Prioritas & Delegasi ala NCLEX: paket kilat

Seorang perawat terdaftar berkata kepada asisten keperawatan, "Periksa pasien di kamar 12." Hak (right) pendelegasian mana yang tidak terpenuhi?

1. ATugas yang benar untuk situasi tersebut
2. BArahan dan komunikasi yang benar
3. COrang yang benar untuk tugas tersebut
4. DKeadaan yang benar

A patient in acute mania paces constantly, has lost weight and will not sit down to eat. Which intervention is most helpful?

1. AWait until the mania settles before worrying about nutrition
2. BInsist that the patient sits at the table until the meal is finished
3. COffer high-calorie finger foods and drinks the patient can take while moving
4. DLeave meals in the room and let the patient eat whenever and whatever they choose

How are neuromuscular blocking drugs, such as vecuronium, safely stored?

1. ASeparate from other drugs, with a warning that they cause paralysis
2. BMixed in the same bin as other high-use drugs
3. CNext to common IV antibiotics so they are easy to find
4. DIn the general stock cupboard with the other IV drugs and no special labels

A flexible bronchoscope contacts mucous membranes but does not enter sterile tissue. Which level of processing is required at a minimum between patients?

1. ACleaning with soap and water only
2. BWiping with an alcohol wipe
3. CHigh-level disinfection
4. DLow-level disinfection

A patient has a calcium of 11,8 mg/dL (2,95 mmol/L) from bone metastases. Which nursing measure is appropriate?

1. AEncourage fluids and mobility as tolerated
2. BGive calcium carbonate antacids for nausea
3. CEncourage bed rest and limit oral fluids
4. DOffer extra milk and cheese at each meal

A patient with blood pressure that is hard to control has a potassium of 2,9 mEq/L, a sodium of 144 mEq/L and a raised serum bicarbonate, without taking a diuretic. Which condition is most likely?

1. APrimary adrenal insufficiency
2. BSyndrome of inappropriate ADH
3. CCentral diabetes insipidus
4. DPrimary hyperaldosteronism

A patient with sickle cell disease is admitted with a painful crisis. What is a key early nursing priority?

1. ARestricting oral fluids
2. BApplying cold packs to the painful areas
3. CGiving prompt, effective analgesia
4. DDelaying pain relief until a diagnosis is confirmed

A nurse teaches a patient with asthma about a new inhaled steroid "preventer". Which statement shows a need for further teaching?

1. A"I will rinse my mouth after using it."
2. B"I will only use it when I'm wheezy."
3. C"I'll keep my reliever inhaler with me."
4. D"I will use it every day even when I feel well."

Seorang pasien penyakit arteri perifer mengalami nyeri tungkai pada malam hari. Posisi mana yang dapat meredakannya?

1. AMembungkus tungkai dengan perban kompresi
2. BMengangkat tungkai di atas bantal di atas level jantung
3. CMenggantungkan tungkai ke bawah di tepi tempat tidur
4. DMenempelkan botol air panas langsung pada kaki

Seorang berusia 82 tahun dengan pneumonia komunitas baru mengalami kebingungan, dengan RR 32/menit, TD 88/52 mmHg, dan urea 9 mmol/L. Apa yang ditunjukkan hal ini?

1. ASkor CURB-65 sebesar 5: risiko tinggi yang membutuhkan tinjauan senior segera
2. BSkor CURB-65 sebesar 3: hanya rawat inap rutin di bangsal umum
3. CSkor CURB-65 sebesar 1: cocok untuk antibiotik oral di rumah
4. DRespons normal terhadap infeksi pada lansia

A patient has Cushing's syndrome. Which nursing assessment is especially important?

1. AMonitoring for a high potassium
2. BChecking for low blood pressure
3. CRegular blood glucose checks
4. DWatching for weight loss

A patient in thyroid storm has a temperature of 40 °C (104 °F). Which measure for the fever is usually avoided?

1. AParacetamol (acetaminophen)
2. BAspirin
3. CFanning with cool air
4. DCooling blankets

Which statement about moist wound healing is correct?

1. AA moist, not wet, wound bed helps cells move and heal faster
2. BA wet wound bed always prevents infection
3. CWounds should be soaked in water for hours every day
4. DWounds heal fastest when left to dry out and form a scab

A patient with bone metastases is starting regular zoledronic acid. Which advice is important?

1. AHave a dental check and report jaw pain or loose teeth
2. BAvoid all physical activity for six months
3. CStop drinking all fluids on the day of each infusion
4. DTake extra calcium only on the day of infusion