Prioritas & Delegasi ala NCLEX: paket kilat

Lembar rumus, langkah-langkah metode utama untuk setiap topik, dan 14 soal latihan, dengan pembahasan lengkap di bagian belakang.

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1Rumus dan metode

Prioritas & delegasi

Metode

  1. Tanyakan apa yang akan paling cepat membahayakan pasien bila tidak dilakukan apa-apa.
  2. Terapkan ABC (C-A-B pada henti jantung), lalu Maslow: kebutuhan fisiologis sebelum keselamatan, keselamatan sebelum kebutuhan psikologis.
  3. Bandingkan pilihannya: akut sebelum kronis, tidak stabil sebelum stabil, tak terduga sebelum yang diharapkan, sistemik sebelum lokal, dan periksa setiap temuan terhadap kondisi dasar pasien.
  4. Lakukan pengkajian sebelum bertindak kecuali dalam keadaan darurat; lalu pilih langkah yang menjadi dasar langkah lainnya.
  5. Untuk delegasi, periksa lima benar: tugas, keadaan, orang, arahan, dan supervisi. Pengkajian, edukasi, dan evaluasi tetap pada perawat terdaftar (RN).

Pengendalian infeksi & keselamatan pasien

Metode

  1. Mulailah dengan kewaspadaan standar untuk setiap pasien: kebersihan tangan, APD sesuai pajanan yang diperkirakan, benda tajam yang aman.
  2. Tambahkan kewaspadaan menurut jalur: kontak (gaun, sarung tangan), droplet (masker bedah), udara (N95, ruang bertekanan negatif).
  3. Jaga barang steril tetap steril: bila ragu, anggap tidak steril; ganti, jangan pernah dilap.
  4. Cegah bahaya di lingkungan: tindakan pencegahan jatuh, restrain hanya sebagai pilihan terakhir, RACE dan PASS untuk kebakaran.
  5. Periksa prinsip benar dalam pemberian obat, dua identitas, dan pengaman tambahan untuk obat berisiko tinggi; laporkan kesalahan dan nyaris cedera.

Nilai laboratorium & elektrolit

Metode

  1. Bandingkan nilainya dengan rentang rujukan laboratorium itu sendiri, lalu dengan kondisi dasar dan tren pasien.
  2. Periksa sampelnya: hemolisis, keterlambatan, atau darah yang diambil dekat jalur IV dapat memberi hasil palsu.
  3. Hubungkan nilai itu dengan tanda khasnya serta obat dan kondisi yang menyebabkannya.
  4. Cari interaksi: kalium atau magnesium yang rendah meningkatkan toksisitas digoksin; dehidrasi menaikkan litium.
  5. Bertindaklah untuk pasien: lakukan pengkajian, tahan obat bila kadarnya tidak aman, bacakan kembali nilai kritis, dan beri tahu penulis resep.

Medikal-bedah: kardiovaskular & respirasi

Metode

  1. Namai masalahnya: kegagalan pompa, arteri tersumbat, irama, bekuan, penyempitan jalan napas, infeksi, atau masalah alat.
  2. Periksa tanda bahaya lebih dulu: hipoksia, hipotensi, nyeri dada, kebingungan baru, anggota gerak yang dingin tanpa denyut.
  3. Sesuaikan oksigen dengan pasien: 94–98% untuk sebagian besar, 88–92% untuk yang berisiko retensi CO₂.
  4. Hubungkan setiap obat dengan tesnya dan risikonya: warfarin dan INR, heparin dan aPTT serta trombosit, diuretik dan kalium.
  5. Pilih tindakan pertama yang aman, lalu lakukan eskalasi dan nilai ulang.

Medikal-bedah: saraf, endokrin & ginjal

Metode

  1. Periksa glukosa pada setiap pasien dengan kebingungan baru, kelemahan, atau kejang.
  2. Gunakan tingkat kesadaran sebagai peringatan paling awal gangguan otak; pupil dan trias Cushing muncul belakangan.
  3. Untuk kegawatan diabetes, bedakan KAD (keton, asidosis) dari HHS (osmolalitas sangat tinggi, dehidrasi); berikan cairan lebih dulu.
  4. Untuk natrium dan air, tentukan apakah ADH berlebih (SIADH) atau kurang (DI), dan koreksi perubahan kronis secara perlahan.
  5. Untuk masalah ginjal, golongkan penyebabnya menjadi prarenal, intrinsik, atau pascarenal, dan pantau kalium dan cairan.

