Prioritas & Delegasi ala NCLEX: paket kilat

Selama infus antibiotik IV, seorang pasien mengalami biduran, mengi, dan suara serak. Apa yang pertama kali dilakukan perawat?

1. AMemperlambat infus menjadi setengah kecepatan
2. BMemberikan difenhidramin oral
3. CMendokumentasikan reaksi dalam rekam medis
4. DMenghentikan infus

Pada giliran jaga yang sibuk, empat tugas jatuh tempo. Mana yang harus dikerjakan perawat lebih dulu?

1. AMemperbarui rencana asuhan keperawatan sebelum audit para manajer
2. BMemberikan tablet vitamin harian rutin yang jatuh tempo pada saat yang sama
3. CDosis pertama antibiotik IV untuk pasien dengan dugaan sepsis
4. DMembantu pasien stabil mengisi kartu menu besok

Which instruction about using a standard walker is correct?

1. APush up from the walker to stand from a chair
2. BCarry the walker and use it only when tired
3. CWalk well ahead of the walker for balance
4. DMove the walker forward, then step into it

A patient with depression has suddenly become calm and is giving away personal possessions. What does this suggest?

1. AA possibly increased suicide risk that needs immediate assessment
2. BThat the patient wants to make new friends on the unit
3. CThat the patient is now ready for discharge today
4. DThat the depression has resolved and observation can be reduced

When blood is drawn from a central venous catheter, why is a small volume of blood usually discarded first, according to policy?

1. ATo check that the catheter tip is still in the right vein
2. BTo lower the patient's hemoglobin for a blood transfusion
3. CTo remove blood clots that form in all central lines
4. DTo avoid diluting the sample with flush or infusion fluid

A middle-aged man has fatigue, joint pain, a raised ALT and new diabetes. His ferritin is very high and his transferrin saturation is above 60%. Which condition is most likely?

1. AHereditary hemochromatosis
2. BIron-deficiency anemia
3. CAnemia of chronic disease
4. DAcute viral hepatitis A

Why are patients encouraged to use an incentive spirometer after abdominal surgery?

1. ATo measure their lung function so the result can go in the discharge letter
2. BTo strengthen the abdominal muscles around the wound
3. CTo encourage deep breaths that prevent atelectasis and chest infection
4. DTo lower their heart rate before mobilising

A patient taking regular ibuprofen suddenly develops severe upper abdominal pain, a rigid abdomen and becomes tachycardic. What is most likely?

1. AConstipation
2. BIndigestion that will settle with antacids
3. CIrritable bowel syndrome
4. DA perforated peptic ulcer

Why is a non-selective beta-blocker such as propranolol usually avoided in a patient with asthma?

1. AIt raises the heart rate sharply during an acute asthma attack
2. BIt can cause bronchospasm by blocking beta-2 receptors
3. CIt makes inhaled corticosteroids work too strongly
4. DIt thickens airway mucus by drying the airways

Satu jam setelah operasi jantung, drain dada mediastinum telah mengalirkan 350 mL darah merah terang dan denyut jantung meningkat. Apa yang harus dilakukan perawat?

1. AMemerah selang dengan keras setiap lima menit
2. BMengklem drain untuk menghentikan kehilangan darah lebih lanjut
3. CMencatat volume dan melanjutkan pemeriksaan setiap jam
4. DSegera melaporkannya kepada tim bedah

A patient who has had type 1 diabetes for 30 years says they no longer feel the warning signs of a hypo. What is this called?

1. AThe dawn phenomenon
2. BInsulin resistance
3. CHypoglycaemia unawareness
4. DDiabetic ketoacidosis

The nurse has four patients. Which one needs to be seen first?

1. AA patient on insulin for DKA whose potassium is now 2,9 mmol/L
2. BA patient with Parkinson's disease whose next dose is due in two hours
3. CA patient with hypothyroidism asking when to take levothyroxine
4. DA patient with stable CKD waiting for a renal diet review

A nasogastric feeding tube appears blocked. What is usually the first step?

1. ACut the end of the tube to release the blockage inside it
2. BFlush gently with warm water in a 50 mL enteral syringe
3. CPush the guidewire back in to clear it
4. DUse a small 5 mL syringe with firm pressure

On the ward after surgery, a patient has a red, blistered area of skin under where the diathermy plate was. What should the nurse do?

1. AIgnore it because skin changes after surgery are normal and expected to fade
2. BApply a hot water bottle to improve the circulation
3. CWash it with alcohol and leave it uncovered
4. DTreat it as a possible burn, report it and complete an incident form