Prioritas & Delegasi ala NCLEX: paket kilat

An arterial blood gas shows pH 7,28, PaCO₂ 40 mmHg (5,3 kPa) and HCO₃⁻ 16 mEq/L (mmol/L). How should the nurse interpret it?

1. ARespiratory alkalosis
2. BMetabolic alkalosis
3. CRespiratory acidosis
4. DMetabolic acidosis

A child who had a tonsillectomy this morning is swallowing again and again while asleep. What should the nurse suspect?

1. ANormal swallowing during sleep
2. BA sore throat from the breathing tube
3. CHunger after fasting for surgery
4. DBleeding from the operation site

How should a newborn be moved through hospital corridors?

1. AIn a bassinet, not carried in the arms
2. BCarried in the nurse’s arms for comfort
3. CIn the arms of any visitor who offers to help
4. DOn the mother’s lap in a wheelchair, without staff

A toddler has bruises of different ages and a burn, and the parent’s explanation does not fit the injuries. What should the nurse do?

1. AReport the concern following child-protection (safeguarding) procedures
2. BConfront the parent and ask them to admit to abuse
3. CDocument only and say nothing to anyone
4. DWait until there is clear proof of abuse before reporting anything at all

A patient on peritoneal dialysis notices that the drained fluid is cloudy and has abdominal pain. What should the nurse do?

1. ARecord it as normal and continue the usual exchanges
2. BSend the fluid for cell count and culture and report it
3. CAdd more glucose to the next bag to clear the fluid
4. DStop dialysis for a week and recheck the fluid later

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. BAsymptomatic bacteriuria, usually not treated with antibiotics
3. CA urinary tract infection that needs urgent IV antibiotics
4. DContamination, so the culture must be repeated every week

A patient with COPD and known carbon dioxide retention needs a nebulised bronchodilator. How should it usually be given?

1. ADriven by high-flow oxygen at 15 L/min for as long as possible
2. BWithout monitoring oxygen saturation
3. CDriven by compressed air, with oxygen given separately if needed
4. DOnly with the patient lying flat

Seorang perawat ragu apakah dosis obat berisiko tinggi yang diresepkan sudah benar. Apa tindakan yang paling aman?

1. AMenunda pemberian dan memeriksanya terlebih dahulu dengan penulis resep atau apoteker
2. BMemberikan dosis karena dokter telah menandatangani resep
3. CMemberikan separuh dosis sebagai kompromi sampai dokter tersedia
4. DMenanyakan kepada pasien apakah dosisnya tampak seperti biasa lalu memberikannya

Seorang pasien hipertensi mengonsumsi amlodipin. Efek samping mana yang paling mungkin diamati perawat?

1. ABatuk kering yang menggelitik
2. BPembengkakan pergelangan kaki
3. CMengi
4. DHiperkalemia

A nurse receives handover on four patients. Which patient should be seen first?

1. AA patient on day 1 after surgery who is newly restless, RR 30/min, SpO₂ 88% on 4 L/min
2. BA patient with pneumonia on IV antibiotics who now has a temperature of 38,2 °C
3. CA patient with COPD on 1 L/min whose SpO₂ has been 89% and stable throughout the night
4. DA patient with asthma who wants a reliever inhaler before a walk

Why are tacrolimus blood levels checked regularly?

1. AThe drug only works if levels are as high as possible
2. BThe levels show whether the patient has diabetes
3. CToo high harms the kidney; too low risks rejection
4. DThe levels show how much urine the kidney is making

Which patient with a spinal cord injury is at risk of autonomic dysreflexia?

1. AA patient with an injury at L3
2. BA patient with an injury at S2
3. CA patient with an injury at T4
4. DA patient with an injury at L5

Which technique is correct when giving a prefilled low molecular weight heparin injection?

1. AInject into a vein in the back of the hand
2. BLeave the air bubble in and inject into a skin fold
3. CRub the site firmly afterwards to help absorption
4. DExpel the air bubble first and inject into the deltoid muscle

Seorang dewasa berberat 70 kg mengalami luka bakar 40% luas permukaan tubuh total. Dengan rumus Parkland, bagaimana kristaloid 24 jam pertama biasanya dibagi?

1. ASeperempat dalam 8 jam pertama sejak tiba, sisanya dalam 16 jam
2. BSetengah dalam 8 jam pertama sejak waktu luka bakar, setengah dalam 16 jam berikutnya
3. CSemuanya dalam jam pertama, lalu hanya cairan oral sepanjang sisa hari
4. DJumlah sama setiap jam selama 24 jam, dihitung sejak tiba di rumah sakit