Prioritas & Delegasi ala NCLEX: paket kilat

A patient receiving IV magnesium sulfate for pre-eclampsia has absent knee reflexes and a respiratory rate of 10/min. What does the nurse do first?

1. AIncrease the infusion to prevent a seizure
2. BGive oral fluids to help clear the drug faster
3. CTurn the patient onto her back and recheck later
4. DStop the magnesium infusion and call for help

Two weeks after birth, a mother says she hears voices telling her the baby is evil. What is the priority?

1. AKeep the mother and baby safe and arrange urgent psychiatric care
2. BReassure her that this is normal “baby blues”
3. CLeave her alone with the baby to bond
4. DAdvise more sleep and book a routine follow-up visit for next month

Which measure is part of the bundle for inserting a central venous catheter to prevent bloodstream infection?

1. AChoosing the femoral vein as the first site in adults
2. BGiving antibiotics to every patient before insertion
3. CRoutine replacement of the catheter on a fixed schedule, such as every three days
4. DChlorhexidine-alcohol skin antisepsis and maximal sterile barrier precautions

A patient takes medicines prescribed by several providers. Which advice best reduces the risk of medication errors at home?

1. AStop taking any medicine that seems to repeat another one, without asking anyone
2. BKeep each provider’s medicines in separate bags
3. COnly tell each provider about the drugs they prescribed
4. DKeep one up-to-date list of all medicines and use one pharmacy where possible

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

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

During surgery under general anesthesia, a patient develops a rising end-tidal CO₂, muscle rigidity and tachycardia, then a high potassium and a rising temperature. Which condition is most likely?

1. AHypoglycemia from fasting
2. BHypovolemic shock
3. CAcute hemolytic transfusion reaction
4. DMalignant hyperthermia

Seorang pasien diabetes tipe 2 sakit akut, sangat dehidrasi, dan memiliki glukosa darah 40 mmol/L tanpa keton yang bermakna. Apa diagnosis yang paling mungkin?

1. AKetoasidosis diabetik disertai dehidrasi
2. BStatus hiperosmolar hiperglikemik
3. CHipoglikemia
4. DDiabetes insipidus

Which feature suggests moisture-associated skin damage rather than a pressure ulcer?

1. AA deep wound over the sacrum with exposed bone and a dark base
2. BNon-blanching redness directly over the hip bone after lying on one side
3. CDiffuse, superficial redness in a skin fold, not over a bony prominence
4. DA round area of necrosis over the heel

Which finding shows that long-standing hypertension has caused target organ damage?

1. AClear lung fields on the chest X-ray
2. BLeft ventricular hypertrophy on the ECG
3. CA heart rate of 72/min
4. DA normal fasting glucose

Seorang pasien pneumonia dengan oksigen hidung aliran tinggi 50 L/menit dengan FiO₂ 0,6 memiliki SpO₂ 90%, RR 34/menit, dan menggunakan otot bantu napas. Tindakan yang paling tepat apa?

1. AMembaringkan pasien datar agar otot pernapasan beristirahat
2. BBeralih ke kanula hidung 4 L/menit untuk mengurangi kekeringan hidung
3. CSegera mengeskalasi ke perawatan kritis untuk meninjau dukungan pernapasan
4. DMelanjutkan dukungan yang sama dan memeriksa ulang dalam empat jam

A patient takes an SGLT2 inhibitor. Which sick-day advice is correct?

1. ADouble the dose during illness to control the glucose
2. BKeep taking it as normal, whatever the illness
3. CPause the drug during illness with vomiting or poor intake
4. DStop drinking fluids while taking the drug

A nurse teaches a woman with recurrent UTIs. Which statement shows a need for further teaching?

1. A"I will drink enough fluids during the day."
2. B"I will wipe from front to back."
3. C"I will pass urine soon after sex."
4. D"I will hold my urine for as long as I can."

Nasihat makanan mana yang mengurangi risiko sumbatan pada ileostomi baru?

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

Seorang pasien kanker prostat yang diketahui melaporkan nyeri punggung baru yang memburuk dan kelemahan tungkai. Tindakan terpenting apa?

1. AMengatur fisioterapi rutin untuk nyeri punggung dalam bulan depan
2. BKemungkinan kompresi medula: eskalasi, steroid sesuai resep, MRI segera
3. CMenyarankan istirahat di rumah dengan parasetamol dan tinjauan pada kunjungan klinik berikutnya
4. DMenenangkan pasien bahwa nyeri punggung umum dan tidak serius