Prioritas & Delegasi ala NCLEX: paket kilat

A patient uses patient-controlled analgesia (PCA) after surgery. Which statement by a family member shows a need for further teaching?

1. A“The pump has limits set by the nurse so she cannot get too much at once.”
2. B“I will tell the nurse if she becomes very sleepy or hard to wake.”
3. C“Only she should press the button when she needs pain relief.”
4. D“I will press the button for her while she is asleep so she stays comfortable.”

A patient with septic shock remains hypotensive, with a mean arterial pressure of 58 mmHg, after adequate IV fluids. What should the nurse anticipate?

1. AA loop diuretic to remove the extra fluid that has been given
2. BA beta-blocker to slow the heart rate
3. CA vasopressor, such as norepinephrine, to raise the pressure
4. DAn oral fluid challenge with a sports drink

Which measure is part of the bundle for inserting a central venous catheter to prevent bloodstream infection?

1. ARoutine replacement of the catheter on a fixed schedule, such as every three days
2. BChlorhexidine-alcohol skin antisepsis and maximal sterile barrier precautions
3. CGiving antibiotics to every patient before insertion
4. DChoosing the femoral vein as the first site in adults

A patient after heart surgery has temporary epicardial pacing wires. Why do staff take special care with electrical safety?

1. APacing wires can only carry current coming from the pacemaker box itself
2. BElectrical safety only matters for patients who have permanent implanted pacemakers
3. CSmall currents can travel along the wires straight to the heart and cause arrhythmias
4. DThe wires make the patient immune to electric shock

Glukosa puasa pasien hari ini 98 mg/dL (5,4 mmol/L), tetapi HbA1c-nya 8,9% (74 mmol/mol). Interpretasi mana yang terbaik?

1. AHbA1c hanya mencerminkan 24 jam terakhir
2. BPasien tidak menderita diabetes
3. CKontrol glukosa buruk selama 2–3 bulan terakhir
4. DHasil baik hari ini menunjukkan bahwa diabetes terkontrol dengan baik

A patient with ongoing hemolytic anemia has an HbA1c of 4,6%, but home glucose readings are often 180–220 mg/dL (10–12 mmol/L). What best explains the gap?

1. AThe patient has true, well-controlled diabetes
2. BShort red cell life span lowers the HbA1c falsely
3. CThe home glucose meter is reading falsely high
4. DHemolysis makes the HbA1c test read too high

Why is an ankle–brachial pressure index (ABPI) measured before applying compression bandages to a leg ulcer?

1. ATo exclude significant arterial disease, as compression could cut off blood flow
2. BTo measure how deep the ulcer is and how much exudate it produces
3. CTo check for a urinary tract infection that could delay ulcer healing
4. DTo work out the patient's fluid needs

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

1. AHyperextending the neck
2. BHead tilt with chin lift
3. CJaw thrust
4. DTurning the head to one side

Seorang pasien asma menggunakan inhaler pelega lebih dari tiga kali seminggu. Apa yang ditunjukkan hal ini?

1. AInhaler pencegah tidak lagi diperlukan
2. BPelega tidak lagi bekerja dan harus dihentikan
3. CAsma terkontrol baik dengan rencana saat ini
4. DKontrol asma buruk dan pengobatan perlu ditinjau

A patient with COPD who is known to retain CO₂ arrives on 15 L/min oxygen. They are now drowsy with SpO₂ 99%. What is the most appropriate action?

1. ARemove the oxygen completely and observe
2. BGive a sedative to help the patient rest
3. CReduce the oxygen to aim for 88–92% and get a blood gas
4. DKeep the oxygen at 15 L/min because the saturation is excellent

What is the dexamethasone suppression test used for?

1. ATo measure kidney function
2. BTo diagnose diabetes insipidus
3. CTo check thyroid function
4. DTo help diagnose Cushing's syndrome

A patient with SIADH is taught about a fluid restriction. Which statement shows a need for further teaching?

1. A"If I feel thirsty, I can drink as much water as I like."
2. B"I will weigh myself every morning."
3. C"I will count all drinks, including soup, in my daily total."
4. D"I will report any headaches or confusion."

Which complication is more typical of Crohn's disease than of ulcerative colitis?

1. ABleeding only from the rectum
2. BInflammation limited to the rectal lining
3. CDisease that is cured by removing the colon
4. DFistulas between the bowel and other organs

Beberapa jam setelah kateter epidural dilepas, seorang pasien yang menggunakan antikoagulan mengalami nyeri punggung dan kelemahan tungkai yang memburuk. Apa yang harus dicurigai?

1. AInfeksi saluran kemih yang menyebabkan nyeri punggung
2. BHematoma epidural, yang membutuhkan tinjauan darurat dan MRI
3. CHilangnya efek blok epidural secara normal sepanjang hari
4. DUlkus tekan sakrum yang menyebabkan nyeri tungkai alih