Prioritas & Delegasi ala NCLEX: paket kilat

A nursing assistant offers to suction a patient’s new tracheostomy. Which response from the RN is best?

1. A“Ask the patient’s family to do the suctioning today.”
2. B“Leave the suctioning until the next shift arrives.”
3. C“Thank you, please suction him as needed and tell me how it went.”
4. D“Suctioning a new tracheostomy is my task; I will do it myself.”

A patient arrives at the emergency department with a plan to end their life, but has normal vital signs. Which ESI level fits best?

1. ALevel 2
2. BLevel 4
3. CLevel 5
4. DLevel 1

Seorang pasien menderita herpes zoster di satu area dada, sistem imunnya normal, dan lesi dapat ditutup sepenuhnya. Kewaspadaan apa yang biasanya diperlukan?

1. AKewaspadaan standar, dengan lesi ditutup
2. BHanya kewaspadaan droplet
3. CKewaspadaan udara di ruang bertekanan negatif
4. DLingkungan protektif dengan tekanan positif

Seorang pasien dengan implan radioaktif tersegel melaporkan bahwa implan jatuh ke tempat tidur. Apa yang harus dilakukan perawat?

1. AMenggunakan forsep bergagang panjang untuk menempatkannya di wadah timbal
2. BMembiarkannya di tempat tidur sampai tim radiasi tiba besok
3. CMengambilnya dengan tangan bersarung tangan dan memasukkannya ke limbah klinis
4. DMeminta pasien memegangnya sampai bantuan tiba

After surgery for colon cancer, a patient's CEA had fallen to normal, but it has been rising over the last two checks. What does this most likely suggest?

1. APossible recurrence that needs further assessment
2. BA normal change after surgery that needs no follow-up
3. CA sign of iron deficiency from the earlier bleeding
4. DA sure sign that the cancer has been fully cured

At the start of a shift, the nurse reviews four new results. Which patient needs attention first?

1. APotassium 5,2 mEq/L in a patient with stable chronic kidney disease
2. BGlucose 180 mg/dL (10 mmol/L) after a meal in a patient with diabetes
3. CSodium 119 mEq/L in a patient with new confusion and vomiting
4. DHemoglobin 11,0 g/dL (110 g/L) in a patient with rheumatoid arthritis

Seorang pasien dengan neutropenia setelah kemoterapi memiliki suhu 38,3 °C. Apa prioritasnya?

1. ATunggu 24 jam untuk melihat apakah demam mereda
2. BBerikan parasetamol saja dan periksa ulang suhu besok
3. CTangani sebagai sepsis neutropenik dan segera berikan antibiotik IV
4. DAnjurkan pasien berjalan-jalan

Seorang pasien menjelang ajal memiliki napas berbunyi berderak akibat sekret di tenggorokan dan tidak sadar. Pendekatan mana yang tepat?

1. ABeri tahu keluarga bahwa pasien tercekik dan memerlukan ventilasi
2. BUbah posisi, pertimbangkan obat antisekretori yang diresepkan, dan dukung keluarga
3. CMulai cairan intravena cepat untuk mengencerkan dan membersihkan sekret
4. DMulai pengisapan orofaring dalam setiap 10 menit sepanjang malam

A patient with stable angina is afraid nicotine patches will harm their heart. Which reply is most accurate?

1. ANicotine patches are much more harmful to the heart than cigarettes
2. BPeople with angina must stop smoking without any help
3. CNicotine replacement only works if smoking continues
4. DNicotine replacement is much safer than smoking and is recommended

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

Mengapa pasien PGK sering mengonsumsi pengikat fosfat bersama makan?

1. AMengikat fosfat makanan yang tidak dapat diekskresikan ginjal
2. BMenggantikan hormon eritropoietin yang hilang
3. CMenurunkan kalium darah dengan mengikatnya di usus
4. DMeningkatkan penyerapan fosfat dari makanan di usus

Two days after surgery, an 80-year-old woman is quiet, sleepy, slow to answer and eating little. Her daughter says she is "not herself". What should the nurse suspect?

1. ANormal tiredness after an operation
2. BHypoactive delirium
3. CThe start of Alzheimer's disease
4. DSimple low mood about being in hospital

Pernyataan mana yang paling tepat menggambarkan toleransi terhadap opioid?

1. APasien telah mengembangkan alergi terhadap obat
2. BPasien memiliki dorongan kompulsif untuk mendapatkan lebih banyak obat
3. CObat tidak lagi menyebabkan konstipasi
4. DDosis yang lebih tinggi dibutuhkan seiring waktu untuk efek yang sama

A patient with cirrhosis and ascites has a falling urine output and a rising creatinine. They have not received nephrotoxic drugs and are not dehydrated. Which complication is likely?

1. AUrinary tract infection
2. BNephrotic syndrome
3. CPolycystic kidney disease
4. DHepatorenal syndrome