Prioritas & Delegasi ala NCLEX: paket kilat

A patient coughs hard after abdominal surgery, and loops of bowel appear through the opened wound. What does the nurse do first?

1. AHelp the patient walk to the toilet to relieve abdominal pressure
2. BPush the bowel gently back into the abdomen with a gloved hand
3. CCover the wound with sterile dressings moistened with saline
4. DLeave the wound uncovered so the surgeon can see it on arrival

A patient with severe sepsis starts oozing blood from IV sites and the gums, and bruises appear on the skin. What should the nurse suspect?

1. AVitamin C deficiency
2. BDisseminated intravascular coagulation (DIC)
3. CAn allergic reaction to the adhesive tape
4. DNormal bruising from blood tests

A patient is booked for an MRI scan. What must the nurse check beforehand?

1. AWhether the patient has eaten a large meal recently
2. BWhether the patient’s blood glucose has been in the normal range today
3. CWhether the patient has any metal implants or devices, such as a pacemaker
4. DWhether the patient has had a hearing test this year

A patient’s white cell differential shows a raised eosinophil count. Which cause is most consistent with this finding?

1. AAn acute bacterial infection
2. BBone marrow suppression from chemotherapy
3. CAn allergic reaction or a parasitic infection
4. DA viral infection such as a cold

Kadar palung vankomisin berada di atas rentang target. Efek samping mana yang menjadi perhatian utama?

1. AKonstipasi dan kembung
2. BGlukosa darah rendah (hipoglikemia)
3. CKerusakan ginjal (nefrotoksisitas)
4. DHitung trombosit meningkat (trombositosis)

The nurse teaches a patient with thrombocytopenia (platelets 25 × 10³/µL) about home safety. Which statement shows a need for further teaching?

1. A"I'll take aspirin if I get a headache"
2. B"I'll use a soft-bristled toothbrush"
3. C"I'll blow my nose gently, not forcefully"
4. D"I'll use an electric razor to shave"

A spontaneously breathing patient is critically ill and hypoxic. Which oxygen delivery gives the highest concentration?

1. ASimple face mask at 5 L/min with the patient sitting up
2. BVenturi mask set to 24%
3. CNon-rebreathe mask with reservoir bag at 15 L/min
4. DNasal cannula at 2 L/min

A patient with stress incontinence is taught self-care. Which statement shows a need for further teaching?

1. A"I'll do my pelvic floor exercises every day."
2. B"I'll try to lose some weight if I can."
3. C"I'll cut down on caffeine."
4. D"I'll drink as little as possible so I don't leak."

How is a patient usually positioned for a thoracentesis?

1. ASitting upright and leaning forward over a table
2. BFlat on the back with the legs raised
3. CLying on the affected side with the head down
4. DProne with the arms by the sides

After intubation, breath sounds are heard on the right side of the chest but not the left. What is the most likely cause?

1. AThe left lung has completely filled with fluid
2. BThe tube cuff has burst during insertion
3. CThe tube has entered the oesophagus
4. DThe tube has entered the right main bronchus

A routine blood test shows a potassium of 6,4 mmol/L. The lab reports that the sample was haemolysed. The patient feels well. What should the nurse do?

1. AInform the doctor and arrange an urgent repeat sample
2. BGive oral potassium supplements straight away
3. CStart dialysis as soon as possible
4. DIgnore it, because haemolysis always gives a normal result

On the first day after a kidney transplant, urine output suddenly falls from 200 mL/h to 10 mL/h. What should the nurse check first?

1. AThe patient's blood glucose level
2. BWhether the patient has eaten
3. CThe patient's temperature and pulse
4. DThat the catheter is not blocked or kinked

Which statement about pain relief in acute pancreatitis is correct?

1. AOnly paracetamol may be given
2. BPain relief should be withheld until the diagnosis is certain
3. COpioids must never be used in pancreatitis
4. DOpioids can be used, and good analgesia is a priority

During radiotherapy to the chest, a patient develops pain on swallowing and is eating less. What is the most likely cause and nursing focus?

1. AA heart attack; give aspirin and arrange an ECG
2. BA stomach ulcer; give an antacid after meals only
3. CRadiation oesophagitis; analgesia, soft food and nutrition support
4. DNormal ageing; no action needed