Prioritas & Delegasi ala NCLEX: paket kilat

A patient has a blood pressure of 210/120 mmHg. Which finding would make this a hypertensive emergency?

1. AA history of high blood pressure for ten years
2. BNew chest pain or confusion suggesting organ damage
3. CMild anxiety about the high reading on the monitor
4. DForgetting to take the blood pressure tablet this morning

Pasien mana yang memerlukan perhatian perawat lebih dulu?

1. APasien yang mengatakan ini "sakit kepala terburuk dalam hidup saya" yang dimulai mendadak, dengan tekanan darah 170/100 mmHg
2. BPasien hipertensi lama dengan tekanan darah 158/94 mmHg dan tanpa gejala
3. CPasien migrain yang diketahui dengan sakit kepala seperti biasanya
4. DPasien nyeri punggung kronis yang meminta kompres hangat

A confused patient keeps pulling at an IV line. Which is a less restrictive option to consider before wrist restraints?

1. ATying both arms to the bed frame
2. BGiving a sedative every few hours
3. CCovering the site with a sleeve or using hand mitts with supervision
4. DUsing a vest restraint in the chair so that the patient’s hands stay down

Which patient with a suspected infection meets at least two SIRS criteria?

1. ATemperature 38,6 °C and heart rate 112/min
2. BRespiratory rate 16/min and WBC 8,000/mm³
3. CTemperature 36,8 °C and respiratory rate 18/min
4. DTemperature 37,2 °C and heart rate 80/min

Faktor mana yang paling mungkin meningkatkan kadar litium pasien?

1. AMakan lebih banyak garam daripada biasanya selama beberapa hari
2. BMeminum setiap dosis bersama makan, bukan sebelumnya
3. CMinum lebih banyak cairan daripada biasanya saat cuaca panas
4. DDehidrasi atau penurunan mendadak asupan natrium

A patient with sepsis has the following new results. Which set best shows organ dysfunction?

1. AWBC 11,5 × 10³/µL, potassium 4,2 mEq/L, albumin 3,8 g/dL
2. BPlatelets 70 × 10³/µL, creatinine doubled, bilirubin raised
3. CCalcium 9,4 mg/dL, phosphate 3,5 mg/dL, magnesium 1,9 mEq/L
4. DHemoglobin 12,5 g/dL, sodium 138 mEq/L, glucose 105 mg/dL

During a vesicant chemotherapy infusion, the patient reports burning and swelling at the cannula site. What should the nurse do first?

1. AIncrease the rate so that the infusion finishes as quickly as possible
2. BStop the infusion straight away and follow the extravasation protocol
3. CApply a warm pack and continue the infusion
4. DFlush the cannula hard with saline

A patient due a blood transfusion is not wearing an identity band. What should the nurse do?

1. AAsk another patient to confirm who the patient is
2. BAsk the patient to state their name and date of birth, then start straight away
3. CCheck the name on the bed and proceed
4. DNot start until a correct identity band is in place and identity is confirmed

A patient with a mechanical heart valve asks to switch from warfarin to apixaban. What is the correct response?

1. AMechanical valves do not need anticoagulation after the first month
2. BAny anticoagulant works equally well once the valve is in place
3. CDirect oral anticoagulants are not used for mechanical valves
4. DAspirin alone can replace warfarin once the valve has healed

Four surgical patients need VTE prevention. For which patient is mechanical prophylaxis alone most appropriate?

1. AA patient who had a brain haemorrhage two days ago
2. BA patient with cancer having bowel surgery
3. CAn obese patient after hip surgery
4. DA patient after an uncomplicated knee replacement

Mengapa metformin biasanya ditahan selama cedera ginjal akut atau di sekitar kontras beryodium pada pasien berisiko?

1. ADapat menumpuk dan meningkatkan risiko asidosis laktat
2. BMenyebabkan hiperkalemia saat ginjal cedera
3. CMenyebabkan hipoglikemia berat bila diberikan bersama kontras
4. DMenghalangi kontras sehingga pemindaian tidak dapat dibaca

Six weeks after a kidney transplant, a patient has a fever, tenderness over the graft, less urine and a rising creatinine. What is most likely?

1. AAcute rejection, needing urgent transplant team review
2. BA side effect of sun exposure
3. CA normal finding as the kidney settles in
4. DDehydration that needs only more oral fluids and rest

When is cold therapy most useful for pain?

1. AOver numb areas where sensation is lost
2. BSoon after an acute soft tissue injury, to reduce swelling
3. CFor long-term muscle stiffness, applied continuously for several hours
4. DDirectly on skin with poor circulation

Two days after surgery, a patient on regular ibuprofen has a low urine output and a rising creatinine, and intake has been poor. What should the nurse do?

1. AGive the next dose with extra food
2. BIncrease the dose to treat the pain better and encourage fluids
3. CChange to a higher-strength NSAID tablet
4. DWithhold the next dose and report to the prescriber