Prioritas & Delegasi ala NCLEX: paket kilat

A patient with asthma has two inhalers: a corticosteroid and salbutamol (albuterol). Which statement shows a need for further teaching?

1. A“I will use my steroid inhaler when I have a sudden attack.”
2. B“I will rinse my mouth after using the steroid inhaler.”
3. C“I will use my steroid inhaler every day, even when I feel well.”
4. D“I will carry my salbutamol inhaler with me.”

A patient is admitted with inhalational anthrax. Which precautions are needed?

1. ADroplet precautions with a surgical mask for everyone who enters
2. BFull contact and droplet precautions for all staff and visitors on the unit
3. CStandard precautions, because it does not usually spread from person to person
4. DAirborne precautions in a negative-pressure room for the whole of the hospital stay

A patient is on a ventilator. Which bed position helps to prevent ventilator-associated pneumonia?

1. ALying completely flat
2. BTrendelenburg position
3. CHead of the bed raised 30 to 45 degrees
4. DHead of the bed raised about 10 degrees

A patient on long-term high-dose corticosteroids asks for the nasal spray influenza vaccine. What should the nurse explain?

1. APeople on steroids should never have any influenza vaccine
2. BThe nasal spray is the best choice for people on steroids, because it is not injected
3. CThe nasal spray is a live vaccine, so the injected inactivated vaccine is used instead
4. DEither type is fine, as long as it is given in the morning

A patient who is breathless during a transfusion has hypotension, fever and bilateral lung infiltrates, with no signs of fluid overload. Which complication is most likely?

1. ATransfusion-related acute lung injury (TRALI)
2. BTransfusion-associated circulatory overload
3. CA mild febrile nonhemolytic reaction
4. DA simple allergic reaction with hives

Pada malam setelah operasi, hemoglobin pasien turun dari 12,5 g/dL menjadi 8,1 g/dL (125 menjadi 81 g/L), dan denyut jantung 118/menit. Apa masalah yang paling mungkin?

1. APengenceran normal setelah operasi yang tidak memerlukan tindakan
2. BDehidrasi
3. CKondisi yang membaik
4. DPerdarahan

Which type of painkiller should a patient with liver cirrhosis usually avoid?

1. ANon-steroidal anti-inflammatory drugs such as ibuprofen
2. BLocal anaesthetic creams
3. CHot packs applied to a painful joint
4. DParacetamol (acetaminophen), given in a carefully reduced and monitored dose

A nurse teaches a patient with reflux disease. Which statement shows a need for further teaching?

1. A"I will try to lose some weight over the next months."
2. B"I will cut down on alcohol."
3. C"I will raise the head of my bed with blocks."
4. D"A big meal just before bed is fine if I take my tablet."

How big should a suction catheter be compared with the tracheostomy or endotracheal tube?

1. ANo more than half the internal diameter of the tube
2. BExactly the same diameter as the tube, for a tight fit
3. CLarger than the tube, so that it clears it completely
4. DAny size, as the diameter does not matter

The stump of a recent below-knee amputation suddenly bleeds heavily through the dressing. What should the nurse do first?

1. AApply a warm compress to the stump
2. BRemove all the dressings and wait for the bleeding to stop by itself
3. CEncourage the patient to walk on crutches to ease the pressure
4. DApply firm direct pressure and call for urgent surgical help

A patient with type 1 diabetes plans a long cycle ride. Which advice is most appropriate?

1. ACheck glucose before and after, and carry fast-acting carbohydrate
2. BTake an extra dose of rapid-acting insulin before setting off
3. CAvoid checking glucose until the ride is over
4. DSkip breakfast so the exercise burns body fat

A patient received IV insulin and glucose for hyperkalaemia an hour ago. What must the nurse monitor over the next few hours?

1. ACapillary glucose, for hypoglycaemia
2. BSkin, for a drug rash
3. CUrine colour, for blood in the urine
4. DPupils, for raised intracranial pressure

Which patient is at highest risk of refeeding syndrome?

1. AAn underweight patient who has eaten very little for 10 days
2. BA patient with a normal BMI eating three meals a day
3. CA patient who missed one lunch because of a scan
4. DA healthy adult after an overnight fast for minor surgery

Seorang pasien menjalani terapi luka tekanan negatif (NPWT). Pompa berbunyi alarm dan balutan kehilangan segelnya. Tindakan mana yang paling tepat?

1. AMemulihkan segel; bila gagal tepat waktu, ganti dengan balutan lembap
2. BMembiarkan foam di dalam luka tanpa hisapan selama beberapa hari sampai ditinjau
3. CMenaikkan hisapan ke pengaturan maksimum untuk menarik segel kembali
4. DMengisi luka dengan kasa kering di atas foam dan merekatkannya dengan ketat