Prioritas & Delegasi ala NCLEX: paket kilat

Pada triase START, seorang dewasa yang tidak dapat berjalan bernapas 22 kali per menit, memiliki nadi radialis, dan mengikuti perintah sederhana, tetapi mengalami fraktur tungkai yang jelas. Kategori mana yang diberikan kepada korban?

1. AHijau (ringan)
2. BHitam (ekspektan)
3. CMerah (segera)
4. DKuning (tertunda)

Seorang pasien setelah operasi besar memiliki keluaran urine 15 mL/jam selama dua jam, denyut jantung 115/menit, dan tangan dingin. Apa yang pertama kali dilakukan perawat?

1. AMenganjurkan pasien minum lebih banyak air dan memeriksa lagi nanti
2. BMengkaji tanda-tanda syok, seperti perdarahan, dan melakukan eskalasi
3. CMembilas kateter dan memeriksa keluaran besok pagi
4. DMenunggu dua jam lagi untuk melihat apakah keluaran membaik

A parent calls because a toddler has swallowed some household cleaner. The child is awake and breathing normally. What should the nurse advise first?

1. AMake the child vomit, using a finger at the back of the throat
2. BGive syrup of ipecac from the medicine cabinet
3. CContact the local poison advice service now for specific advice
4. DWait to see whether any symptoms develop over the next day

A nurse teaches parents about using an infant car seat. Which statement shows a need for further teaching?

1. A“We will use the car seat for every trip, even short ones.”
2. B“We will install the seat in the back seat, facing the rear.”
3. C“We will put the rear-facing seat in the front so we can see the baby.”
4. D“We will make sure the harness straps are snug against the baby’s chest.”

A patient is scheduled for a liver biopsy. Which laboratory results should the nurse check before the procedure?

1. AHbA1c and lipid panel
2. BSerum sodium and chloride
3. CTSH and free T₄
4. DPlatelet count and PT/INR

The nurse teaches a patient with iron-deficiency anemia who is starting oral iron. Which statement shows a need for further teaching?

1. A"I can take it with orange juice to help absorption"
2. B"I'll keep the tablets out of reach of the children"
3. C"My stools may look darker while I take the tablets"
4. D"I'll take my iron tablet with a big glass of milk"

Transfusi darah akan dimulai. Apa pemeriksaan keselamatan yang paling penting?

1. AMemeriksa preferensi makanan pasien
2. BIdentifikasi pasien yang positif dan dicocokkan dengan komponen darah di samping tempat tidur
3. CHanya memeriksa berat badan pasien
4. DMenghangatkan semua darah di microwave

During a blood transfusion, an older patient with heart failure becomes breathless with a rising blood pressure, raised JVP and crackles in the lungs. What is the most likely cause?

1. ATransfusion-associated circulatory overload
2. BA febrile non-haemolytic reaction
3. CTransfusion-related acute lung injury with hypotension
4. DAnaphylaxis

A patient with a mechanical heart valve asks to switch from warfarin to apixaban. What is the correct response?

1. AAny anticoagulant works equally well once the valve is in place
2. BMechanical valves do not need anticoagulation after the first month
3. CDirect oral anticoagulants are not used for mechanical valves
4. DAspirin alone can replace warfarin once the valve has healed

A patient with a confirmed type A aortic dissection is hypertensive and tachycardic while awaiting surgery. Which drug class is usually given first to lower the heart rate and blood pressure?

1. AAn intravenous beta-blocker
2. BAn intravenous thrombolytic
3. CAn intravenous fluid bolus
4. DOral aspirin

Seorang pasien stroke memahami apa yang dikatakan tetapi kesulitan menemukan kata dan berbicara dengan frasa pendek yang terbata-bata. Jenis afasia apa ini?

1. ADisartria akibat otot wajah lemah
2. BAfasia ekspresif (Broca)
3. CAfasia global tanpa pemahaman
4. DAfasia reseptif (Wernicke)

A patient with AKI has a low urine sodium and concentrated urine. What does this suggest?

1. AA post-renal blockage, with urine backed up
2. BA pre-renal cause, with kidneys holding salt and water
3. CAcute tubular necrosis, with damaged and leaking tubules
4. DDiabetes insipidus, with too little ADH

Pendekatan transfusi sel darah merah mana pada pasien stabil dengan perdarahan saluran cerna yang sesuai dengan bukti terkini?

1. AAmbang restriktif, sering sekitar 70 g/L, pada sebagian besar pasien stabil
2. BMentransfusi dua unit secara rutin sebelum setiap endoskopi
3. CTidak pernah mentransfusi, berapa pun hemoglobin atau gejalanya
4. DMentransfusi semua orang agar hemoglobin selalu di atas 150 g/L

Seorang pasien ensefalopati hepatik gelisah pada malam hari. Benzodiazepin disarankan untuk tidur. Apa yang harus dilakukan perawat?

1. AMemberikannya dengan dosis dua kali lipat untuk memastikan tidur
2. BMempertanyakannya, karena sedatif dapat memperburuk ensefalopati
3. CMemberikannya, karena hati tidak memengaruhi sedatif
4. DMemberikannya dan menghentikan laktulosa untuk menghindari diare