Medikal-bedah: saluran cerna, perioperatif & onkologi

Metode

  1. Tanyakan apa yang mungkin tersembunyi: perdarahan dalam, infeksi tanpa demam, hipoventilasi di balik SpO₂ yang normal.
  2. Gunakan waktu setelah operasi untuk mempersempit komplikasi: perdarahan dalam hitungan jam, masalah dada dalam hitungan hari, masalah luka dan kebocoran belakangan.
  3. Untuk nyeri, kaji, tangani dengan analgesia multimodal, nilai ulang, dan pantau sedasi pada setiap opioid.
  4. Untuk pasien kanker, perlakukan setiap penyakit selama nadir sebagai sepsis neutropenik dan ketahui kegawatan onkologi.
  5. Untuk luka bakar, hitung hanya area derajat sebagian dan seluruh ketebalan kulit, mulai jam Parkland pada waktu luka bakar, dan titrasi menurut produksi urine.

2Soal latihan

1.Prioritas & delegasiSedang

A patient is receiving continuous tube feeds. Which action best reduces the risk of aspiration?

  1. AIncrease the feed rate so the stomach empties sooner
  2. BLay the patient flat for an hour after each bag is hung
  3. CTurn the feed off only while the patient is asleep at night
  4. DKeep the head of the bed raised to at least 30 degrees
2.Prioritas & delegasiSulit

Seorang pasien dengan perdarahan saluran cerna atas memiliki denyut jantung 128/menit dan tekanan darah 84/50 mmHg. Semua ini diresepkan. Mana yang dimulai perawat lebih dulu?

  1. AInfus penghambat pompa proton IV
  2. BCairan IV atau darah melalui kanula berukuran besar
  3. CTablet zat besi oral
  4. DMemesan endoskopi diagnostik untuk pagi berikutnya
3.Pengendalian infeksi & keselamatan pasienSedang

A patient wants to use their own electric hair dryer in the hospital. What is correct?

  1. AIt can be used straight away if it looks new
  2. BIt can be plugged into an extension lead under the bed
  3. CIt is checked for electrical safety according to hospital policy before use
  4. DIt can be used in the bathroom near the sink if the patient is careful
4.Pengendalian infeksi & keselamatan pasienSulit

A small-bore feeding tube has just been inserted blindly at the bedside. Which method is the most reliable way to confirm its position before the first feeding?

  1. ABy an x-ray reviewed by a competent clinician
  2. BBy checking that the patient can still talk
  3. CBy putting the end in water to look for bubbles
  4. DBy listening over the stomach while injecting air
5.Nilai laboratorium & elektrolitSedang

Two sets of blood cultures are ordered for a patient with suspected sepsis. How are they best collected?

  1. ABoth from the same site, one minute apart, to save time for the patient
  2. BFrom the existing IV line while the infusion continues to run
  3. CAfter the first antibiotic dose, so the infusion is not delayed
  4. DFrom two separate venipuncture sites, using strict aseptic technique
6.Nilai laboratorium & elektrolitSulit

A patient with advanced chronic kidney disease has a mildly raised troponin that has stayed the same on several tests over months. There is no chest pain and the ECG is unchanged. What is the best interpretation?

  1. AA sign of skeletal muscle injury, because troponin comes from all muscles
  2. BProof of an acute myocardial infarction that needs emergency treatment now
  3. CA laboratory error, because troponin is never raised in kidney disease
  4. DA chronic stable rise; infarction needs a rising or falling pattern
7.Keperawatan klinisSedang

Why is lactulose given to a patient with hepatic encephalopathy?

  1. ATo reduce the absorption of ammonia from the gut
  2. BTo lower the blood glucose
  3. CTo stop bleeding from varices
  4. DTo increase the liver's production of albumin
8.Keperawatan klinisSulit

Why are early surgery and early mobilisation recommended for older patients with a hip fracture?

  1. AThey allow the bone to heal fully without any need for pain relief
  2. BThey mainly reduce the cost of the operation
  3. CThey make physiotherapy and rehabilitation unnecessary after discharge
  4. DThey reduce complications such as pneumonia, pressure ulcers and delirium
9.Medikal-bedah: kardiovaskular & respirasiSedang

Mengapa masker wajah sederhana tidak boleh digunakan dengan aliran oksigen di bawah sekitar 5 L/menit?

