Prioritas & Delegasi ala NCLEX: paket kilat

A drowsy patient who has just returned from surgery starts to vomit. What should the nurse do first?

1. ATurn the patient onto their side
2. BRaise the legs above the heart
3. CGive a drink of water
4. DGive an oral anti-sickness tablet

A patient with raised intracranial pressure is being nursed on the ward. Which position is best?

1. AHead down with the legs raised above the heart
2. BHead of the bed at about 30 degrees with the neck straight
3. CSitting forward with the chin on the chest
4. DFlat on the back with the head turned well over to one side

Seorang pasien menderita herpes zoster di satu area dada, sistem imunnya normal, dan lesi dapat ditutup sepenuhnya. Kewaspadaan apa yang biasanya diperlukan?

1. ALingkungan protektif dengan tekanan positif
2. BHanya kewaspadaan droplet
3. CKewaspadaan udara di ruang bertekanan negatif
4. DKewaspadaan standar, dengan lesi ditutup

A nurse has a needlestick from a patient whose HIV and hepatitis status is unknown. What should happen?

1. ANothing, because the source patient is probably not infected
2. BThe nurse is assumed to be infected and stops all work
3. CThe source patient is tested per policy, and the nurse has baseline tests
4. DThe nurse waits six months before having any blood tests at all

Seorang pasien menerima enoksaparin subkutan (heparin berat molekul rendah). Pernyataan mana tentang pemantauan yang benar?

1. ATidak pernah diperlukan pemeriksaan darah apa pun
2. BaPTT harus diperiksa setiap 6 jam untuk menyesuaikan dosis
3. CINR digunakan untuk menyesuaikan setiap dosis, seperti pada warfarin
4. DTidak ada aPTT rutin; trombosit dan fungsi ginjal diperiksa sebagai gantinya

A patient with a heart murmur and fever has three sets of blood cultures, taken hours apart, all growing the same Streptococcus species. What does this suggest?

1. APersistent bacteremia, as in infective endocarditis
2. BA urinary tract infection that has spread to the skin
3. CA normal finding in patients with heart murmurs
4. DContamination of all three samples during collection

A patient without diabetes is started on high-dose prednisolone. Why might capillary blood glucose be monitored?

1. ASteroids make glucose meters inaccurate
2. BSteroids always cause hypoglycaemia
3. CSteroids can raise the blood glucose
4. DSteroids destroy the pancreas

A patient has a high fever with rigors, jaundice and right upper quadrant pain. Which condition is most likely?

1. AGastro-oesophageal reflux disease
2. BSimple biliary colic
3. CAscending cholangitis
4. DAcute appendicitis

A patient is starting doxazosin, an alpha-blocker, for hypertension. Which advice is most important?

1. ATake it with a large glass of grapefruit juice to improve absorption
2. BTake the first dose at bedtime, as dizziness and fainting can occur
3. CStop it suddenly if the heart rate rises after the first few doses
4. DAvoid all potassium-containing foods

A patient has new chest pain at rest. The ECG shows ST depression, but serial troponins remain normal. Which diagnosis fits best?

1. AST-elevation myocardial infarction
2. BNon-ST-elevation myocardial infarction
3. CStable angina
4. DUnstable angina

A patient with a new ileal conduit has threads of mucus in their urine. What should the nurse explain?

1. AThe kidneys have stopped working properly after surgery
2. BThis proves a serious kidney infection
3. CThis is a sign that the stoma is dying
4. DThis is normal, because the conduit is made from bowel

A patient's corrected calcium is 1,7 mmol/L (about 6,8 mg/dL). Which ECG change is most typical?

1. AA prolonged QT interval
2. BST elevation in all leads
3. CA shortened QT interval
4. DTall, peaked T waves

Which task for a stable patient with an established ileostomy can usually be delegated to a trained healthcare assistant (nursing assistant)?

1. AAssessing the stoma for signs of necrosis
2. BTeaching the patient about high-output risks
3. CDeciding whether IV fluids are needed
4. DEmptying the pouch and measuring the output

A patient with cirrhosis takes spironolactone and furosemide. Which blood result should the nurse report before the next dose?

1. APotassium 6,0 mmol/L
2. BSodium 138 mmol/L
3. CPotassium 4,2 mmol/L
4. DSodium 141 mmol/L