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. ATugas yang benar
2. BArahan dan komunikasi yang benar
3. COrang yang benar
4. DPengawasan dan evaluasi yang benar

Pada triase START, seorang dewasa yang tidak dapat berjalan bernapas 28 kali per menit, tidak memiliki nadi radialis, dan pengisian kapiler 4 detik. Kategori mana yang diberikan kepada korban?

1. AHijau (ringan)
2. BHitam (ekspektan)
3. CMerah (segera)
4. DKuning (tertunda), karena frekuensi napas di bawah 30/menit

Mengapa pena insulin tidak boleh digunakan untuk lebih dari satu pasien, meskipun dengan jarum baru?

1. AInsulin dalam pena akan kedaluwarsa lebih cepat bila digunakan bersama
2. BDarah dapat mengalir balik ke kartrid dan menyebarkan infeksi
3. CPenggunaan bersama pena mengubah dosis yang diberikan
4. DSetiap pena hanya berisi satu dosis insulin

A patient with suspected sepsis has orders for blood cultures and an IV antibiotic. What is the correct order of actions?

1. AGive the antibiotic and take the cultures an hour later
2. BDraw the blood cultures first, then give the antibiotic without delay
3. CGive the antibiotic first so that treatment starts, and take the cultures the next day
4. DWait for the culture results before starting the antibiotic

Seorang pasien dengan nyeri dada yang dimulai satu jam lalu memiliki troponin pertama yang normal. Interpretasi mana yang benar?

1. APasien dapat langsung dipulangkan
2. BInfark belum disingkirkan; troponin diulang sesuai protokol
3. CInfark sudah disingkirkan, sehingga tidak perlu pemeriksaan troponin lagi
4. DTroponin tidak berguna pada pasien dengan nyeri dada

A patient on high-dose dexamethasone has a white cell count of 15 × 10³/µL, mostly mature neutrophils with no bands. They have no fever and no signs of infection. What is the most likely explanation?

1. AA steroid effect that moves neutrophils into the circulating blood
2. BA laboratory error, because steroids always lower the white count
3. CCertain sepsis that needs antibiotics started without delay
4. DA new leukemia that is confirmed by this result alone

A patient with COPD and known carbon dioxide retention needs a nebulised bronchodilator. How should it usually be given?

1. ADriven by compressed air, with oxygen given separately if needed
2. BWithout monitoring oxygen saturation
3. CDriven by high-flow oxygen at 15 L/min for as long as possible
4. DOnly with the patient lying flat

A patient with suspected appendicitis says the pain suddenly eased, but an hour later has pain all over the abdomen, a rigid abdomen and a fever. What is most likely?

1. AThe analgesia has started working
2. BThe appendix has perforated, causing peritonitis
3. CThe patient has developed gastroenteritis
4. DThe appendicitis has resolved without treatment

A patient has pneumonia in the right lung only. In which side-lying position will oxygenation usually be best?

1. ALying on the right side, with the affected lung down
2. BFlat on the back with no pillows
3. CProne with the head down
4. DLying on the left side, with the healthy lung down

A patient with end-stage COPD has severe breathlessness at rest despite optimal treatment and wants comfort-focused care. Which measure is recognised to help?

1. AEncouraging long walks to build fitness
2. BA low-dose opioid with a hand-held fan and calm positioning
3. CStopping all medicines, including inhalers
4. DHigh-flow oxygen at 15 L/min whatever the oxygen saturation is

A patient with Graves' eye disease has gritty eyes and swelling around them in the morning. Which advice is most appropriate?

1. AUse lubricating drops and sleep with the head raised
2. BRub the eyes firmly each morning to reduce the swelling
3. CStay in bright sunlight to dry the eyes
4. DSmoking more will not affect the eyes

Seorang lansia dengan diabetes tipe 2 memiliki glukosa 48 mmol/L, osmolalitas 365 mOsm/kg, tanpa keton bermakna, dan kebingungan. Apa prioritas pertama?

1. ABolus insulin IV besar untuk menormalkan glukosa dalam satu jam
2. BPembatasan cairan ketat untuk menghindari edema serebral
3. CCairan IV yang hati-hati dengan pemeriksaan ketat osmolalitas, natrium, dan glukosa
4. DGlukosa oral untuk mencegah hipoglikemia selama pengobatan

Which early symptoms suggest local anaesthetic systemic toxicity?

1. AMild itching of the feet the next day
2. BIncreased hunger and thirst over several hours, with a dry mouth
3. CA red rash only at the injection site, with no other symptoms
4. DTingling around the mouth, a metallic taste and tinnitus

A nurse teaches a patient going home between chemotherapy cycles. Which statement shows a need for further teaching?

1. A"I'll check my temperature whenever I feel hot, shivery or unwell."
2. B"I'll keep the emergency number and call if I feel shivery."
3. C"I'll wash my hands often and avoid people with infections."
4. D"If I get a fever, I'll take paracetamol and see if it settles."