Prioritas & Delegasi ala NCLEX: paket kilat

A nurse teaches foot care to a patient with diabetes. Which statement shows a need for further teaching?

1. A“I will dry well between my toes after washing.”
2. B“I will check the soles of my feet every day with a mirror.”
3. C“I will soak my feet in hot water every evening.”
4. D“I will wear shoes that fit well, even at home.”

Which patient finding after a total knee replacement needs the nurse’s action first?

1. AAsks for an ice pack to help with swelling around the knee
2. BPain of 4/10 when the physiotherapist bends the knee during the morning session
3. CA small amount of dried blood on the dressing
4. DSudden calf pain and swelling in the operated leg, with new breathlessness

Why does a nurse wear chemotherapy-tested gloves and a gown when emptying the urinal of a patient who recently had chemotherapy?

1. AThe body fluids can contain active drug for a time after treatment
2. BThe patient is on airborne precautions after treatment
3. CThe urine always contains infectious bacteria after chemotherapy
4. DChemotherapy makes the urine strongly acidic and corrosive

Tindakan perawat mana yang menunjukkan bahwa lima momen kebersihan tangan dijalankan?

1. AIa membersihkan tangannya hanya di awal dan akhir shift
2. BIa membersihkan tangannya hanya bila tampak kotor
3. CIa memakai sarung tangan yang sama di antara dua pasien
4. DIa membersihkan tangannya setelah menyentuh pagar tempat tidur

Seorang pasien yang mengonsumsi furosemid memiliki kalium 2,9 mEq/L. Temuan mana yang diharapkan perawat?

1. AGelombang T tinggi dan runcing pada EKG
2. BKesemutan di sekitar mulut dengan tanda Chvostek positif
3. CKelemahan otot dan kram tungkai
4. DDiare dan kram perut akibat usus yang terlalu aktif

An 82-year-old woman without a catheter has a urine culture growing bacteria, but no fever, urinary symptoms or change in mental state. What is the best interpretation?

1. APyelonephritis, which needs admission and IV fluids today
2. BA urinary tract infection that needs urgent IV antibiotics
3. CAsymptomatic bacteriuria, usually not treated with antibiotics
4. DContamination, so the culture must be repeated every week

How does CPAP help a patient with obstructive sleep apnoea?

1. AIt delivers bronchodilator drugs deep into the lungs overnight
2. BIt strengthens the breathing muscles during the day
3. CIt removes excess carbon dioxide from the lungs by gentle suction
4. DIt keeps the upper airway open during sleep with continuous air pressure

During a blood transfusion, an older patient with heart failure becomes breathless with a rising blood pressure, raised JVP and crackles in the lungs. What is the most likely cause?

1. AA febrile non-haemolytic reaction
2. BAnaphylaxis
3. CTransfusion-associated circulatory overload
4. DTransfusion-related acute lung injury with hypotension

A woman had lymph nodes removed from her left armpit for breast cancer. Which advice helps reduce the risk of lymphoedema?

1. AApply tight jewellery to the left wrist
2. BAvoid BP cuffs and injections on the left arm where possible
3. CUse only the left arm for heavy lifting to build up its muscles
4. DKeep the left arm hanging down and as still as possible all day

A patient with obstructive sleep apnoea who uses CPAP at home is having surgery. Which plan is safest after the operation?

1. ALeave the CPAP machine at home, as it is not needed while in hospital
2. BGive extra opioids so the patient sleeps through the night
3. CUse their CPAP machine and monitor closely, using opioids with caution
4. DNurse the patient lying flat on their back to keep the airway open

Setelah cedera kepala, seorang pasien memiliki cairan jernih menetes dari hidung. Apa kekhawatiran utamanya?

1. AKebocoran CSF dari fraktur tengkorak
2. BPilek biasa atau serangan demam alergi
3. CLendir normal yang diproduksi setelah menangis
4. DReaksi alergi terhadap kontras CT

A patient has had a high sodium of 160 mmol/L for several days. Why must it be corrected slowly?

1. AThe sodium will rise again if corrected quickly
2. BRapid correction can cause brain swelling
3. CRapid correction raises the blood glucose
4. DRapid correction causes kidney stones

Fase penyembuhan luka mana yang melibatkan pembentukan jaringan granulasi dan pembuluh darah baru?

1. AFase proliferatif
2. BFase inflamasi
3. CFase maturasi
4. DFase hemostasis (pembekuan)

A patient taking oral capecitabine reports red, painful, peeling palms and soles. What should the nurse do?

1. AAdvise hot soaks for the hands and feet
2. BTell the patient to take a double dose next time
3. CReassure that it is a sign of an unrelated allergy to washing powder
4. DReport it; this is hand-foot syndrome and treatment may need changing