Prioritas & Delegasi ala NCLEX: paket kilat

A nurse gives IV morphine for severe pain. When should the nurse reassess the pain and sedation?

1. AAt the end of the shift
2. BOnly when the patient asks for more
3. CWithin about 15–30 minutes
4. DAt the next routine round in four hours

After a head injury, a patient passes large amounts of very dilute urine, is thirsty and has a rising serum sodium. Which condition is most likely?

1. ADiabetic ketoacidosis
2. BDiabetes insipidus
3. CAcute kidney injury with oliguria
4. DSIADH

Tindakan keselamatan pasien mana yang paling tepat untuk pasien dengan alergi lateks?

1. AHanya menggunakan sarung tangan lateks berbedak
2. BMenghindari semua sarung tangan selama perawatan pasien
3. CMenggunakan sarung tangan lateks dan mencuci tangan dengan baik sesudahnya
4. DMenggunakan peralatan bebas lateks dan mendokumentasikan alergi dengan jelas

Over a few hours, the emergency department sees many previously healthy people with the same unusual severe symptoms. What should the nurse do?

1. ATell only the patients’ families about the pattern
2. BSend the patients home quickly to avoid crowding the emergency department
3. CReport it to infection prevention and public health authorities promptly
4. DTreat each patient and wait to see if more arrive next week

When do the blood counts usually reach their lowest point (nadir) after many standard chemotherapy regimens?

1. AOn the same day as treatment
2. BAbout 6 months after treatment
3. CWithin 1–2 hours of treatment
4. DAbout 7–14 days after treatment

Four patients had a thyroidectomy earlier today. Which result should the nurse act on first?

1. AHemoglobin 12,1 g/dL (121 g/L) after surgery
2. BGlucose 145 mg/dL (8,0 mmol/L) after surgery
3. CSodium 136 mEq/L on IV fluids after surgery
4. DCalcium 7,2 mg/dL (1,8 mmol/L) with tingling lips

What is the best way to protect the heels of a bed-bound patient from pressure damage?

1. AApply a tight bandage to the heels
2. BRest the heels on a rolled-up towel
3. CMassage the heels firmly several times a day to help circulation
4. DOffload the heels so they do not touch the mattress

A nurse teaches a patient with heart failure about self-care. Which statement shows a need for further teaching?

1. A"I only need to weigh myself once a month."
2. B"I will weigh myself each morning after passing urine."
3. C"I will report it if I need more pillows to sleep."
4. D"I will take my water tablet in the morning."

Rheumatic heart disease most often follows which infection?

1. AA fungal infection of the lungs
2. BA group A streptococcal throat infection
3. CStaphylococcal infection of the skin
4. DA viral infection of the upper airway

The monitor shows a regular broad-complex tachycardia at 180/min. The patient is alert with BP 126/78 mmHg and no chest pain. What is the most appropriate plan?

1. AReassure the patient, as this is a normal rhythm
2. BStart chest compressions straight away and give a dose of IV adrenaline
3. CRecord a 12-lead ECG, call senior help and anticipate an antiarrhythmic
4. DDeliver an unsynchronised shock immediately, before any other assessment

Which blood gas pattern is typical of acute kidney injury?

1. AHigh pH and low carbon dioxide
2. BHigh pH and high bicarbonate
3. CLow pH and low bicarbonate
4. DLow pH and high carbon dioxide only

A nurse teaches a patient with Hashimoto's thyroiditis about levothyroxine. Which statement shows a need for further teaching?

1. A"I will report palpitations or chest pain."
2. B"I will take the tablets at the same time each day."
3. C"I can stop the tablets once I feel back to normal."
4. D"I will have regular blood tests to check my dose."

Why are accurate fluid balance charts kept after major surgery?

1. ATo record when visitors come and go
2. BTo detect dehydration, fluid overload or kidney problems early
3. CTo check how far the patient has walked and how often they get out of bed
4. DTo decide which meal the patient will have next

A 60 kg adult with 25% TBSA burns arrives 2 hours after the injury, having had no IV fluids. Using the Parkland formula, what hourly rate is needed for the rest of the first 8 hours?

1. A1000 mL/h
2. B250 mL/h
3. C500 mL/h
4. D375 mL/h