Prioritas & Delegasi ala NCLEX: paket kilat

Pasien mana yang harus ditemui perawat lebih dulu setelah serah terima?

1. APasien osteoartritis yang melaporkan kekakuan setiap pagi
2. BPasien dengan gips baru yang mengatakan kakinya terasa kebas dan jari kakinya dingin
3. CPasien yang mengonsumsi diuretik dan mengeluarkan 400 mL urine sejak pukul 08,00
4. DPasien yang ingin dibantu mandi sebelum tamu tiba

Pada triase START, seorang dewasa tidak bernapas. Jalan napas diposisikan ulang dan korban tetap tidak bernapas. Apa kategori yang benar?

1. AMerah, karena tidak bernapas adalah temuan yang paling mendesak
2. BMerah, dan segera mulai RJP
3. CHitam (meninggal atau ekspektan)
4. DKuning, dan kembali lagi nanti

Why is “QD” (once daily) on The Joint Commission’s “Do Not Use” list?

1. AIt is only allowed for intravenous medicines
2. BIt is a Latin abbreviation, and only plain English abbreviations may be used
3. CIt can be misread as QID or QOD, so the drug is given too often or too rarely
4. DIt means “every day at bedtime” in some hospitals

During flu season, a nurse wakes up with fever, cough and muscle aches. What is the best action?

1. AStay home and inform the employer according to the illness policy
2. BTake an antipyretic so the fever does not show at work
3. CGo to work but wear a surgical mask for the whole shift
4. DGo to work but avoid caring for patients who have weak immune systems

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

1. AInternational normalized ratio
2. BSerum lithium level
3. CAbsolute neutrophil count
4. DSerum amylase

A trauma patient receives many units of blood quickly and then develops muscle twitching and low blood pressure. Which laboratory value is most likely to explain this?

1. AA high serum magnesium
2. BA low ionized calcium
3. CA high serum sodium
4. DA low serum glucose

Which is a first-line nursing measure to help prevent constipation in hospital?

1. AEncouraging fluids, fibre and mobility
2. BGiving an enema to every patient on admission
3. CKeeping the patient in bed
4. DRestricting fluids to reduce urine output

An acutely ill patient without COPD is on 15 L/min oxygen, and their SpO₂ is now 100% and stable. What should be done?

1. AStop the oxygen and the saturation monitoring because the patient is now well
2. BKeep the oxygen at 15 L/min for at least a week to be on the safe side
3. CIncrease the oxygen further to build up a reserve
4. DReduce the oxygen to keep the SpO₂ within the prescribed target range

Apa yang dimaksud dengan fraksi ejeksi?

1. AVolume darah yang dipompa jantung setiap menit
2. BTekanan di ventrikel kiri pada akhir pengisian diastolik
3. CPersentase darah ventrikel yang dipompa keluar pada setiap denyut
4. DVolume darah yang dipompa keluar pada setiap denyut jantung

A patient is going home after a spontaneous pneumothorax treated with a chest drain. Which advice is correct?

1. AFly home as soon as possible so they can recover in comfort there
2. BTake up scuba diving to strengthen the lungs
3. CStop smoking and do not fly until a doctor confirms full resolution
4. DExpect it never to happen again, so no follow-up is needed

A patient with type 1 diabetes has gastroenteritis and cannot eat. Which sick-day advice is correct?

1. AAvoid drinking fluids to reduce the vomiting
2. BCheck glucose once a day only and rest in bed until better
3. CKeep taking basal insulin and check glucose and ketones more often
4. DStop all insulin until normal eating restarts

The nurse has four renal patients. Which one needs to be seen first?

1. AA patient with a potassium of 6,8 mmol/L who reports palpitations
2. BA patient with a creatinine slightly above their usual level
3. CA patient with mild itching from uraemia who wants a cream
4. DA patient with CKD asking about their phosphate binder

How are skin staples usually removed from a healed incision?

1. AOnly the staples at each end, leaving the others for good
2. BThe staples are left in permanently under the skin
3. CAlternate staples first, then the rest if the wound holds
4. DAll staples at once by pulling each one straight up from the skin

Seorang pasien dengan varises esofagus yang diketahui muntah darah segar dalam jumlah banyak. Pengobatan mana yang harus diantisipasi perawat sebelum endoskopi?

1. AOktreotid atau terlipresin, ditambah antibiotik IV, selama resusitasi
2. BInfus salin cepat hingga tekanan darah tinggi
3. COAINS oral untuk nyeri dan makanan tinggi protein
4. DPemeriksaan menelan barium segera sebelum pengobatan obat apa pun