Prioritas & Delegasi ala NCLEX: paket kilat

Tugas mana yang harus didelegasikan perawat kepada asisten keperawatan untuk pasien dengan kewaspadaan jatuh?

1. AMemutuskan apakah alarm tempat tidur masih diperlukan
2. BMengedukasi keluarga cara mencegah jatuh di rumah
3. CMembantu pasien ke toilet setiap 2 jam sesuai rencana
4. DMengkaji dan mencatat skor risiko jatuh pasien setiap pagi

Tugas mana yang paling tepat dikerjakan sendiri oleh RN dan bukan didelegasikan kepada asisten keperawatan?

1. AMengajak pasien stabil berjalan di koridor pada hari ketiga setelah operasi
2. BMembantu pasien dengan perawatan mulut
3. CMenimbang pasien gagal jantung setiap pagi
4. DMembantu pasien turun dari tempat tidur untuk pertama kali setelah operasi

Why can side rails be dangerous for a confused, restless patient?

1. ASide rails stop staff from reaching the patient in an emergency
2. BThe patient may climb over them or get trapped in gaps
3. CSide rails make the bed move by itself
4. DSide rails always cause pressure injuries

Several patients on a ward develop vomiting and diarrhea within two days, and a norovirus outbreak is suspected. What should the nurse do first?

1. ANotify the infection prevention team and place affected patients on contact precautions
2. BMove the affected patients to different wards so that fewer people are exposed
3. CAsk visitors to bring in bottled water for all patients
4. DWait for all the stool results to come back before taking any action

A patient with chronic kidney disease receives an erythropoiesis-stimulating agent such as epoetin alfa. Which assessments are most important?

1. ASerum glucose and ketones
2. BSerum amylase and lipase
3. CLiver enzymes and bilirubin
4. DHemoglobin and blood pressure

A trauma patient receives many units of blood quickly and then develops muscle twitching and low blood pressure. Which laboratory value is most likely to explain this?

1. AA high serum sodium
2. BA low serum glucose
3. CA high serum magnesium
4. DA low ionized calcium

Why are patients with atrial fibrillation often given anticoagulants?

1. ATo slow the heart rate directly and prevent palpitations
2. BTo lower the blood pressure
3. CTo convert the rhythm back to normal
4. DTo reduce the risk of stroke from clots in the atria

How should pain be assessed in a patient with advanced dementia who cannot describe it?

1. ABy checking the blood pressure only
2. BWith an observational pain tool that scores facial expression, behaviour and body language
3. CBy assuming the patient has no pain unless they are crying out or calling for help
4. DBy asking the patient to rate their pain on a numerical scale from 0 to 10

After a prescribed IV fluid bolus for hypotension, what should the nurse do next?

1. AStop all monitoring if the patient says they feel better
2. BStart a second fluid bolus straight away without checking anything
3. CWait until the next routine observations in four hours
4. DReassess heart rate, blood pressure, urine output and lung sounds

A patient with a valid, documented do-not-attempt-CPR decision (DNACPR in the UK, DNR or DNAR in the US) is found in cardiac arrest. What should the nurse do?

1. ACall the arrest team and let them decide whether to resuscitate
2. BStart CPR but use only chest compressions
3. CStart full CPR because the patient's family is not present
4. DNot start CPR, call for support, and provide dignity and comfort

Which finding most suggests fluid overload in a patient with chronic kidney disease?

1. AA dry mouth and a low blood pressure when standing
2. BA weight loss of 1 kg (2,2 lb) after a hot day
3. CA weight gain of 2 kg (4,4 lb) in two days with ankle swelling
4. DDark yellow urine and thirst

During a TURP, a patient becomes confused and nauseated, with a slow pulse and a raised BP. The sodium is 121 mmol/L. What is most likely?

1. ATURP syndrome from absorbed irrigation fluid
2. BA normal reaction to the spinal anaesthetic
3. CAn allergic reaction to the catheter
4. DHypoglycaemia from fasting for many hours before surgery

Which is a usual benefit of laparoscopic over open abdominal surgery?

1. ANo risk of any complications at all
2. BLess pain and a shorter hospital stay
3. CNo need for a general anaesthetic ever
4. DLarger wounds that heal faster

In recovery, an awake and anxious patient cannot lift their head, and their breaths are shallow and weak. What is the most likely cause?

1. AResidual neuromuscular blockade
2. BNormal tiredness after surgery
3. CA simple panic attack
4. DOpioid overdose with pinpoint pupils