Prioritas & Delegasi ala NCLEX: paket kilat

A patient coughs hard after abdominal surgery, and loops of bowel appear through the opened wound. What does the nurse do first?

1. APush the bowel gently back into the abdomen with a gloved hand
2. BCover the wound with sterile dressings moistened with saline
3. CHelp the patient walk to the toilet to relieve abdominal pressure
4. DLeave the wound uncovered so the surgeon can see it on arrival

A patient with known abdominal aortic aneurysm suddenly has severe back pain, a pulsing mass in the abdomen and a falling blood pressure. What should the nurse do?

1. AGive an oral analgesic and reassess the patient in about one hour
2. BEncourage the patient to walk to ease the back pain
3. CCall for emergency help at once and prepare for urgent surgery
4. DPalpate the mass firmly to check its size and spread

When should the transparent dressing over a peripheral IV site be changed?

1. AOnly when the patient asks for a new dressing
2. BWhen it is damp, loose or visibly soiled
3. COnly when the IV catheter is removed, whatever its state
4. DEvery hour, so the site can be cleaned again

Seorang perawat melihat rekannya berpindah dari satu pasien ke pasien berikutnya tanpa kebersihan tangan. Tindakan terbaik apa?

1. AMelaporkannya secara anonim kepada manajer sebulan kemudian
2. BMenunggu untuk melihat apakah rekan tersebut melakukannya lagi lain kali
3. CTidak mengatakan apa-apa, untuk menghindari konflik dalam tim
4. DMengingatkan rekan tersebut dengan sopan saat itu juga

In the third trimester of pregnancy, a woman's alkaline phosphatase (ALP) is about twice the usual adult range, and the other liver tests are normal. What is the best interpretation?

1. AA sign of acute viral hepatitis
2. BA sign of new bone cancer
3. CA normal rise from placental ALP
4. DA sign of blocked bile ducts

A patient on a stable dose of levothyroxine now has a TSH of 9,8 mIU/L. She recently started taking her calcium and iron supplements with her morning levothyroxine. What is the most likely explanation?

1. AThe TSH is low, showing that the dose is now too high
2. BThe result is normal for a person on levothyroxine therapy
3. CThe supplements are reducing levothyroxine absorption
4. DThe supplements are causing an overactive thyroid gland

When a patient returns to the ward from theatre, what should the nurse assess first?

1. AThe discharge date
2. BThe patient's dietary preferences for the next meal
3. CAirway, breathing, circulation and level of consciousness
4. DWhether visitors are waiting to see the patient

A patient taking regular ibuprofen suddenly develops severe upper abdominal pain, a rigid abdomen and becomes tachycardic. What is most likely?

1. AIndigestion that will settle with antacids
2. BA perforated peptic ulcer
3. CIrritable bowel syndrome
4. DConstipation

Why is a raised serum lactate concerning in a patient with shock?

1. AIt means the kidneys are working harder than normal to clear fluid
2. BIt confirms a bacterial infection is present
3. CIt suggests tissues are short of oxygen and using anaerobic metabolism
4. DIt shows only that the patient has eaten a large meal in the past hour

A day after a myocardial infarction, a patient has frequent ventricular ectopic beats on the monitor. Which blood results should be checked first?

1. AAlbumin and bilirubin
2. BFerritin and vitamin B₁₂
3. CPotassium and magnesium
4. DAmylase and lipase

Why is an ACE inhibitor often given to a patient with diabetes and albumin in the urine?

1. AIt stops the kidneys from passing so much urine at night
2. BIt lowers the blood glucose to normal
3. CIt protects the kidneys and reduces albumin loss
4. DIt raises potassium to protect the heart

Which task can the registered nurse delegate to a trained healthcare assistant (nursing assistant)?

1. ATeaching a new patient how to inject insulin
2. BChecking pre-meal glucose and reporting results out of range
3. CAssessing a confused patient whose glucose is 2,6 mmol/L (47 mg/dL)
4. DDeciding the dose of correction insulin from the glucose result

Apa prioritas pertama saat pasien tiba di ruang pemulihan setelah anestesi umum?

1. ASegelas air
2. BBalutan luka dan drain
3. CJalan napas dan pernapasan
4. DRiwayat obat

A nurse teaches a carer about overnight tube feeding at home. Which statement shows a need for further teaching?

1. A"I'll flush the tube with water before and after his medicines."
2. B"I'll check the external length mark on the tube every day."
3. C"I'll stop the feed and call if he coughs or struggles to breathe."
4. D"I'll let him lie flat so he sleeps better while the feed runs."