Prioritas & Delegasi ala NCLEX: paket kilat

Monitor jantung menunjukkan garis datar (asistol) pada seorang pasien, tetapi pasien duduk dan berbicara. Apa yang pertama kali dilakukan perawat?

1. AMenyiapkan defibrilator untuk memberikan kejut
2. BSegera memulai kompresi dada
3. CMemeriksa pasien dan kabel elektroda
4. DMemanggil tim henti jantung

During a power cut, which patient is the nurse’s first priority?

1. AA patient who depends on a ventilator
2. BA patient whose call light is not working
3. CA patient whose bed will not raise electrically
4. DA patient watching television when it switched off

Mengapa pemeriksaan ganda independen digunakan untuk beberapa obat, seperti infus insulin dan heparin?

1. AUntuk membagi tanggung jawab antara dua perawat bila terjadi kesalahan
2. BAgar proses persiapan lebih cepat
3. COrang kedua yang memeriksa secara terpisah menemukan kesalahan yang terlewat
4. DKarena obat ini sangat mahal bila terbuang

Seorang perawat dengan herpes labialis (sariawan demam) ditugaskan di ruang bayi baru lahir. Tindakan mana yang paling tepat?

1. ATidak memberi tahu siapa pun, dan menutupi lesi dengan riasan selama shift
2. BBekerja seperti biasa, karena herpes labialis sangat umum
3. CMemberi tahu manajer, yang dapat menugaskan ulang perawat untuk sementara
4. DMemakai sarung tangan dan bekerja seperti biasa

Two sets of blood cultures are ordered for a patient with suspected sepsis. How are they best collected?

1. AFrom the existing IV line while the infusion continues to run
2. BAfter the first antibiotic dose, so the infusion is not delayed
3. CFrom two separate venipuncture sites, using strict aseptic technique
4. DBoth from the same site, one minute apart, to save time for the patient

A patient with heavy alcohol use and a poor diet has a hemoglobin of 10,1 g/dL (101 g/L), an MCV of 110 fL and a low red cell folate. Which explanation fits best?

1. AFolate deficiency, made worse by a direct alcohol effect
2. BIron deficiency from slow, chronic bleeding in the gut
3. CAnemia caused by long-standing chronic kidney disease
4. DThalassemia trait inherited from one of the parents

Which rule is essential for safe use of patient-controlled analgesia (PCA)?

1. AThe nurse should press it every hour
2. BOnly the patient should press the button
3. CThe button should be pressed before each meal
4. DRelatives should press it while the patient sleeps

A patient with a possible neck injury after a fall needs their airway opened. Which manoeuvre is preferred?

1. ATurning the head to one side
2. BHyperextending the neck
3. CHead tilt with chin lift
4. DJaw thrust

A patient who had a leg amputation says they feel burning pain in the missing foot. What is the best response?

1. ATell the patient the pain must be imaginary as the foot has gone
2. BAdvise that it will be ignored until it stops
3. CExplain that burning pain in the missing foot shows wound infection
4. DExplain that phantom limb pain is real and arrange treatment

Seconds after an intramuscular injection, a patient becomes pale, sweaty and faint, with a heart rate of 48/min. There is no rash, wheeze or swelling, and they recover quickly when laid flat. What is the most likely cause?

1. AA vasovagal reaction
2. BA myocardial infarction
3. CA tension pneumothorax
4. DAnaphylaxis

How does bladder training help urge incontinence?

1. AThe time between voids is slowly increased
2. BThe patient goes to the toilet every 15 minutes
3. CThe patient drinks as little as possible
4. DA catheter is used every night

Seorang pasien yang menggunakan prednisolon dosis tinggi jangka panjang berada tiga hari setelah operasi usus. Ia hanya melaporkan nyeri perut ringan, tetapi denyut jantung naik menjadi 115/menit dan suhu 37,4 °C. Mengapa perawat harus sangat khawatir?

1. ASteroid dapat menutupi demam, nyeri, dan peritonisme, menyembunyikan komplikasi
2. BSteroid menyebabkan takikardia pada semua pasien, sehingga tidak perlu tindakan
3. CNyeri ringan menunjukkan usus sembuh seperti yang diharapkan
4. DSteroid melindungi terhadap infeksi, sehingga sepsis sangat tidak mungkin

Suplemen herbal mana yang umum ditanyakan sebelum operasi karena dapat meningkatkan perdarahan?

1. AGinkgo biloba
2. BMinyak peppermint
3. CChamomile
4. DCranberry

A nurse has a needlestick injury after taking blood from a patient with hepatitis B. What should the nurse do first?

1. AFinish the shift and report it the next day
2. BWash the site with soap and running water, without scrubbing
3. CScrub the area hard with a nail brush and alcohol
4. DSuck the wound to remove as much of the blood as possible