Prioritas & Delegasi ala NCLEX: paket kilat

On a postpartum unit, which patient is the most appropriate to assign to an LPN/LVN?

1. ASevere pre-eclampsia on a magnesium sulfate infusion
2. BDay 1 after an uncomplicated vaginal birth, stable vital signs
3. CA new admission transferred from the labor ward with a fever of 38,6 °C
4. DOne hour after birth with heavy bleeding and a boggy uterus

Weeks after a kidney transplant, a patient has a fever, less urine and tenderness over the new kidney. What should the nurse suspect?

1. ANormal healing of the transplant
2. BDehydration from drinking too much
3. CRejection of the transplant
4. DA side effect of eating salty food

Many intensive care units bathe patients daily with chlorhexidine. What is the main purpose?

1. ATo reduce skin bacteria and bloodstream infections linked to central lines
2. BTo treat existing wound infections without the need for antibiotics
3. CTo moisturize dry skin in older patients
4. DTo lower the patient’s body temperature

A patient in a vest restraint has slid down in bed, and the vest is pressing against the neck. What should the nurse do first?

1. ARelease the restraint at once and reposition the patient
2. BCall the provider to ask about a different restraint
3. CWrite a note about the event in the chart
4. DTighten the vest so the patient cannot slide down again

A patient's potassium is unexpectedly 5,8 mEq/L. The sample was taken after the tourniquet was on for several minutes while the patient pumped their fist. What is the best interpretation?

1. AThe result confirms true hyperkalemia and needs no further checking
2. BFist pumping lowers potassium, so the true level is even higher
3. CTourniquet time affects only the glucose result, not the potassium
4. DThe result may be falsely high and should be repeated with better technique

A patient with diabetes had a glucose of 58 mg/dL (3,2 mmol/L), took 15 g of fast-acting carbohydrate and, 15 minutes later, the glucose is 64 mg/dL (3,6 mmol/L). The patient is alert. What should the nurse do next?

1. AGive a long-acting insulin dose to stabilize it
2. BWait until the next meal before giving anything
3. CGive another 15 g of fast carbohydrate and recheck
4. DGive a protein snack only and recheck tomorrow

What happens in third-degree (complete) heart block?

1. AThe ventricles beat very fast and regularly
2. BEvery impulse reaches the ventricles, but each one is slightly delayed
3. CNo impulses from the atria reach the ventricles, so they beat independently
4. DThe atria beat chaotically with no P waves, and the ventricular rate is irregular

Pasien cedera kepala menunjukkan tekanan darah naik, denyut jantung turun, dan napas tidak teratur. Ini menunjukkan:

1. ASyok hipovolemik akibat perdarahan dalam yang tersembunyi
2. BSepsis
3. CSerangan panik
4. DPeningkatan tekanan intrakranial (trias Cushing)

Apa yang dimaksud dengan rehabilitasi paru pada PPOK?

1. ALatihan dan edukasi terawasi yang meredakan sesak napas
2. BOperasi untuk mengangkat area paru yang paling rusak
3. CTes fungsi paru yang diulang setiap enam bulan
4. DKursus steroid oral dan antibiotik yang diberikan di rumah setiap musim dingin

Pada hari ke-6 infus heparin, jumlah trombosit turun lebih dari setengah dan pasien memiliki lengan bengkak yang baru. Apa yang harus diantisipasi perawat?

1. AMelanjutkan heparin dan memberikan transfusi trombosit
2. BBeralih ke LMWH karena merupakan obat yang berbeda
3. CMenghentikan semua antikoagulasi selama dua minggu
4. DMenghentikan semua heparin dan memulai antikoagulan non-heparin

Setelah trombolisis IV untuk stroke, observasi mana yang paling penting dalam 24 jam pertama?

1. ABerat badan harian dan keseimbangan cairan saja
2. BBunyi usus dan lingkar perut setiap jam
3. CPemeriksaan neurologis dan tekanan darah yang sering
4. DArus puncak dan saturasi oksigen setiap jam

Seorang pasien dengan pemberian makan enteral kontinu semalaman menerima insulin yang disesuaikan dengan makanan. Pukul 02:00 selang tersumbat dan pemberian makan berhenti. Apa risiko utamanya, dan apa yang harus dilakukan perawat?

1. AHiperglikemia; berikan dosis insulin tambahan segera
2. BHipoglikemia; periksa glukosa sering dan ikuti rencana untuk penutup glukosa
3. CTidak ada risiko; insulin akan tersimpan sampai pemberian makan dimulai lagi
4. DKetoasidosis; hentikan semua insulin sampai pagi

Which is a common side effect of opioids, especially when given by epidural or spinal route?

1. AHair growth
2. BRinging in the ears
3. CIncreased hunger
4. DItching

A category (stage) 4 pressure ulcer is now healing and shallower. How should it be documented according to standard guidance?

1. AAs a fully healed ulcer that can be removed from the record
2. BAs a healing category 4 pressure ulcer
3. CAs a category 1 pressure ulcer now
4. DAs a category 2 pressure ulcer now