  1. AMasker memberikan terlalu banyak oksigen pada aliran rendah
  2. BCO₂ yang dihembuskan dapat terkumpul di masker dan terhirup kembali
  3. COksigen tidak dapat dilembapkan pada aliran rendah
  4. DTali elastis terlalu longgar pada aliran rendah
10.Medikal-bedah: kardiovaskular & respirasiSulit

A 74-year-old man with a known abdominal aortic aneurysm suddenly has severe back and abdominal pain. His heart rate is 128/min and BP 82/50 mmHg. What is the priority?

  1. ACall for emergency help and prepare for urgent vascular surgery
  2. BGive oral analgesia and reassess the pain in an hour
  3. CEncourage him to walk to ease the back pain
  4. DArrange a routine outpatient ultrasound scan of the aneurysm
11.Medikal-bedah: saraf, endokrin & ginjalSedang

Why is nimodipine given to patients after a subarachnoid haemorrhage?

  1. ATo raise the blood pressure and improve perfusion
  2. BTo stop seizures in the first few days
  3. CTo reduce brain injury from delayed vasospasm
  4. DTo dissolve the blood clot around the aneurysm
12.Medikal-bedah: saraf, endokrin & ginjalSulit

At bedtime, a patient was given their rapid-acting insulin by mistake instead of their long-acting insulin. What should the nurse do?

  1. ATell the prescriber and check glucose often overnight
  2. BSay nothing, because the patient is asleep and seems fine
  3. CGive glucagon now, before the glucose has fallen
  4. DGive the long-acting dose as well and check glucose at breakfast
13.Medikal-bedah: saluran cerna, perioperatif & onkologiSedang

Why should antacids usually be taken at a different time from other medicines?

  1. AThey can reduce the absorption of many other drugs
  2. BThey make all other drugs much more toxic
  3. CThey stop the kidneys from clearing other drugs
  4. DThey destroy other drugs before they are swallowed
14.Medikal-bedah: saluran cerna, perioperatif & onkologiSulit

An 80-year-old has a fluid balance 3 L positive two days after surgery. They are now breathless, with crackles at both lung bases and swollen ankles. What should the nurse do?

  1. ALie the patient flat with the legs raised
  2. BEncourage the patient to drink more fluids
  3. CIncrease the IV fluid rate to improve kidney flow
  4. DStop the IV fluids, sit the patient up and escalate

3Larutan

1.Prioritas & delegasi

Jawaban: D · Keep the head of the bed raised to at least 30 degrees

Mengapa ini jawabannya

Raising the head of the bed to at least 30 degrees during and after feeding lowers the risk of reflux and aspiration. Lying flat greatly increases the risk.

Jawaban

D · Keep the head of the bed raised to at least 30 degrees
2.Prioritas & delegasi

Jawaban: B · Cairan IV atau darah melalui kanula berukuran besar

Mengapa ini jawabannya

Takikardia dan hipotensi menunjukkan syok hipovolemik, sehingga memulihkan volume sirkulasi didahulukan, dengan cairan atau produk darah sesuai resep dan pemantauan ketat. Supresi asam dan endoskopi menyusul setelah resusitasi berjalan, dan zat besi oral termasuk pemulihan kemudian.

Jawaban

B · Cairan IV atau darah melalui kanula berukuran besar
3.Pengendalian infeksi & keselamatan pasien

Jawaban: C · It is checked for electrical safety according to hospital policy before use

Mengapa ini jawabannya

Electrical items from home can be faulty and cause shocks or fires. Policies usually require them to be inspected before use, and extension cords near patients are avoided.

Jawaban

C · It is checked for electrical safety according to hospital policy before use
4.Pengendalian infeksi & keselamatan pasien

Jawaban: A · By an x-ray reviewed by a competent clinician

Mengapa ini jawabannya

An x-ray is the most reliable way to confirm the position of a newly placed blind-inserted feeding tube, and US guidance recommends it before first use. In the UK, testing a gastric aspirate (pH 5,5 or below) is the first-line check for nasogastric tubes, with x-ray used when no aspirate is obtained or the pH is too high. Both reject air auscultation and the bubble test, and a tube in the airway can still allow talking.

