Prioritas & Delegasi ala NCLEX: paket kilat

Which newborn finding needs prompt reporting?

1. AJaundice that appears within the first 24 hours
2. BMild jaundice that first appears on the third day
3. CBluish hands and feet in the first hours
4. DMilia (small white spots) on the nose

A nurse must care for a patient with a radioactive implant. Which approach best limits the nurse’s exposure?

1. ALimit time in the room, keep as far away as possible and use shielding
2. BStand close to the patient to finish care faster
3. CSpend longer in the room each time but visit less often during the shift
4. DWear a surgical mask to block the radiation

Seorang pasien yang menggunakan diuretik berisiko jatuh tinggi dan sering bangun pada malam hari. Tindakan mana yang paling membantu?

1. AJadwal ke toilet, dengan bel panggil dan alat bantu jalan dalam jangkauan
2. BMenjaga ruangan benar-benar gelap pada malam hari agar pasien tidur
3. CMenyuruh pasien tidak minum apa pun setelah makan siang
4. DMemberikan diuretik saat menjelang tidur agar bekerja semalaman

A patient’s white cell differential shows a raised eosinophil count. Which cause is most consistent with this finding?

1. AAn acute bacterial infection
2. BAn allergic reaction or a parasitic infection
3. CBone marrow suppression from chemotherapy
4. DA viral infection such as a cold

Mengapa pasien gagal hati dapat memiliki INR yang meningkat tanpa mengonsumsi warfarin?

1. ABilirubin langsung merusak faktor pembekuan
2. BHati membuat sebagian besar faktor pembekuan, sehingga produksinya menurun
3. CGinjal berhenti membersihkan faktor pembekuan dari darah
4. DAlbumin adalah faktor pembekuan, dan kadarnya menurun

A patient has painless jaundice, itching, dark urine and pale stools. ALP is markedly raised, conjugated (direct) bilirubin is high and ALT is only mildly raised. What is the most likely cause?

1. AAcute viral hepatitis with widespread liver cell damage
2. BGilbert syndrome, a harmless inherited bilirubin disorder
3. CIncreased breakdown of red blood cells (hemolytic anemia)
4. DBlockage of bile flow, for example by a tumor in the bile duct

Modern wound care generally aims to keep a healing wound bed:

1. ACompletely dry and open to the air
2. BMoist but not wet
3. CSoaked in antiseptic solution every day
4. DTightly packed with dry gauze

Seorang pasien yang menerima vankomisin IV mengalami kemerahan (flushing) dan ruam merah gatal di wajah dan leher selama infus cepat. Apa penyebab dan respons yang paling mungkin?

1. ARespons normal; tingkatkan laju infus
2. BReaksi terkait infus; hentikan atau perlambat infus dan beri tahu penulis resep
3. CTerbakar sinar matahari; oleskan krim dan lanjutkan
4. DGagal hati; hentikan semua obat secara permanen

After varicose vein surgery, which advice is usually given?

1. AStay in bed for two weeks with the legs hanging down
2. BWear the compression stockings as advised and walk regularly
3. CAvoid all walking until the bruising has gone
4. DStand still for long periods to help the veins heal

As the defibrillator charges, a nurse sees a colleague still holding the patient's bed rail. What should the nurse do?

1. ACall clearly for everyone to stand clear and check before the shock
2. BTurn off the defibrillator and start a new cycle of CPR
3. CDeliver the shock now, as the bed rail is not part of the patient
4. DAsk the colleague to hold the patient's hand instead

In the first trimester of pregnancy, why is propylthiouracil often preferred to carbimazole for hyperthyroidism?

1. APropylthiouracil works faster than any other drug
2. BCarbimazole has a higher risk of birth defects early on
3. CPropylthiouracil has no side effects at all
4. DCarbimazole cannot cross into the mother's blood

A nurse teaches a carer to give buccal midazolam for prolonged seizures. Which statement shows a need for further teaching?

1. A"I will give it into the space between his gum and cheek."
2. B"I will call an ambulance if the care plan tells me to."
3. C"I will write down the time the seizure started and the time I gave the dose."
4. D"I will put something between his teeth so he does not bite his tongue."

Tanda mana yang menunjukkan pankreatitis akut berat dengan perdarahan ke dalam jaringan?

1. ARuam ungu di telapak tangan dan kaki
2. BMemar di sekitar umbilikus atau pinggang
3. CPembengkakan bibir, lidah, dan wajah
4. DPerubahan warna kuning pada kuku jari

An hour after a line flush, a patient receiving parenteral nutrition has rigors and a temperature of 39,1 °C. What should the nurse suspect and do?

1. AA normal reaction; give paracetamol and continue the infusion
2. BFluid overload; reduce the infusion rate only
3. CLine infection; escalate and take blood cultures
4. DLow blood glucose; give a sugary drink