Prioritas & Delegasi ala NCLEX: paket kilat

Which SBAR recommendation is the clearest?

1. A“I will keep watching him and call again tomorrow.”
2. B“I just wanted to let you know about him.”
3. C“He seems a bit off tonight, so maybe you could come up and do something about it.”
4. D“I would like you to see him within 15 minutes and consider a fluid bolus.”

Seorang pasien menerima kalium klorida IV melalui jalur perifer dan mengeluh rasa terbakar di lokasi, yang tampak merah. Apa yang pertama kali dilakukan perawat?

1. AMenghentikan infus dan mengkaji lokasi IV
2. BMenaikkan kecepatan infus agar dosis selesai lebih cepat
3. CMemasang kompres hangat dan melanjutkan infus
4. DMengatakan kepada pasien bahwa rasa terbakar itu wajar dan melanjutkan

Dua pasien yang terinfeksi organisme yang sama dirawat, dan tidak ada ruang tunggal yang tersedia. Apa pilihan yang dapat diterima?

1. AMenempatkan mereka dalam satu ruangan (kohorting), sesuai saran pengendalian infeksi
2. BMenempatkan masing-masing bersama pasien yang daya tahan tubuhnya lemah
3. CMenempatkan mereka di koridor
4. DMenghentikan kewaspadaan kontak

A patient on oxygen needs an MRI scan. Which plan is safe?

1. ALeave the steel cylinder on the patient’s bed during the scan
2. BTake the usual steel cylinder into the room if it is tightly strapped to the trolley frame
3. CRemove the oxygen for the scan without telling anyone
4. DUse only MRI-safe equipment, and never take a standard steel oxygen cylinder into the scanner room

A breathless patient in the emergency department has a BNP below 100 pg/mL. What does this suggest?

1. AThe patient has had a myocardial infarction in the past day
2. BSevere heart failure is certainly the cause of the problem
3. CHeart failure is an unlikely cause of the breathlessness
4. DThe kidneys are failing and the patient needs dialysis

A patient has a sodium of 150 mEq/L, a glucose of 180 mg/dL and a BUN of 28 mg/dL. Using the formula 2 × Na + glucose/18 + BUN/2,8, what is the calculated serum osmolality?

1. AAbout 320 mOsm/kg, which is high
2. BAbout 358 mOsm/kg, which is high
3. CAbout 300 mOsm/kg, which is normal
4. DAbout 285 mOsm/kg, which is normal

Which is the correct technique for using a metered-dose inhaler without a spacer?

1. APress the canister twice quickly, then breathe in fast and breathe straight out again
2. BBreathe out, then breathe in slowly and deeply while pressing the canister, then hold
3. CPress the canister and wait one minute before breathing in
4. DBreathe in quickly through the nose while pressing the canister

Which task is most appropriate for a registered nurse to delegate to a trained healthcare assistant (unlicensed assistive personnel)?

1. ATeaching a patient to inject insulin for the first time
2. BGiving a dose of intravenous antibiotic
3. CMeasuring and recording vital signs on a stable patient
4. DAssessing a patient who has just reported new chest pain

Why are patients with mitral stenosis at high risk of atrial fibrillation?

1. AThe coronary arteries become blocked by the valve
2. BThe right ventricle shrinks and stops contracting properly over time
3. CThe left atrium enlarges as it pushes blood through the narrow valve
4. DThe narrow valve presses on the sinus node and slows it down directly

After positive end-expiratory pressure (PEEP) is increased on a ventilated patient, the blood pressure falls. What is the most likely reason?

1. APEEP directly weakens the heart muscle and its contraction
2. BPEEP causes immediate blood loss from the alveolar capillaries
3. CPEEP lowers the blood oxygen level
4. DHigher chest pressure reduces venous return to the heart

Seorang pasien SIADH memiliki natrium 126 mmol/L dan gejala ringan. Pengobatan mana yang biasanya lini pertama?

1. ATambahan air oral
2. BDesmopresin
3. CInfus glukosa 5% IV
4. DPembatasan cairan

A patient with polycystic kidney disease suddenly has the worst headache of their life and neck stiffness. What should the nurse suspect?

1. APain spreading upwards from a kidney cyst
2. BA urinary infection that has spread
3. CA migraine linked to high blood pressure
4. DA subarachnoid haemorrhage from a brain aneurysm

Mengapa luka bakar superfisial (hanya kemerahan, seperti terbakar matahari) tidak dihitung saat menghitung luas luka bakar untuk resusitasi cairan?

1. ASawar kulit utuh, sehingga sedikit cairan hilang
2. BSelalu sembuh sepenuhnya dalam satu hari
3. CMenyebabkan kehilangan cairan lebih banyak daripada kedalaman lain mana pun
4. DSelalu terlalu kecil untuk diukur secara akurat pada bagan

A patient with a PICC line develops swelling and aching of the same arm and prominent veins on the chest. What should the nurse suspect?

1. ANormal swelling after line insertion
2. BLymphoedema from a previous operation
3. CA catheter-related deep vein thrombosis
4. DAn allergy to the dressing