Prioritas & Delegasi ala NCLEX: paket kilat

A patient taking warfarin has an INR of 5,2 and no signs of bleeding. What should the nurse do?

1. AEncourage the patient to take aspirin for pain
2. BGive the usual dose and recheck the INR next month
3. CGive a double dose to correct the result
4. DHold the warfarin dose and inform the provider

A provider asks a nurse to perform a procedure that is outside the nurse’s scope of practice. What should the nurse do?

1. ADo it, because the provider gave the instruction
2. BAsk a nursing assistant to do it instead
3. CDo it just this once and promise the provider not to do it again
4. DDecline, explain why and suggest who can safely do it

A family member tells the nurse, “My father is not himself. Something is wrong.” The hospital has a family-activated rapid response system. What is correct?

1. AOnly doctors may call the rapid response team
2. BThe family should call emergency services from outside the hospital
3. CThe family can call the rapid response team if they are worried and staff have not responded
4. DThe family must wait for the next scheduled ward round to raise the concern with a doctor

A competent adult patient with pneumonia wants to leave the hospital against medical advice. What should the nurse do?

1. AHide the patient’s clothes and belongings so that they cannot leave the ward
2. BApply wrist restraints until the provider arrives to speak with the patient
3. CExplain the risks, notify the provider and follow the policy for leaving against advice
4. DLock the doors so the patient cannot leave

In countries that screen all pregnant women (such as the US), a vaginal-rectal swab is taken at about 36–37 weeks. Which organism is it screening for?

1. ACandida albicans
2. BStaphylococcus aureus
3. CHepatitis B virus
4. DGroup B Streptococcus

A patient has painless jaundice, itching, dark urine and pale stools. ALP is markedly raised, conjugated (direct) bilirubin is high and ALT is only mildly raised. What is the most likely cause?

1. AIncreased breakdown of red blood cells (hemolytic anemia)
2. BGilbert syndrome, a harmless inherited bilirubin disorder
3. CBlockage of bile flow, for example by a tumor in the bile duct
4. DAcute viral hepatitis with widespread liver cell damage

Why does a patient with a suspected TIA need urgent specialist assessment?

1. AThe symptoms will come back permanently within an hour
2. BThe risk of a full stroke is highest in the days after a TIA
3. CThe patient needs urgent surgery on the brain
4. DA TIA always turns into a brain tumour unless it is treated

A patient is taught to self-inject low-molecular-weight heparin. Which statement shows a need for further teaching?

1. A"I will change the injection site each time."
2. B"I will report any unusual bleeding or bruising."
3. C"I will inject into the fatty tissue of my abdomen."
4. D"I will rub the area firmly after the injection."

How is a patient usually positioned for a thoracentesis?

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

Seorang pasien sesak napas dengan masker non-rebreather 15 L/menit memiliki kantong reservoir yang kolaps sepenuhnya pada setiap napas. Apa yang harus dilakukan perawat?

1. AMembiarkannya, karena kantong yang kolaps menunjukkan segel yang baik
2. BMengurangi aliran menjadi 2 L/menit agar kantong tidak kolaps
3. CMemeriksa pasokan dan aliran oksigen agar kantong tetap mengembang
4. DMelepas kantong, karena masker bekerja tanpanya

A patient with advanced CKD asks how to manage indigestion. Which option should they avoid?

1. ARaising the head of the bed at night
2. BMagnesium-containing antacids
3. CEating smaller, more frequent meals
4. DAvoiding large meals late in the evening

A patient with a head injury now has a blood pressure of 190/70 mmHg, a pulse of 48/min and irregular breathing. How should the nurse interpret this?

1. ANeurogenic shock from a spinal cord injury
2. BCushing's triad, a late sign of raised intracranial pressure
3. CHypovolaemic shock from internal bleeding
4. DA normal stress response to pain, anxiety and the noise of the ward

Nasihat makanan mana yang mengurangi risiko sumbatan pada ileostomi baru?

1. AMakan banyak kacang dan biji sejak hari pertama
2. BMenelan makanan dengan cepat tanpa banyak mengunyah
3. CMengunyah dengan baik, dan memasukkan makanan berserat secara perlahan
4. DMinum sangat sedikit cairan agar keluaran tetap kental

Which patient has the highest risk of postoperative nausea and vomiting?

1. AA male smoker having a short procedure without opioids
2. BA man with no history of nausea having local anaesthetic only
3. CA non-smoking woman with motion sickness who will need opioids
4. DA smoker who has never had nausea after surgery