA completely normal iron status

Setelah operasi, seorang pasien yang menerima cairan IV hipotonik dalam volume besar mengalami sakit kepala, mual, dan kebingungan. Hasil mana yang paling menjelaskan hal ini?

1. ANatrium 126 mEq/L
2. BGlukosa 110 mg/dL (6,1 mmol/L)
3. CKalsium 9,4 mg/dL (2,35 mmol/L)
4. DKalium 4,2 mEq/L

Skor NEWS2 seorang pasien naik menjadi 7. Apa respons yang tepat?

1. AMelanjutkan observasi setiap 12 jam
2. BPenilaian darurat oleh tim klinis dengan keterampilan perawatan kritis
3. CMemberikan sedatif dan memeriksa ulang nanti
4. DMencatat skor, meningkatkan observasi, dan menunggu visite bangsal pagi

Seorang pasien yang menerima vankomisin IV mengalami kemerahan (flushing) dan ruam merah gatal di wajah dan leher selama infus cepat. Apa penyebab dan respons yang paling mungkin?

1. ATerbakar sinar matahari; oleskan krim dan lanjutkan
2. BGagal hati; hentikan semua obat secara permanen
3. CReaksi terkait infus; hentikan atau perlambat infus dan beri tahu penulis resep
4. DRespons normal; tingkatkan laju infus

A patient taking simvastatin drinks a large glass of grapefruit juice every morning. Why is this a concern?

1. AIt causes the cholesterol level to rise sharply
2. BIt raises statin levels and the risk of muscle damage
3. CIt turns the statin into a blood thinner
4. DIt stops the statin from being absorbed from the gut at all

A patient on spironolactone and an ACE inhibitor has a potassium of 6,8 mmol/L (6,8 mEq/L) with peaked T waves. What is usually given first to protect the heart?

1. AIntravenous calcium gluconate or chloride
2. BA dose of digoxin
3. COral potassium supplements
4. DAn IV furosemide bolus as the only treatment

Pernyataan mana tentang insulin basal kerja panjang seperti glargin yang benar?

1. AHanya diberikan setelah makan besar untuk menutupi karbohidrat
2. BMemiliki puncak kerja tajam sekitar 30 menit setelah injeksi
3. CDicampur dengan insulin kerja cepat dalam spuit yang sama
4. DPada diabetes tipe 1 insulin ini dilanjutkan bahkan saat pasien tidak makan

A patient with a brain tumour on high-dose dexamethasone has a capillary glucose of 16 mmol/L (288 mg/dL). They have no history of diabetes. What is the best explanation?

1. AA lab error, because steroids lower blood glucose
2. BSteroid-induced hyperglycaemia, which needs monitoring and treatment
3. CA sign that the brain tumour has now spread to the pancreas
4. DNormal for this patient, so no action is needed

Which advice has good evidence for reducing cancer-related fatigue?

1. ARegular light to moderate activity, such as walking
2. BComplete bed rest for the whole course of treatment
3. CDrinking several strong coffees every evening
4. DAvoiding all daily activities

Hours after an oesophageal dilatation, a patient has chest pain, fever and crackling swelling under the skin of the neck. What should the nurse suspect?

1. AOesophageal perforation
2. BNormal discomfort after the procedure
3. CSimple reflux after the dilatation
4. DAn allergic reaction to the sedative