Prioritas & Delegasi ala NCLEX: paket kilat

On day 3 after hip surgery, a patient suddenly becomes short of breath with sharp chest pain and an SpO₂ of 88%. What should the nurse do first?

1. AGive the next dose of oral analgesia and reassess the patient in an hour
2. BEncourage the patient to walk to improve the circulation
3. CRaise the head of the bed, give oxygen and call for urgent help
4. DMassage the patient’s calves to ease any muscle cramp

Seorang perawat mengawasi asisten keperawatan baru. Kapan perawat harus memeriksa pekerjaan asisten dengan paling ketat?

1. AKetika asisten baru dalam tugas tersebut atau pasien kurang stabil
2. BHanya di akhir giliran jaga, ketika dokumentasi ditinjau
3. CTidak pernah, karena asisten memegang sertifikat untuk peran tersebut
4. DHanya ketika asisten meminta bantuan untuk tugas yang dirasa sulit

A patient has a non-violent restraint. In most nursing policies, how often at minimum is it released for range of motion, toileting and skin care?

1. AOnce a day, during the bath
2. BOnce every 12-hour shift
3. COnly when the patient asks for it
4. DAt least every 2 hours

A patient with a common cold asks for antibiotics “to be on the safe side”. Which response is best?

1. AExplain that antibiotics do not work on viruses and overuse breeds resistant bacteria
2. BSuggest using leftover antibiotics from a previous illness
3. CTell the patient that antibiotics will shorten the cold by several days
4. DAsk the provider to prescribe antibiotics anyway so that the patient is reassured

A patient with sickle cell disease takes hydroxyurea. Which laboratory test is monitored regularly for an adverse effect?

1. ASerum lithium level
2. BUrine ketone level
3. CSerum amylase level
4. DComplete blood count

A young adult has fatigue, bruising and fever. The white cell count is 85 × 10³/µL with many blasts, the hemoglobin is 7,9 g/dL (79 g/L) and the platelets are 22 × 10³/µL. What is the most likely diagnosis?

1. AAcute leukemia
2. BIron-deficiency anemia
3. CPolycythemia vera
4. DAcute viral infection

Which adverse effects should be monitored for in a patient receiving IV gentamicin?

1. AConstipation and urinary retention
2. BHyperglycaemia and tremor
3. CKidney damage and hearing loss
4. DHair loss and weight gain

A nurse teaches a patient with diabetes about foot care. Which statement shows a need for further teaching?

1. A"I will wear well-fitting shoes."
2. B"I will see the podiatrist about hard skin."
3. C"I will walk barefoot at home to toughen my feet."
4. D"I will check my feet every day for cuts or blisters."

Seorang pasien yang mengonsumsi warfarin mulai makan salad bayam dan kale dalam jumlah besar setiap hari. Apa kekhawatiran utamanya?

1. AVitamin K tambahan dapat meningkatkan INR
2. BTidak ada interaksi antara makanan dan warfarin
3. CSayuran hijau merusak hati pada pengguna warfarin
4. DVitamin K tambahan dapat menurunkan INR

A patient with asthma needs their reliever every three hours and their peak flow is falling well below their personal best. What does their action plan most likely advise?

1. AFollow the worsening-asthma steps and get a same-day review
2. BDo extra exercise to open the airways
3. CWait two weeks to see whether it improves without any change
4. DStop the preventer inhaler for a few days to rest the lungs

What does a positive pronator drift test show?

1. AA normal response in older adults
2. BSubtle weakness in one arm
3. CWeakness of the eye muscles
4. DLoss of hearing on one side

Selama infus alteplase untuk stroke, pasien mengalami sakit kepala hebat, muntah, dan GCS yang menurun. Apa yang harus dilakukan perawat pertama kali?

1. AMempercepat infus agar selesai lebih cepat
2. BMemberikan sedatif untuk menenangkan pasien dan melanjutkan
3. CMemberikan antiemetik dan memeriksa ulang GCS satu jam kemudian
4. DMenghentikan infus dan segera memanggil tim stroke

Why is IV albumin often given after a large-volume paracentesis?

1. ATo prevent low blood pressure and kidney injury from fluid shifts
2. BTo raise the blood glucose after the procedure
3. CTo replace the clotting factors and platelets lost in the drained fluid
4. DTo treat infection in the ascitic fluid

Strategi cairan mana yang umumnya direkomendasikan pada jam-jam pertama pankreatitis akut?

1. ATanpa cairan IV sama sekali, hanya seteguk kecil air oral
2. BKristaloid seimbang terarah-tujuan, dipandu oleh respons
3. CVolume sangat besar, apa pun respons pasien
4. DAlbumin IV saja sebagai pengganti kristaloid apa pun