Prioritas & Delegasi ala NCLEX: paket kilat

A patient has a serum potassium of 2,9 mEq/L. Which finding should the nurse expect?

1. AMuscle weakness and U waves on the ECG
2. BA rise in urine output and thirst only
3. CTall, peaked T waves and muscle twitching
4. DFlushed, warm skin and a slow heart rate

A patient is bleeding internally after a fall. Which finding is usually an early sign of hypovolemic shock?

1. ARestlessness and a rising heart rate while the blood pressure is still normal
2. BA very low blood pressure with fixed, dilated pupils
3. CLoss of consciousness with gasping breaths
4. DA slow heart rate with warm, dry, flushed skin and a normal blood pressure throughout

A parent calls because a toddler has swallowed some household cleaner. The child is awake and breathing normally. What should the nurse advise first?

1. AContact the local poison advice service now for specific advice
2. BMake the child vomit, using a finger at the back of the throat
3. CWait to see whether any symptoms develop over the next day
4. DGive syrup of ipecac from the medicine cabinet

A flexible bronchoscope contacts mucous membranes but does not enter sterile tissue. Which level of processing is required at a minimum between patients?

1. AHigh-level disinfection
2. BCleaning with soap and water only
3. CLow-level disinfection
4. DWiping with an alcohol wipe

Which blood collection practice helps prevent hemolysis of the sample?

1. ALeaving the tourniquet on for at least 3 minutes
2. BUsing the smallest needle available for every patient
3. CGently inverting the tubes instead of shaking them
4. DForcing blood quickly through a needle into the tube

A patient with diabetes and chronic kidney disease had a CT scan with IV contrast. Two days later, the creatinine has risen from 1,4 to 2,0 mg/dL (124 to 177 µmol/L). Which action is most appropriate?

1. AReport it, monitor urine output and hold metformin until reviewed
2. BRestrict all fluids to protect the kidneys from more contrast
3. CGive extra metformin, because the glucose rises after contrast
4. DIgnore it, because contrast never affects kidney function

Selama infus IV, area di sekitar kanula menjadi bengkak, dingin, dan pucat, dan tetesan infus melambat. Apa yang mungkin terjadi?

1. AEmboli udara
2. BKelebihan cairan dalam sirkulasi
3. CFlebitis akibat infeksi bakteri pada dinding vena
4. DInfiltrasi cairan ke jaringan sekitar

A day after surgery, a patient's haemoglobin has fallen from 125 g/L to 85 g/L (12,5 to 8,5 g/dL) and their heart rate has risen to 118/min. What is the priority?

1. ADocument the result and take no further action
2. BRecheck the haemoglobin next week
3. CEscalate urgently, as the patient may be bleeding
4. DEncourage the patient to eat iron-rich foods

What is the main problem in heart failure with preserved ejection fraction?

1. AA blocked pulmonary artery
2. BA stiff ventricle that fills poorly in diastole
3. CA dilated ventricle that cannot contract strongly
4. DA leaking aortic valve

Seorang pasien asma memiliki riwayat mengi setelah minum aspirin. Ibuprofen diresepkan untuk nyeri pascaoperasi. Apa yang harus dilakukan perawat?

1. AMenahannya dan meminta alternatif
2. BMemberikannya hanya bila skor nyeri di atas 8/10
3. CMemberikannya, karena ibuprofen tidak terkait dengan aspirin
4. DMemberikannya bersamaan dengan inhaler pelega

A patient has just started haemodialysis. What usually happens to their protein needs?

1. AProtein must be replaced only by IV infusion
2. BThey fall to almost zero to rest the kidneys
3. CThey stay exactly the same as they were before dialysis
4. DThey increase, because dialysis removes amino acids

During haemodialysis, a patient suddenly becomes breathless with chest pain, and air is seen in the line. What should the nurse do first?

1. AClamp the lines and lay the patient left side down, head low
2. BSit the patient upright and give a drink of water
3. CSpeed up the pump to clear the air into the patient
4. DContinue the session and recheck in 30 minutes

In the UK National Early Warning Score (NEWS2), what does an aggregate score of 5 or more usually trigger?

1. AAn urgent review by a clinician skilled in acute illness
2. BDischarge planning for the next day
3. CNo change unless the patient complains
4. DRoutine observations once every 12 hours, with no other change in care

An incontinent patient has diffuse, shiny, red and broken skin in the natal cleft and buttocks with irregular edges, not over a bony prominence. What is most likely?

1. AA category 4 pressure ulcer over the sacrum
2. BA full-thickness burn
3. CIncontinence-associated dermatitis
4. DAn arterial ulcer caused by poor circulation