Prioritas & Delegasi ala NCLEX: paket kilat

A nurse teaches a patient about storing insulin at home. Which statement shows a need for further teaching?

1. A“I will keep unopened insulin in the fridge.”
2. B“I will check the expiry date on the label before I use the vial.”
3. C“I will not leave my insulin in a hot car.”
4. D“I will keep my spare insulin in the freezer so it lasts longer.”

A victim heavily contaminated with an industrial chemical arrives at the emergency department with stable vital signs. What should happen first?

1. ADecontamination before the victim enters the treatment area
2. BPlacing the victim in the waiting room until a doctor is free
3. CFull assessment inside the main department straight away
4. DTaking the victim straight to the X-ray department

Which patient has the highest risk of a burn from a heating pad?

1. AA patient with diabetic peripheral neuropathy
2. BA patient recovering from a cold
3. CA patient with a sprained wrist who is fully alert
4. DA healthy young adult with a strained muscle

A nurse cannot find a confused patient who was in their room 15 minutes ago. What should the nurse do first?

1. AWait an hour in case the patient comes back
2. BDocument the absence at the end of the shift
3. CAlert staff and security at once, following the missing-patient procedure
4. DCall the family to ask whether the patient has gone home on their own

How should a patient collect a clean-catch midstream urine sample?

1. AClean the area, start voiding into the toilet, then catch the middle part
2. BFill the cup completely, then add tap water if there is not enough
3. CCollect the very first urine of the stream directly in the sterile cup
4. DCollect urine from the toilet bowl after voiding into the toilet

Kalsium total pasien adalah 7,9 mg/dL (2,0 mmol/L), dengan albumin 2,4 g/dL (24 g/L) dan tanpa gejala. Tes mana yang paling baik untuk memperjelas apakah hipokalsemia sejati ada?

1. AKalsium terionisasi
2. BNatrium serum
3. CBerat jenis urine
4. DHbA1c

Why is continuous bladder irrigation used after a transurethral resection of the prostate (TURP)?

1. ATo stretch the bladder back to its normal size
2. BTo measure the patient's kidney function
3. CTo give antibiotics directly into the kidneys
4. DTo stop blood clots from blocking the catheter

Seorang pasien yang menerima makanan enteral melalui selang setelah lama kelaparan mengalami fosfat rendah, kalium rendah, dan aritmia. Apa yang paling mungkin?

1. AHipertiroidisme
2. BSindrom refeeding
3. CKetoasidosis diabetik
4. DSindrom dumping

A patient with stable angina is afraid nicotine patches will harm their heart. Which reply is most accurate?

1. ANicotine replacement only works if smoking continues
2. BPeople with angina must stop smoking without any help
3. CNicotine patches are much more harmful to the heart than cigarettes
4. DNicotine replacement is much safer than smoking and is recommended

A ventilated patient is coughing, and the high-pressure alarm sounds. Coarse sounds are heard over the trachea. What should the nurse do first?

1. AAssess the patient and suction if secretions are present
2. BDeflate the endotracheal tube cuff fully
3. CIncrease the tidal volume on the ventilator to overcome it
4. DTurn the alarm off and reassess the patient in an hour

Pada pasien dengan cedera medula spinalis akut di C6, gambaran mana yang menunjukkan syok neurogenik?

1. ATekanan darah normal, nadi cepat, dan demam tinggi
2. BTekanan darah rendah, nadi lambat, dan kulit hangat dan kering
3. CTekanan darah tinggi, nadi lambat, dan sakit kepala berdenyut
4. DTekanan darah rendah, nadi cepat, dan kulit dingin dan lembap

A patient on levothyroxine has palpitations, weight loss and poor sleep. TSH is suppressed, and free T4 is high. What is the most likely explanation?

1. AThe dose is too high
2. BThe thyroid has stopped working
3. CA normal response to the drug
4. DThe dose is too low

Which finding suggests a deep tissue pressure injury?

1. AA small scratch on the skin with a little fresh red blood
2. BDry, flaky skin on both shins
3. CIntact skin that is purple or maroon over a bony area
4. DPale pink skin that blanches quickly when pressed

While a central line is disconnected, a patient suddenly becomes breathless with chest pain and hypotension. Air embolism is suspected. What should the nurse do first?

1. AClamp the line, lie the patient left side down, head low; give oxygen
2. BGive the patient a drink and observe for an hour
3. CRemove the central line straight away and leave the site open to the air
4. DSit the patient fully upright and flush the line