Prioritas & Delegasi ala NCLEX: paket kilat

A nursing assistant offers to suction a patient’s new tracheostomy. Which response from the RN is best?

1. A“Suctioning a new tracheostomy is my task; I will do it myself.”
2. B“Ask the patient’s family to do the suctioning today.”
3. C“Thank you, please suction him as needed and tell me how it went.”
4. D“Leave the suctioning until the next shift arrives.”

Anak mana yang harus ditemui perawat lebih dulu?

1. ARemaja dengan asma yang puncak arus ekspirasinya 90% dari nilai terbaik pribadinya
2. BBayi dengan RSV yang mengalami napas cuping hidung, retraksi dada, dan SpO₂ 89%
3. CAnak usia sekolah dengan gips di kaki yang meminta minum
4. DBalita dengan suhu 38,4 °C yang sedang bermain dengan mainan

Why is keeping a patient warm (normothermia) during surgery part of infection prevention?

1. AWarm patients do not need antibiotic prophylaxis
2. BCold makes bacteria grow faster in the operating room air and on the drapes
3. CLow body temperature reduces blood flow and immune function in the wound
4. DWarmth sterilizes the surgical site

A patient takes medicines prescribed by several providers. Which advice best reduces the risk of medication errors at home?

1. AKeep each provider’s medicines in separate bags
2. BStop taking any medicine that seems to repeat another one, without asking anyone
3. CKeep one up-to-date list of all medicines and use one pharmacy where possible
4. DOnly tell each provider about the drugs they prescribed

Seorang pasien yang mengonsumsi warfarin untuk fibrilasi atrium memiliki INR 1,4. Apa artinya?

1. APasien tidak perlu lagi mengonsumsi warfarin
2. BAntikoagulasi di bawah target, sehingga gumpalan darah dan stroke lebih mungkin terjadi
3. CDosisnya tepat dan tidak perlu diubah
4. DPasien berisiko tinggi mengalami perdarahan dan segera memerlukan vitamin K

A patient recovering from acute tubular necrosis now passes 4–5 L of urine a day. Which electrolyte changes should the nurse watch for?

1. AHigh potassium and high sodium from retention
2. BNo changes, because the kidneys are now normal
3. CLow potassium and low sodium from urine losses
4. DHigh calcium and high phosphate from bone loss

Which measure helps reduce the risk of surgical site infection?

1. AChanging the wound dressing every hour
2. BShaving the area with a razor the night before surgery
3. CLeaving the patient cool during surgery to slow bacterial growth
4. DRemoving hair, if needed, with clippers rather than a razor

Which patient should the nurse assess first?

1. AA patient with COPD whose SpO₂ is 89% and within their target range
2. BA patient with asthma who can only speak in single words
3. CA patient with diabetes whose glucose is 11 mmol/L (198 mg/dL) before lunch
4. DA postoperative patient who rates their pain as 6/10

Which skin changes around the ankles are typical of chronic venous insufficiency?

1. AA sharply defined red patch with fever
2. BBrown staining, swelling and dry, itchy skin
3. CPale, shiny, hairless skin with weak pulses
4. DA cold, white foot with no pulse

An adult inhales a peanut while laughing and now has a persistent cough and wheeze on one side. Where is the peanut most likely to have lodged?

1. AThe nasal cavity
2. BThe left main bronchus
3. CThe right main bronchus
4. DThe oesophagus

A urine dipstick is positive for nitrites. What does this suggest?

1. AThe patient is dehydrated and needs more fluid
2. BBacteria that convert nitrate are present
3. CThe kidneys are losing too much protein
4. DThe urine has a lot of glucose in it

Seorang pasien hemodialisis bertanya mengapa cairan di antara sesi harus dibatasi. Penjelasan mana yang benar?

1. AMinum air membuat dialisis mengeluarkan terlalu banyak kalium dari darah
2. BCairan berlebih menumpuk, menaikkan TD dan menyebabkan sesak napas serta kram saat dialisis
3. CCairan tambahan melemahkan dinding fistula dan membuatnya lebih mungkin pecah
4. DPembatasan cairan terutama untuk mempersingkat waktu di mesin

Which initial treatment is usual for symptomatic hypercalcaemia of malignancy?

1. AOral calcium tablets and vitamin D
2. BIV fluids followed by an IV bisphosphonate
3. CA high-calcium diet with extra milk
4. DFluid restriction and a thiazide diuretic

Seorang berusia 74 tahun dengan penyakit ginjal kronis mengalami nyeri hebat setelah operasi. Masalah opioid mana yang paling penting?

1. AMorfin adalah opioid paling aman pada gagal ginjal, sehingga dosis dapat dinaikkan bebas
2. BFungsi ginjal tidak berpengaruh pada cara tubuh menangani opioid
3. CMetabolit morfin menumpuk, sehingga dosis lebih rendah atau opioid lain mungkin diperlukan
4. DOpioid tidak boleh digunakan pada lansia, apa pun nyerinya