Prioritas & Delegasi ala NCLEX: paket kilat

An older patient becomes confused over a few hours, with attention that comes and goes. What does this suggest?

1. ALong-standing dementia that is expected
2. BA personality change that is permanent and expected
3. CNormal aging that needs no action
4. DDelirium, which needs the cause found quickly

A child with sickle cell disease in a pain crisis develops chest pain, fever and an SpO₂ of 89%. What does this most likely mean?

1. AAcute chest syndrome, which needs urgent escalation and oxygen
2. BAnxiety that will settle with reassurance
3. CAn ordinary pain crisis that will improve with rest
4. DA minor chest infection that can safely wait until the morning round

A patient has severe neutropenia after chemotherapy. Which route for measuring temperature should be avoided?

1. ATemporal artery
2. BOral
3. CTympanic
4. DRectal

An 80-year-old patient took a sleeping tablet an hour ago and now wants to go to the bathroom. What should the nurse do?

1. AWalk with the patient to the bathroom and stay close by
2. BTell the patient to wait until the morning
3. CRaise all four side rails so the patient stays in bed
4. DTell the patient to go alone and use the call light if needed

A patient has macrocytic anemia with numbness and tingling of the feet and poor balance. Which deficiency is most likely?

1. AVitamin B₁₂
2. BIron (low ferritin)
3. CFolate (folic acid)
4. DVitamin C (ascorbic acid)

A patient without diabetes in the ICU with sepsis has a glucose of 260 mg/dL (14,4 mmol/L) and an HbA1c of 5,2%. What is the best interpretation?

1. AStress hyperglycemia from acute illness
2. BLong-standing undiagnosed type 2 diabetes
3. CA meter error, because HbA1c is normal
4. DType 1 diabetes from autoimmune damage

Why is blood pressure monitored closely in a patient with an epidural infusion?

1. ABlood pressure readings show whether the catheter is infected
2. BEpidurals always cause severe hypertension that needs regular treatment
3. CThe epidural pump uses the blood pressure to set the rate
4. DThe local anaesthetic can block sympathetic nerves and cause hypotension

Seorang pasien asma berat menjadi tenang, dengan "silent chest", kelelahan, dan frekuensi napas yang menurun. Apa yang ditunjukkan hal ini?

1. AHanya kecemasan
2. BPerbaikan serangan ketika bronkospasme mereda dan saluran napas melebar
3. CAsma yang mengancam jiwa dengan henti napas yang segera terjadi
4. DPemulihan normal setelah nebulizer

A peripheral cannula site is red, warm, tender and swollen along the vein. What should the nurse do?

1. ACover the site and keep using it until it blocks
2. BFlush the cannula hard to clear it
3. CRemove the cannula, document and monitor the site
4. DLeave it in place, as this is normal after 24 hours

Seorang pasien yang mengonsumsi warfarin untuk fibrilasi atrium memiliki INR 8,5 tetapi tidak ada perdarahan. Penanganan apa yang paling mungkin?

1. AMemberikan protamin sulfat IV segera untuk membalikkannya
2. BMenahan warfarin, memberi tahu pemberi resep, dan segera memeriksa ulang INR
3. CMemberikan konsentrat kompleks protrombin dan transfusi darah
4. DMelanjutkan dosis biasa dan memeriksa INR lagi sebulan kemudian

A patient with Conn's syndrome starts spironolactone. Which blood test should the nurse watch most closely?

1. APotassium
2. BGlucose
3. CCalcium
4. DAmylase

Seorang pasien dengan pemberian makan enteral kontinu semalaman menerima insulin yang disesuaikan dengan makanan. Pukul 02:00 selang tersumbat dan pemberian makan berhenti. Apa risiko utamanya, dan apa yang harus dilakukan perawat?

1. AHipoglikemia; periksa glukosa sering dan ikuti rencana untuk penutup glukosa
2. BKetoasidosis; hentikan semua insulin sampai pagi
3. CHiperglikemia; berikan dosis insulin tambahan segera
4. DTidak ada risiko; insulin akan tersimpan sampai pemberian makan dimulai lagi

Why is the "whoosh" test no longer used to check nasogastric tube position?

1. AThe test is far too painful for most patients to tolerate
2. BThe air always makes the tube block
3. CIt needs an X-ray machine at the bedside
4. DAir can be heard even when the tube is in the lung

A sacral wound has heavy exudate, and the surrounding skin is white, soft and wrinkled. What should the nurse do?

1. AUse a dressing that adds even more moisture
2. BApply a tight plastic film directly over the wound
3. CProtect the skin edges and use a more absorbent dressing
4. DLeave the same dressing in place for a week so the wound is not disturbed