Prioritas & Delegasi ala NCLEX: paket kilat

Seorang pasien bertanya kepada asisten keperawatan tentang efek samping obat baru. Apa yang harus dilakukan asisten?

1. AMencari obat itu secara daring dan membacakan isinya
2. BMenenangkan pasien bahwa efek samping jarang terjadi
3. CMengatakan bahwa perawat akan datang untuk menjawab, dan memberi tahu perawat
4. DMenjelaskan efek samping yang tercantum dalam leaflet pasien untuk obat tersebut

Empat pasien tiba di instalasi gawat darurat bersamaan. Siapa yang harus dilihat lebih dulu?

1. ARemaja dengan luka sayat di lengan yang perdarahannya terkendali
2. BOrang dewasa dengan migrain dan tekanan darah 150/90 mmHg
3. COrang dewasa dengan pergelangan kaki berubah bentuk dan nadi normal di kaki
4. DAnak 2 tahun yang air liurnya menetes, duduk condong ke depan, dan memiliki stridor

Kapan kewaspadaan droplet untuk pasien dengan Neisseria meningitidis biasanya dihentikan?

1. ASetelah demam hilang selama satu jam
2. BSetelah 24 jam pengobatan antibiotik yang efektif
3. CSegera setelah dosis antibiotik pertama diberikan
4. DHanya setelah pasien dipulangkan

A nurse teaches a patient about care of a surgical incision at home. Which statement shows a need for further teaching?

1. A“I will wash my hands with soap before I touch or change the dressing.”
2. B“I will keep the dressing clean and dry as I was shown.”
3. C“If the wound gets red and drains pus, I will wait for my appointment next month.”
4. D“I will call the clinic if I get a fever or more pain around the wound.”

A patient's potassium is 7,0 mEq/L. Which ECG change would the nurse expect?

1. AFlattened T waves
2. BTall, peaked T waves
3. CDelta waves before the QRS
4. DProminent U waves

A patient receiving parenteral nutrition with lipid emulsion has a triglyceride level of 620 mg/dL (7,0 mmol/L). Why is this result important?

1. AIt is a normal fasting value for adults
2. BIt shows the nutrition is fully effective
3. CIt raises the risk of acute pancreatitis
4. DIt means the patient needs more lipid

For a patient in skin traction on the leg, which is correct?

1. AThe weights hang freely and do not rest on the bed or floor
2. BThe rope is tied to the bed frame to keep it still
3. CThe weights are removed whenever the patient feels uncomfortable
4. DThe weights rest on the floor overnight

Pasien mana yang harus dikaji pertama oleh perawat bangsal pada awal sif?

1. APasien dengan nyeri punggung kronis berskor 4/10
2. BPasien dengan kebingungan yang baru muncul dan frekuensi napas 28/menit
3. CPasien yang menunggu pemulangan dengan observasi stabil
4. DPasien yang meminta laksatif

A patient has episodes of severe headache, sweating and palpitations with very high blood pressure. Which rare cause should be considered?

1. AStable angina
2. BPhaeochromocytoma
3. CAortic stenosis
4. DAsthma

The stump of a recent below-knee amputation suddenly bleeds heavily through the dressing. What should the nurse do first?

1. AApply firm direct pressure and call for urgent surgical help
2. BRemove all the dressings and wait for the bleeding to stop by itself
3. CApply a warm compress to the stump
4. DEncourage the patient to walk on crutches to ease the pressure

Komplikasi hemodialisis mana yang menyebabkan sakit kepala, mual, gelisah, dan kadang kejang, terutama pada sesi-sesi pertama?

1. APeritonitis bakteri
2. BHipoglikemia akibat dialisat
3. CSindrom disekuilibrium dialisis
4. DEmboli udara vena melalui selang

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

1. ANo concern, because more drainage always lowers the ICP safely
2. BAn infected drain, so the dressing should be removed
3. COverdrainage of CSF, so act per protocol and inform the team
4. DUnderdrainage, so the drain should be lowered further

In the UK National Early Warning Score (NEWS2), what does an aggregate score of 5 or more usually trigger?

1. ANo change unless the patient complains
2. BAn urgent review by a clinician skilled in acute illness
3. CDischarge planning for the next day
4. DRoutine observations once every 12 hours, with no other change in care

At the end of an operation, the final count shows one swab missing. What should happen?

1. ARecord the count as correct to avoid a delay
2. BLet the patient leave and search the theatre later
3. CClose the wound, as the swab was probably thrown away
4. DTell the surgeon, search, and X-ray if it is not found