Prioritas & Delegasi ala NCLEX: paket kilat

On day 3 after hip surgery, a patient suddenly becomes short of breath with sharp chest pain and an SpO₂ of 88%. What should the nurse do first?

1. AGive the next dose of oral analgesia and reassess the patient in an hour
2. BMassage the patient’s calves to ease any muscle cramp
3. CEncourage the patient to walk to improve the circulation
4. DRaise the head of the bed, give oxygen and call for urgent help

A patient on a cardiac monitor suddenly becomes unresponsive, and the monitor shows ventricular fibrillation. What is the priority once help has been called?

1. ADefibrillate as soon as the defibrillator is available, with CPR until then
2. BCheck the blood potassium level before any shock is considered
3. CRecord a full 12-lead ECG to confirm the rhythm before doing anything else at all
4. DGive an oral antiarrhythmic tablet and recheck the rhythm in five minutes

Before a defibrillator shock is delivered, what must the person operating it do?

1. ACall “all clear” and check that nobody is touching the patient or bed
2. BAsk a colleague to hold the paddles in place
3. CHold the patient’s hand to keep them still
4. DKeep the oxygen mask on the patient’s face, held against the chest

A patient who speaks little English is being discharged with new medications. The patient’s 12-year-old child offers to interpret. What should the nurse do?

1. ALet the child interpret, because the family prefers it
2. BUse a professional medical interpreter
3. CGive written instructions in English only
4. DUse simple English and many hand gestures

Kadar palung vankomisin berada di atas rentang target. Efek samping mana yang menjadi perhatian utama?

1. AHitung trombosit meningkat (trombositosis)
2. BGlukosa darah rendah (hipoglikemia)
3. CKerusakan ginjal (nefrotoksisitas)
4. DKonstipasi dan kembung

Seorang pasien dengan muntah hebat memiliki kalium 3,0 mEq/L, klorida 88 mEq/L, dan bikarbonat tinggi. Pola apa yang ditunjukkan ini?

1. AHasil normal yang tidak memerlukan tindak lanjut
2. BKalium tinggi dengan asidosis metabolik akibat dehidrasi
3. CKehilangan asam lambung: kalium dan klorida rendah, alkalosis metabolik
4. DKetoasidosis diabetik dengan anion gap tinggi

After removing a peripheral IV cannula, what should the nurse check?

1. AThat the patient's blood glucose is normal before removal
2. BThat the site is left uncovered and bleeding freely
3. CThat the cannula is intact, and apply pressure until bleeding stops
4. DThat the cannula is put back in its sterile packet for the next patient

An arterial blood gas shows a low PaO₂ with a low or normal PaCO₂. How is this classified?

1. AMetabolic acidosis
2. BNormal blood gas
3. CType 1 respiratory failure
4. DType 2 respiratory failure

Apa arti hasil D-dimer yang meningkat?

1. ADosis antikoagulan terlalu rendah dan harus dinaikkan
2. BTrombosis vena dalam telah disingkirkan dengan aman
3. CTerdapat pemecahan fibrin, tetapi tidak membuktikan adanya bekuan
4. DEmboli paru atau TVD telah dikonfirmasi

Seorang pasien dengan nyeri dada memiliki elevasi ST di sadapan II, III, dan aVF. TD 86/54 mmHg, paru bersih, dan vena leher distensi. Obat resep mana yang harus dipertanyakan perawat?

1. AAspirin kunyah 300 mg
2. BGliseril trinitrat sublingual
3. COksigen bila SpO₂ turun di bawah target
4. DAntiemetik IV

Which picture fits anterior cord syndrome?

1. ANormal movement but complete loss of position sense
2. BArms much weaker than legs after a neck injury
3. CWeakness on one side and loss of pain sensation on the other side
4. DLoss of movement and pain sense, with position sense kept

Which task can the registered nurse delegate to a trained healthcare assistant (nursing assistant)?

1. AAssessing a confused patient whose glucose is 2,6 mmol/L (47 mg/dL)
2. BChecking pre-meal glucose and reporting results out of range
3. CTeaching a new patient how to inject insulin
4. DDeciding the dose of correction insulin from the glucose result

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

1. ARinging in the ears
2. BIncreased hunger
3. CHair growth
4. DItching

A patient has a category (stage) 2 pressure ulcer on the sacrum. Which plan is most appropriate?

1. AOffload the area, manage moisture, support nutrition and dress it
2. BLeave it uncovered and dry it with a hair dryer
3. CMassage around the wound every hour to stimulate blood flow to the skin
4. DSit the patient upright in a chair for most of the day