Prioritas & Delegasi ala NCLEX: paket kilat

Seorang pasien yang baru diberi tahu menderita kanker menangis, tetapi juga muntah beberapa kali dan tidak dapat menahan cairan. Apa yang ditangani perawat lebih dulu?

1. AMenghubungi rohaniwan rumah sakit
2. BDukungan emosional tentang diagnosis
3. CMuntah dan kehilangan cairan
4. DEdukasi tentang kemoterapi

A patient admitted with a stroke this morning asks for a glass of water. What should the nurse do first?

1. AGive thickened fluids without checking the swallow
2. BCheck that a swallow screen has been done before giving anything by mouth
3. CGive the water through a straw so it goes down slowly
4. DAsk the family to help the patient drink while sitting upright in a chair at the bedside

Where is a gait belt placed when helping a patient to walk?

1. AAround the hips, directly on bare skin
2. BAround the patient’s waist, over clothing
3. CAround both thighs, just above the knees
4. DAround the chest, under the arms

Which patient with a suspected infection meets the qSOFA criteria that signal a higher risk of a poor outcome?

1. ARespiratory rate 20/min, alert, systolic BP 110 mmHg, heart rate 110/min
2. BRespiratory rate 18/min, alert, systolic BP 130 mmHg, temperature 38,5 °C
3. CRespiratory rate 24/min, new confusion, systolic BP 95 mmHg
4. DRespiratory rate 16/min, alert, systolic BP 105 mmHg, WBC 13,000/mm³

A patient with iron-deficiency anemia started oral iron. Which result is usually the earliest sign that treatment is working?

1. AA rise in the platelet count
2. BA rise in the reticulocyte count
3. CA fall in the mean cell volume (MCV)
4. DA fall in the white cell count

A patient with acute pancreatitis has a rising BUN, a falling calcium and a glucose of 250 mg/dL (13,9 mmol/L) over the first 48 hours. What do these results suggest?

1. AIncreasingly severe pancreatitis
2. BA lab error from lipemic samples
3. CA resolving, mild pancreatitis
4. DAn unrelated new kidney stone

Stoma kolostomi yang baru tampak ungu tua hingga hitam pada hari kedua pascaoperasi. Apa yang ditunjukkan hal ini?

1. AKonstipasi
2. BStoma normal yang sehat
3. CMemar pascaoperasi normal pada stoma yang tidak memerlukan tindakan
4. DKemungkinan iskemia stoma, yang memerlukan evaluasi segera

Seorang pasien dengan luka bakar 30% luas permukaan tubuh dirawat inap. Komplikasi dini mana yang paling dikhawatirkan dalam 24 jam pertama?

1. AJaringan parut dan kontraktur
2. BKonstipasi
3. CLuka tekan akibat imobilitas berkepanjangan
4. DSyok hipovolemik akibat kehilangan cairan

How is orthostatic (postural) hypotension usually assessed?

1. ABP only standing, after a brisk walk along the corridor
2. BBP in both arms at the same moment while sitting
3. CBP once sitting, then once lying down straight after a large meal
4. DBP lying after rest, then again after 1 and 3 minutes standing

A patient with squamous cell lung cancer becomes confused, thirsty and constipated, with abdominal pain. Which electrolyte disturbance is most likely?

1. AHyponatraemia
2. BHypercalcaemia
3. CHypomagnesaemia
4. DHypokalaemia

Why are tacrolimus blood levels checked regularly?

1. AThe levels show how much urine the kidney is making
2. BThe drug only works if levels are as high as possible
3. CThe levels show whether the patient has diabetes
4. DToo high harms the kidney; too low risks rejection

An older patient with a UTI is now confused, with a respiratory rate of 24/min, BP 88/50 mmHg and a pulse of 120/min. What should happen?

1. AEncourage oral fluids and wait for the urine culture
2. BStart sepsis care at once, with IV antibiotics and fluids
3. CGive oral antibiotics and recheck in four hours
4. DTreat the confusion with a sedative

Seorang pasien dengan ileostomi baru memiliki keluaran sangat tinggi. Apa risiko utamanya?

1. ADehidrasi dan kehilangan natrium, kalium, dan magnesium
2. BKelebihan cairan dan pembengkakan pergelangan kaki
3. CKalsium tinggi dan batu ginjal dalam beberapa hari
4. DKonstipasi dan impaksi feses di usus di atas stoma

A nurse teaches a carer about overnight tube feeding at home. Which statement shows a need for further teaching?

1. A"I'll flush the tube with water before and after his medicines."
2. B"I'll stop the feed and call if he coughs or struggles to breathe."
3. C"I'll let him lie flat so he sleeps better while the feed runs."
4. D"I'll check the external length mark on the tube every day."