Prioritas & Delegasi ala NCLEX: paket kilat

During labor, the nurse sees the umbilical cord in the vagina after the membranes rupture. What is the first action?

1. ARelieve pressure on the cord by lifting the presenting part with a gloved hand
2. BPush the cord back into the uterus
3. CWait for the next contraction before acting
4. DAsk the patient to walk around the room to bring the baby lower and speed up labor

Pada triase START, seorang dewasa yang tidak dapat berjalan bernapas 24 kali per menit, memiliki nadi radialis, tetapi tidak dapat mengikuti perintah sederhana. Kategori mana yang diberikan kepada korban?

1. AKuning (tertunda)
2. BMerah (segera)
3. CHitam (ekspektan)
4. DHijau (ringan)

Which IV fluid can be given with packed red blood cells in the same line?

1. A5% dextrose in water
2. B0,9% sodium chloride
3. CLactated Ringer’s (Hartmann’s) solution
4. D5% dextrose in 0,45% sodium chloride

Pasangan organisme dengan kewaspadaan berbasis transmisinya mana yang benar?

1. AC. difficile – udara
2. BCampak – hanya kontak
3. CInfluenza – hanya udara
4. DGondongan – droplet

Kapan pasien penyakit ginjal kronis harus mengonsumsi pengikat fosfat seperti kalsium asetat atau sevelamer?

1. AHanya ketika pasien merasa tidak enak badan
2. BHanya sekali seminggu
3. CMenjelang tidur dengan perut kosong
4. DBersama makan

Hasil pasien mana yang harus dilaporkan perawat lebih dulu?

1. AGlukosa 42 mg/dL (2,3 mmol/L) pada pasien yang berkeringat dan bingung
2. BKreatinin 1,6 mg/dL (141 µmol/L) pada pasien PGK stabil yang sudah diketahui
3. CKolesterol total sedikit di atas target
4. DHbA1c 7,4% (57 mmol/mol) pada pasien diabetes tipe 2

When should discharge planning usually begin?

1. AOn the morning of discharge
2. BOnly after the patient asks to go home
3. CAfter the patient has been home for a week
4. DOn or soon after admission

A patient with small cell lung cancer has hyponatraemia, concentrated urine and no signs of dehydration. Which condition and first measure fit best?

1. ASIADH, often managed first with fluid restriction
2. BDiabetes insipidus, managed with extra fluids
3. CDehydration, managed with an IV fluid bolus
4. DCushing's syndrome, managed with potassium

Why are beta-blockers often started after a myocardial infarction?

1. AThey raise the heart rate to improve blood flow to the muscle
2. BThey reduce cholesterol in the blood
3. CThey dissolve the clot that is blocking the coronary artery
4. DThey lower the heart's oxygen demand and reduce arrhythmias

Seorang perawat merencanakan perawatan untuk empat pasien. Pasien mana yang harus dikaji pertama kali?

1. APasien gagal jantung stabil yang menunggu penimbangan harian
2. BPasien PPOK yang SpO₂-nya turun dari 90% menjadi 83% dengan rasa kantuk baru
3. CPasien ulkus vena yang waktunya ganti balutan
4. DPasien hipertensi terkontrol yang bertanya tentang garam

When a patient sticks out their tongue, it points to the right. Which nerve is affected?

1. AThe left trigeminal nerve (V)
2. BThe right hypoglossal nerve (XII)
3. CThe left hypoglossal nerve (XII)
4. DThe right facial nerve (VII)

Seorang pasien dengan dugaan stroke tiba dua jam setelah onset. Glukosa kapiler 2,4 mmol/L (43 mg/dL). Apa yang harus dilakukan selanjutnya?

1. AMemberikan trombolisis segera tanpa pemeriksaan lebih lanjut
2. BMengabaikan glukosa, karena tidak relevan untuk penilaian stroke
3. CMengobati glukosa rendah dan menilai ulang tanda neurologis
4. DMemberikan insulin IV untuk melindungi sel otak

When breaking bad news, what is the first step in frameworks such as SPIKES?

1. AGive the diagnosis as quickly as possible in the corridor
2. BAsk the family to decide what the patient should be told
3. CGive all treatment options before checking understanding
4. DSet up a private setting with enough time

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

1. ARecord it and continue as planned, as this is expected
2. BGive the rest of the preparation more quickly
3. CStop the preparation and escalate to the medical team
4. DEncourage plain water only, as much as possible