Jawaban

A · By an x-ray reviewed by a competent clinician
5.Nilai laboratorium & elektrolit

Jawaban: D · From two separate venipuncture sites, using strict aseptic technique

Mengapa ini jawabannya

Taking cultures from two separate sites helps distinguish true bacteremia (growth in both sets) from skin contamination (growth in only one). The skin is cleaned carefully, the bottle tops are disinfected, and cultures are taken before antibiotics.

Jawaban

D · From two separate venipuncture sites, using strict aseptic technique
6.Nilai laboratorium & elektrolit

Jawaban: D · A chronic stable rise; infarction needs a rising or falling pattern

Mengapa ini jawabannya

Troponin is often chronically raised in CKD and other conditions. Acute infarction is diagnosed by a rise and/or fall in troponin together with symptoms or ECG changes, so serial results are compared with the patient's baseline.Diperiksa dengan: Troponin Test · MedlinePlus (NIH) (2023)

Jawaban

D · A chronic stable rise; infarction needs a rising or falling pattern
7.Keperawatan klinis

Jawaban: A · To reduce the absorption of ammonia from the gut

Mengapa ini jawabannya

Lactulose acidifies the colon and speeds transit, reducing ammonia absorption. The dose is usually adjusted to give two to three soft stools a day.

Jawaban

A · To reduce the absorption of ammonia from the gut
8.Keperawatan klinis

Jawaban: D · They reduce complications such as pneumonia, pressure ulcers and delirium

Mengapa ini jawabannya

Delayed surgery and immobility increase the risk of chest infection, VTE, pressure ulcers, delirium and loss of independence. Guidelines recommend surgery within about 24–48 hours of admission (UK guidance: the day of or day after) and mobilisation soon after.

Jawaban

D · They reduce complications such as pneumonia, pressure ulcers and delirium
9.Medikal-bedah: kardiovaskular & respirasi

Jawaban: B · CO₂ yang dihembuskan dapat terkumpul di masker dan terhirup kembali

Mengapa ini jawabannya

Masker wajah sederhana membutuhkan sekitar 5–10 L/menit untuk membilas CO₂ yang dihembuskan keluar dari masker. Pada aliran lebih rendah, pasien dapat menghirup kembali CO₂; kanula hidung lebih sesuai untuk aliran rendah.

Jawaban

B · CO₂ yang dihembuskan dapat terkumpul di masker dan terhirup kembali
10.Medikal-bedah: kardiovaskular & respirasi

Jawaban: A · Call for emergency help and prepare for urgent vascular surgery

Mengapa ini jawabannya

Sudden abdominal or back pain with hypotension in a patient with an AAA suggests rupture, which is often fatal without urgent repair. The team is called at once, large-bore IV access and blood are arranged, and the patient goes to theatre. Fluid may be limited so the blood pressure is not pushed high (permissive hypotension), as directed by the team.

Jawaban

A · Call for emergency help and prepare for urgent vascular surgery
11.Medikal-bedah: saraf, endokrin & ginjal

Jawaban: C · To reduce brain injury from delayed vasospasm

Mengapa ini jawabannya

Nimodipine, a calcium channel blocker, reduces the risk of poor outcome from delayed cerebral ischaemia caused by vasospasm. Blood pressure must be monitored because it can cause hypotension.

Jawaban

C · To reduce brain injury from delayed vasospasm
12.Medikal-bedah: saraf, endokrin & ginjal

Jawaban: A · Tell the prescriber and check glucose often overnight

Mengapa ini jawabannya

Rapid-acting insulin without a meal can cause hypoglycaemia. The nurse informs the prescriber, monitors glucose closely, offers carbohydrate, follows advice about the missed basal dose and reports the incident.

Jawaban

A · Tell the prescriber and check glucose often overnight
13.Medikal-bedah: saluran cerna, perioperatif & onkologi

Jawaban: A · They can reduce the absorption of many other drugs

Mengapa ini jawabannya

Antacids can bind or change the absorption of drugs such as some antibiotics (tetracyclines, quinolones), iron and levothyroxine. Doses are usually separated by a couple of hours.

Jawaban

A · They can reduce the absorption of many other drugs
14.Medikal-bedah: saluran cerna, perioperatif & onkologi

Jawaban: D · Stop the IV fluids, sit the patient up and escalate

Mengapa ini jawabannya

Older patients and those with heart or kidney disease can develop fluid overload. The nurse stops fluids, sits the patient up, gives oxygen if needed and asks for medical review, often for diuretics.

Jawaban

D · Stop the IV fluids, sit the patient up and escalate

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