Prioritas & Delegasi ala NCLEX: paket kilat

A patient has a nasogastric tube on suction. Which task can the nurse delegate to a nursing assistant?

1. AGiving mouth care
2. BChecking the tube’s position
3. CIrrigating the tube when it blocks
4. DAssessing the drainage for blood

Seorang pasien yang diselamatkan dari kebakaran rumah mengalami luka bakar pada wajah, rambut hidung hangus, dan suara serak. Apa prioritasnya?

1. AMembersihkan dan membalut luka bakar wajah
2. BMemberikan pereda nyeri
3. CMelindungi jalan napas, bersiap untuk bantuan jalan napas dini
4. DMemulai resusitasi cairan IV yang dihitung dari luas luka bakar

A nurse has just given an intramuscular injection with a safety needle. What should the nurse do next with the needle?

1. ALay it on the medication tray and discard it later
2. BActivate the safety device and drop it into a sharps container at once
3. CBend the needle to make it unusable, then discard it
4. DRecap it carefully with both hands and dispose of it after the drug round

A nurse teaches a patient going home with an MRSA wound infection. Which statement shows a need for further teaching?

1. A“I can share towels with my family if I wash them every week.”
2. B“I will keep the wound covered with a clean, dry dressing.”
3. C“I will put used dressings in a sealed bag before throwing them out.”
4. D“I will wash my hands after touching my dressing.”

A patient on peritoneal dialysis notices that the drained fluid is cloudy and has abdominal pain. What should the nurse do?

1. AStop dialysis for a week and recheck the fluid later
2. BRecord it as normal and continue the usual exchanges
3. CSend the fluid for cell count and culture and report it
4. DAdd more glucose to the next bag to clear the fluid

A patient with thalassemia major has received regular red cell transfusions for years. The ferritin is now very high. What does this most likely show, and what treatment is used?

1. AIron deficiency, treated with IV iron supplements
2. BAcute infection, treated with broad-spectrum antibiotics
3. CIron overload, treated with iron chelation therapy
4. DLiver failure, treated with a liver transplant at once

An older adult has left lower abdominal pain, fever and a raised CRP. Which condition is most likely?

1. AGastric ulcer
2. BBiliary colic
3. CAppendicitis
4. DDiverticulitis

A drowsy patient in recovery is making snoring sounds and the SpO₂ is falling. What is the first action?

1. AOpen the airway with a head tilt–chin lift or jaw thrust
2. BGive sips of oral fluid to clear the throat and wake them
3. CWait for the patient to wake up fully
4. DLie the patient face down

Seorang pasien dengan nyeri dada meminta gliseril trinitrat. Informasi mana yang berarti perawat harus menahannya dan menghubungi pemberi resep?

1. APasien mengonsumsi statin setiap hari
2. BTekanan darah pasien 150/90 mmHg
3. CPasien mengonsumsi sildenafil hari ini
4. DPasien sakit kepala minggu lalu

A patient on an unfractionated heparin infusion has a nosebleed that will not stop, and the aPTT is far above the target range. What is the most appropriate action?

1. AContinue the infusion at the same rate and pack the nose firmly
2. BIncrease the infusion, as the aPTT will settle
3. CGive vitamin K and continue the infusion at a slightly lower rate
4. DStop the infusion, inform the prescriber and anticipate protamine

Komplikasi hemodialisis mana yang menyebabkan sakit kepala, mual, gelisah, dan kadang kejang, terutama pada sesi-sesi pertama?

1. AHipoglikemia akibat dialisat
2. BSindrom disekuilibrium dialisis
3. CEmboli udara vena melalui selang
4. DPeritonitis bakteri

Near the end of a haemodialysis session, a patient has painful leg cramps and a falling blood pressure. What is the most likely cause?

1. AThe dialysate is too cold
2. BFluid is being removed too quickly
3. CAn allergic reaction to the needles
4. DNot enough fluid is being removed

Suplemen herbal mana yang umum ditanyakan sebelum operasi karena dapat meningkatkan perdarahan?

1. AMinyak peppermint
2. BChamomile
3. CCranberry
4. DGinkgo biloba

Empat pasien berada di bangsal bedah. Pasien mana yang harus dikaji pertama oleh perawat?

1. AEmpat jam setelah operasi usus: nadi 118/menit, TD 90/55 mmHg
2. BIleostomi stabil: meminta bantuan mengganti kantong
3. CHari ke-3 setelah operasi: meminta pencahar untuk konstipasi
4. DNeutropenik: suhu normal satu jam lalu, merasa baik