Prioritas & Delegasi ala NCLEX: paket kilat

A patient reports pain of 8/10. Before giving the prescribed as-needed analgesic, what does the nurse do first?

1. ATell the patient to wait until the next scheduled dose is due in two hours
2. BAsk the nursing assistant to reposition the patient
3. CGive the strongest analgesic on the chart straight away
4. DAssess the location, character and onset of the pain and the vital signs

A patient taking an MAO inhibitor antidepressant is taught about diet. Which statement shows a need for further teaching?

1. A“I can still eat aged cheese and cured salami.”
2. B“A sudden severe headache is a warning sign.”
3. C“I will check with the pharmacist before cold remedies.”
4. D“I will avoid tap beer and red wine.”

During routine handwashing with soap and water (medical asepsis), how are the hands held?

1. AHigher than the elbows, so water runs down the arms
2. BTouching the inside of the sink for support
3. CLower than the elbows, so water runs off the fingertips
4. DLevel with the shoulders, away from the sink

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

1. AEither type is fine, as long as it is given in the morning
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. DPeople on steroids should never have any influenza vaccine

A patient with schizophrenia is starting clozapine. Which laboratory value must be monitored regularly?

1. AInternational normalized ratio
2. BAbsolute neutrophil count
3. CSerum lithium level
4. DSerum amylase

A patient with jaundice and nausea has a positive IgM antibody to hepatitis A virus (IgM anti-HAV). What does this show?

1. APast hepatitis B infection that has cleared
2. BA current or recent hepatitis A infection
3. CImmunity from hepatitis A vaccine long ago
4. DChronic hepatitis A lasting many years

Which group of features is typical of nephrotic syndrome?

1. ASevere loin pain and fever
2. BBlood in the urine, high blood pressure and reduced urine output only
3. CHeavy proteinuria, low serum albumin and oedema
4. DPolyuria, thirst and weight loss

In a patient with a head injury, which is usually the earliest sign of rising intracranial pressure?

1. AIrregular breathing pauses
2. BA fixed, dilated pupil on both sides
3. CA change in level of consciousness
4. DA slow pulse with high blood pressure

What is the purpose of cardiac resynchronisation therapy (a biventricular pacemaker)?

1. ATo make both ventricles contract together and more efficiently
2. BTo deliver a shock whenever the heart rate exceeds 100/min
3. CTo replace a damaged heart valve
4. DTo slow the atrial rate in patients with atrial fibrillation

Sebelum dosis digoksin pagi, nadi apikal pasien 54/menit dan ia merasa mual. Apa yang harus dilakukan perawat?

1. AMemberikan dosis dan antiemetik, lalu memeriksa nadi lagi besok
2. BMemberikan setengah dosis dan memeriksa nadi lagi dalam satu jam
3. CMemberikan dosis, karena hanya nadi radial yang dihitung
4. DMenahan dosis dan melaporkannya, karena toksisitas mungkin terjadi

Mengapa pasien ditimbang sebelum dan sesudah setiap sesi hemodialisis?

1. AUntuk menghitung dosis setiap obat untuk minggu berikutnya
2. BUntuk memeriksa penurunan berat badan akibat malnutrisi
3. CKarena mesin tidak dapat dimulai tanpa berat badan
4. DUntuk melihat berapa banyak cairan yang dikeluarkan dan memandu berat kering

A nurse teaches the family of a patient on insulin how to manage a severe hypo. Which statement shows a need for further teaching?

1. A"When she can swallow, I will give her a snack."
2. B"I will give the glucagon as I was shown."
3. C"I will put her on her side and call an ambulance straight away."
4. D"If she is unconscious, I will pour juice into her mouth."

Why are antimotility drugs such as loperamide avoided in C. difficile infection?

1. AThey make the stool sample test positive falsely
2. BThey cause serious liver failure in most patients who take them
3. CThey kill the normal bowel bacteria
4. DThey may keep toxin in the bowel and risk toxic megacolon

Pada hari ke-3 setelah operasi pinggul, seorang pasien lansia menjadi bingung akut, dengan perhatian yang berfluktuasi dan agitasi. Apa yang harus dilakukan perawat pertama kali?

1. AMerestrain pasien dan memberikan sedatif dosis besar segera
2. BMengasumsikan itu demensia dan melanjutkan rencana perawatan tanpa perubahan
3. CMeminta keluarga membawa pasien pulang agar tenang
4. DMencari penyebab seperti hipoksia, infeksi, nyeri, atau obat, dan mengeskalasi