Prioritas & Delegasi ala NCLEX: paket kilat

Seorang perawat meminta asisten keperawatan menggunakan lift mekanis. Asisten mengatakan belum pernah dilatih menggunakannya. Hak pendelegasian mana yang dilanggar bila perawat berkeras?

1. AOrang yang benar
2. BPengawasan dan evaluasi yang benar
3. CArahan dan komunikasi yang benar
4. DTugas yang benar

A nursing assistant has twice not reported abnormal vital signs to the RN. What is the RN’s best action?

1. AStop delegating any tasks to the assistant for the rest of the year
2. BSay nothing to the assistant and quietly recheck all of the assistant’s vital signs in secret
3. CTalk to the assistant privately, restate what must be reported and follow up closely
4. DComplain about the assistant to the patients during care

Why are patients on long-term corticosteroids at higher risk from infections?

1. ASteroids only affect the risk of fungal skin rashes
2. BSteroids kill the patient’s normal skin bacteria
3. CSteroids suppress the immune response and can hide signs of infection
4. DSteroids make the patient’s blood more acidic, which helps bacteria grow

A nurse calls a provider using SBAR about a patient with falling blood pressure. Which statement is the “Recommendation”?

1. A“I am calling about Mr. Jansen in room 12, who is hypotensive.”
2. B“He is 72 and had a bowel resection yesterday.”
3. C“I think he needs to be assessed now. Can you come within the next 15 minutes?”
4. D“His blood pressure has fallen from 130/80 to 88/50 over the last two hours.”

For most hospitalized adults with diabetes who are critically ill, which glucose target range is commonly recommended?

1. AAbout 140–180 mg/dL (7,8–10 mmol/L)
2. BAbout 300–350 mg/dL (16,7–19,4 mmol/L)
3. CAbout 60–80 mg/dL (3,3–4,4 mmol/L)
4. DAbout 250–300 mg/dL (13,9–16,7 mmol/L)

Seorang pasien gagal jantung mengonsumsi lisinopril, spironolakton, dan suplemen kalium. Hari ini kaliumnya 6,0 mEq/L. Apa penjelasan yang paling mungkin?

1. ABeberapa obat yang menaikkan kalium dikonsumsi bersamaan
2. BSuplemen kalium tidak berpengaruh pada kadar serum
3. CLisinopril menurunkan kalium
4. DSpironolakton menyebabkan kehilangan kalium

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

Which action is most important in protecting a patient with severe neutropenia from infection?

1. ATaking rectal temperatures regularly
2. BKeeping fresh flowers and plants in the room to help the patient's mood
3. CGiving routine intramuscular injections
4. DStrict hand hygiene by everyone who has contact with the patient

Nasihat mana yang membantu mencegah TVD selama penerbangan panjang atau setelah operasi?

1. ADuduk dengan tungkai disilangkan agar nyaman
2. BMemakai pita elastis ketat tepat di bawah lutut
3. CMelakukan latihan pergelangan kaki secara teratur dan minum cairan yang cukup
4. DMinum lebih sedikit agar tidak perlu bangun ke toilet

During a cardiac arrest, the monitor shows an organised rhythm, but there is no pulse. What should the team do?

1. AStop CPR, because an organised rhythm on the monitor means recovery
2. BContinue CPR and give adrenaline (epinephrine), as the rhythm is non-shockable
3. CGive adenosine to slow the rhythm down
4. DDeliver an unsynchronised shock at once and then check the pulse

Mengapa pasien ditimbang sebelum dan sesudah setiap sesi hemodialisis?

1. AKarena mesin tidak dapat dimulai tanpa berat badan
2. BUntuk memeriksa penurunan berat badan akibat malnutrisi
3. CUntuk menghitung dosis setiap obat untuk minggu berikutnya
4. DUntuk melihat berapa banyak cairan yang dikeluarkan dan memandu berat kering

An 89-year-old with stage 5 CKD and severe heart failure, who has capacity, decides not to start dialysis. What is the nurse's best response?

1. AStop all care, because nothing more can be done
2. BAsk the family to change the patient's mind
3. CRespect the decision and support symptom-focused care
4. DTell the patient they must start dialysis by law

Which pain pattern classically suggests a duodenal rather than a gastric ulcer?

1. APain straight after eating that is worsened by food
2. BPain 2–3 hours after meals and at night, eased by eating
3. CPain only on deep breathing that eases when sitting forwards
4. DPain in the right lower abdomen with fever and vomiting

A worker has a hydrofluoric acid burn on the hand and severe pain. After irrigation with water, which specific treatment is commonly applied?

1. ASilver sulfadiazine cream
2. BIce cubes wrapped in a cloth
3. CSodium bicarbonate paste
4. DCalcium gluconate gel