Prioritas & Delegasi ala NCLEX: paket kilat

An older patient becomes confused over a few hours, with attention that comes and goes. What does this suggest?

1. ALong-standing dementia that is expected
2. BNormal aging that needs no action
3. CA personality change that is permanent and expected
4. DDelirium, which needs the cause found quickly

Several patients on a unit develop diarrhea within two days. What should the nurse do first?

1. AWait to see if more patients become unwell
2. BPlace affected patients on contact precautions and inform infection control
3. CMove the affected patients into shared rooms with other patients to free up beds
4. DGive all patients antidiarrheal drugs without assessment

A parent says, “I tell my son his medicine is candy so he takes it.” What should the nurse teach?

1. AIt only matters for medicines that taste bitter or are hard to swallow
2. BThis is a good idea and makes giving medicine easier
3. CIt is fine as long as the medicine is kept in the fridge
4. DDo not call medicine candy, because the child may take it when no one is watching

A patient was harmed by a medication error and asks the nurse what happened. Which approach is best?

1. ATell the patient nothing happened to avoid worry
2. BBlame the pharmacy for the error so that the nurse and the ward are not at fault
3. CBe honest that an error occurred and involve the provider and team in disclosure per policy
4. DTell the patient to make a formal complaint to find out

Which IV fluid can be given through the same line as a red cell transfusion?

1. A5% dextrose in water
2. B0,45% sodium chloride
3. CLactated Ringer's (Hartmann's) solution
4. D0,9% sodium chloride

The nurse teaches a patient who is collecting a 24-hour urine sample at home. Which statement shows a need for further teaching?

1. A"I'll ask whether any foods or drugs should be avoided first"
2. B"I'll keep the container cool as the laboratory told me to"
3. C"I'll empty my bladder at the end time and add that urine"
4. D"If I forget to save one void, I'll just carry on to the end"

A patient is having a 12-lead ECG. Where are the chest electrodes placed?

1. AIn a straight line down the centre of the sternum from top to bottom
2. BAnywhere on the chest where the skin is clear
3. COn both shoulders and both hips only
4. DIn standard numbered positions across the front and left of the chest

Seorang pasien dengan perdarahan saluran cerna akut memiliki denyut jantung 120/menit dan tekanan darah 90/60 mmHg. Apa prioritas keperawatan setelah memanggil bantuan?

1. AMemasang akses IV berukuran besar dan bersiap untuk penggantian cairan atau darah
2. BMenganjurkan pasien berjalan sendiri ke kamar mandi
3. CMenunda tindakan sampai warna tinja diperiksa
4. DMemberikan makanan dalam porsi besar untuk memulihkan energi

Why is aspirin chewed rather than swallowed whole in a suspected acute coronary syndrome?

1. AChewing speeds absorption, giving a faster antiplatelet effect
2. BChewing stops the aspirin from irritating the lining of the stomach
3. CChewing changes aspirin into an anticoagulant
4. DWhole aspirin tablets cannot be absorbed at all from the gut

A 28-year-old woman taking the combined pill comes in breathless and anxious. RR is 30/min, heart rate 118/min and SpO₂ 90% on air. A colleague says it is a panic attack. What should the nurse conclude?

1. AThe saturation is normal for an anxious person who is breathing fast
2. BBreathing into a paper bag is the best first treatment for her
3. CLow oxygen saturation is not explained by anxiety; PE must be excluded
4. DShe should be sent home after a sedative

A patient on peritoneal dialysis has gained weight and has higher glucose levels. Which part of the treatment is the likely cause?

1. AGlucose absorbed from the dialysis fluid
2. BAir entering the abdomen during exchanges
3. CSodium lost into the dialysis fluid
4. DProtein lost into the dialysis fluid

A patient with an insulin pump is admitted with nausea, a glucose of 19 mmol/L (342 mg/dL) and blood ketones of 3,1 mmol/L. What is the priority?

1. AIncrease the pump rate and recheck the ketones in 12 hours
2. BSuspect failed insulin delivery and give insulin by another route
3. CGive an antiemetic only, because nausea is causing the high glucose
4. DDisconnect the pump and give no insulin until the ketones clear

What is the main treatment for a venous leg ulcer with an adequate arterial supply?

1. AKeeping the leg hanging down all day
2. BCompression therapy
3. CSurgery to amputate the limb
4. DStrong oral antibiotics for all ulcers

Seorang pasien yang menerima filgrastim (G-CSF) setelah kemoterapi bertanya efek samping apa yang diharapkan. Efek samping mana yang paling umum?

1. ANyeri tulang yang pegal, karena sumsum tulang dirangsang
2. BGangguan pendengaran permanen
3. CPenurunan cepat jumlah sel darah putih
4. DKerontokan rambut total dalam beberapa hari setelah suntikan pertama