Prioritas & Delegasi ala NCLEX: paket kilat

An older patient with dementia is restless at night and keeps trying to get out of bed. Which measure should the nurse try first?

1. ACheck for pain, thirst or a full bladder, and offer toileting
2. BGive a sedative from the as-needed list without first assessing the patient
3. CRaise all four bed rails so the patient cannot climb out
4. DApply wrist restraints for the rest of the night

A patient is admitted with suspected meningococcal meningitis. Which precautions are needed until treatment has been given for long enough?

1. ADroplet precautions
2. BContact precautions only
3. CStandard precautions only
4. DAirborne precautions

During routine handwashing with soap and water (medical asepsis), how are the hands held?

1. AHigher than the elbows, so water runs down the arms
2. BLower than the elbows, so water runs off the fingertips
3. CLevel with the shoulders, away from the sink
4. DTouching the inside of the sink for support

The laboratory reports that a blood sample labeled with one patient’s name has a blood group different from that patient’s previous result. What is the most likely problem and response?

1. AA laboratory machine fault, so no action is needed
2. BA normal change in the patient’s blood group over the years since the last test
3. CThe previous result was wrong, so it is deleted
4. DA wrong-patient sample, so the test is repeated and the event reported

Why must a blue-top (citrate) coagulation tube be filled to the correct level?

1. AAn overfull tube is needed to measure the potassium level
2. BUnderfilled tubes always give a falsely low hemoglobin and hematocrit
3. CThe laboratory charges extra when a tube is not filled correctly
4. DThe blood-to-anticoagulant ratio must be right for accurate clotting times

A patient admitted with heavy alcohol use and malnutrition has a glucose of 52 mg/dL (2,9 mmol/L) and low magnesium. Which prescribed treatment should be given before the IV glucose?

1. AOral iron
2. BIV potassium
3. CIV insulin
4. DIV thiamine

How does ulcerative colitis differ from Crohn's disease?

1. AUlcerative colitis affects only the colon, continuously from the rectum
2. BUlcerative colitis can affect any part of the gut from mouth to anus
3. CUlcerative colitis typically causes patchy "skip" lesions
4. DUlcerative colitis always affects the full thickness of the bowel wall

A patient with diabetes is found confused with slurred speech and weakness on one side. What should the nurse check first?

1. ASerum cholesterol
2. BUrine output for the last day
3. CBody mass index
4. DCapillary blood glucose

A patient with COPD is prescribed long-term oxygen therapy. How many hours a day is it usually needed to improve survival?

1. AOnly when walking outside
2. BOnly during meals
3. CAt least 15 hours a day
4. DAbout one hour each morning

Tiga minggu setelah infark miokard, seorang pasien mengalami demam, nyeri dada pleuritik yang mereda saat condong ke depan, dan gesekan perikardium. Kondisi mana yang paling mungkin?

1. AGagal ventrikel kiri akut
2. BDiseksi aorta akut
3. CSTEMI baru pada arteri lain
4. DSindrom pasca-infark miokard (Dressler)

Pasien yang menggunakan fenitoin jangka panjang harus diedukasi tentang efek samping mana?

1. AGangguan pendengaran bertahap dan permanen
2. BPenurunan berat badan dan tidak tahan panas
3. CRambut rontok di kulit kepala pada hampir semua pasien
4. DPertumbuhan berlebih gusi, sehingga kebersihan mulut yang baik penting

A man who takes tamsulosin for BPH is listed for cataract surgery. Which statement is correct?

1. ATamsulosin has no effects outside the urinary tract, so nothing changes
2. BThe dose should be doubled before surgery to prevent urinary retention
3. CIt should be swapped for oxybutynin the night before to protect the eye
4. DThe eye surgeon must be told, as it can cause floppy iris during surgery

A patient with a new colostomy asks what to eat at home. Which advice is most appropriate?

1. AEat only liquids until the stoma is removed
2. BEat a normal, balanced diet and introduce foods gradually
3. CAvoid all fruit and vegetables for the rest of their life
4. DDrink as little fluid as possible to reduce output

During bowel preparation, an older patient becomes dizzy and confused. Blood tests show sodium 127 mmol/L. What should the nurse do?

1. AStop the preparation and escalate to the medical team
2. BEncourage plain water only, as much as possible
3. CGive the rest of the preparation more quickly
4. DRecord it and continue as planned, as this is expected