Prioritas & Delegasi ala NCLEX: paket kilat

A patient with asthma has two inhalers: a corticosteroid and salbutamol (albuterol). Which statement shows a need for further teaching?

1. A“I will use my steroid inhaler when I have a sudden attack.”
2. B“I will use my steroid inhaler every day, even when I feel well.”
3. C“I will rinse my mouth after using the steroid inhaler.”
4. D“I will carry my salbutamol inhaler with me.”

Six hours after surgery, a patient has not passed urine, feels the urge to go and has a firm swelling above the pubic bone. What is the most likely problem?

1. ADehydration from fasting before surgery
2. BA normal effect of the anesthetic
3. CUrinary retention
4. DAcute kidney injury with no urine made

Kapan perawat boleh menggunakan alat pemadam api pada kebakaran?

1. ASelalu, bahkan sebelum alarm dibunyikan, untuk menghemat waktu
2. BHanya bila api kecil, alarm telah dibunyikan, dan jalan keluar bebas
3. CSetiap kali ada asap, meskipun jalan keluar terhalang
4. DTidak pernah; hanya petugas pemadam kebakaran yang boleh memakai alat pemadam

Pada pagi hari operasi, pasien mengatakan operasi dilakukan pada lutut kiri, tetapi formulir persetujuan menyebutkan lutut kanan. Apa yang harus dilakukan perawat?

1. ABerhenti dan memberi tahu dokter bedah, agar lokasi dipastikan terlebih dahulu
2. BMengikuti pasien, karena pasien paling tahu tubuhnya sendiri
3. CMenandai kedua lutut agar salah satunya dapat dioperasi
4. DMengikuti formulir persetujuan, karena sudah ditandatangani

A urine culture report states "mixed growth of three organisms, likely contamination." What is the nurse's best response?

1. AInform the provider and arrange a new, correctly collected sample
2. BRecord the result as a confirmed urinary tract infection
3. CDiscard the report, because a mixed growth is always normal
4. DStart treatment for all three organisms with three antibiotics

A patient with a heart murmur and fever has three sets of blood cultures, taken hours apart, all growing the same Streptococcus species. What does this suggest?

1. AContamination of all three samples during collection
2. BA normal finding in patients with heart murmurs
3. CA urinary tract infection that has spread to the skin
4. DPersistent bacteremia, as in infective endocarditis

Why is blood pressure monitored closely in a patient with an epidural infusion?

1. AThe local anaesthetic can block sympathetic nerves and cause hypotension
2. BBlood pressure readings show whether the catheter is infected
3. CEpidurals always cause severe hypertension that needs regular treatment
4. DThe epidural pump uses the blood pressure to set the rate

A patient with known cirrhosis suddenly vomits large amounts of bright red blood and becomes tachycardic. What is the most likely cause?

1. AA Mallory-Weiss tear from a small amount of vomiting
2. BSwallowed blood from a nosebleed
3. CBleeding from ruptured oesophageal varices
4. DA lower GI bleed from diverticular disease

Seorang pasien yang baru memulai antihipertensi merasa pusing saat bangun dari tempat tidur. Nasihat yang benar apa?

1. ABerdiri dengan cepat agar darah terus bergerak
2. BMinum dosis ganda keesokan paginya
3. CBerhenti minum tablet tanpa memberi tahu dokter atau perawat
4. DDuduk sejenak di tepi tempat tidur sebelum berdiri

A patient with an inferior myocardial infarction develops complete heart block with a heart rate of 38/min. What is the most likely reason?

1. AThe left anterior descending artery supplies the SA node only
2. BThe right coronary artery usually supplies the AV node
3. CInferior infarcts always destroy the bundle of His permanently
4. DHeart block is caused by the thrombolytic drug

A patient has acute glomerulonephritis with oedema and high blood pressure. Which nursing care is most appropriate?

1. AEncourage a high-salt diet to balance the fluids
2. BMonitor BP, fluid balance and daily weight
3. CGive large amounts of IV fluid
4. DCheck the weight once a week

Seorang pasien dengan dugaan stroke tiba dua jam setelah onset. Glukosa kapiler 2,4 mmol/L (43 mg/dL). Apa yang harus dilakukan selanjutnya?

1. AMemberikan trombolisis segera tanpa pemeriksaan lebih lanjut
2. BMengobati glukosa rendah dan menilai ulang tanda neurologis
3. CMemberikan insulin IV untuk melindungi sel otak
4. DMengabaikan glukosa, karena tidak relevan untuk penilaian stroke

When is cold therapy most useful for pain?

1. AOver numb areas where sensation is lost
2. BSoon after an acute soft tissue injury, to reduce swelling
3. CFor long-term muscle stiffness, applied continuously for several hours
4. DDirectly on skin with poor circulation

After forearm fracture surgery, a patient has severe pain not eased by opioids, made worse by passively moving the fingers. What should the nurse do?

1. AReassure the patient that this pain is expected
2. BApply ice and a tighter bandage to reduce the swelling
3. CRaise the arm as high as possible and give a further dose of opioid
4. DLoosen any tight dressing, keep the arm at heart level and escalate