Prioritas & Delegasi ala NCLEX: paket kilat

Which newborn finding needs prompt reporting?

1. AMilia (small white spots) on the nose
2. BMild jaundice that first appears on the third day
3. CBluish hands and feet in the first hours
4. DJaundice that appears within the first 24 hours

Pada giliran jaga yang sibuk, empat tugas jatuh tempo. Mana yang harus dikerjakan perawat lebih dulu?

1. AMemperbarui rencana asuhan keperawatan sebelum audit para manajer
2. BDosis pertama antibiotik IV untuk pasien dengan dugaan sepsis
3. CMembantu pasien stabil mengisi kartu menu besok
4. DMemberikan tablet vitamin harian rutin yang jatuh tempo pada saat yang sama

Kapan respirator N95 dilepas setelah merawat pasien dengan kewaspadaan udara?

1. ASegera setelah memasuki ruangan
2. BTidak pernah; dipakai selama sisa shift
3. CSetelah keluar dari ruangan dan menutup pintu
4. DSebelum melepas sarung tangan, di dalam ruangan

A patient with pneumonia has low blood pressure and a raised serum lactate. What does the raised lactate suggest?

1. AA normal response to having a fever
2. BRecovery from the infection is beginning
3. CMild dehydration from poor intake, with no further concern
4. DPoor tissue perfusion, a sign of sepsis-related shock

When is a peak level for an IV aminoglycoside such as gentamicin usually drawn?

1. AAt any time convenient for the patient
2. BAbout 30 minutes after the infusion ends
3. CJust before the next dose is started
4. DExactly 24 hours after the first dose

An RN cares for a patient on a 24-hour urine collection. Which task can be delegated to unlicensed assistive personnel (UAP), such as a nursing or healthcare assistant?

1. ATeaching the patient why the 24-hour collection is needed
2. BInterpreting the creatinine clearance result when it comes back
3. CDeciding whether to restart the collection after a missed sample
4. DSaving all urine in the collection container as instructed

Why can a very low serum albumin contribute to oedema?

1. AIt raises the blood pressure in the capillaries and pushes fluid out
2. BIt increases the number of red cells
3. CIt makes the kidneys retain potassium
4. DIt lowers the oncotic pressure that holds fluid in the blood vessels

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

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

A patient takes both digoxin and furosemide. Why does the nurse watch the potassium level closely?

1. AHigh potassium is the main effect of furosemide
2. BPotassium has no link with either medicine
3. CLow potassium increases the risk of digoxin toxicity
4. DLow potassium makes digoxin stop working completely

Seorang pasien dengan TVD betis yang terkonfirmasi telah memulai antikoagulasi terapeutik dan bertanya apakah ia harus tetap di tempat tidur. Jawaban paling akurat apa?

1. ATungkai harus dipijat sebelum setiap berjalan
2. BBerjalan sesuai toleransi biasanya dianjurkan setelah diobati
3. CBerjalan tidak diperbolehkan sampai bekuan larut sepenuhnya
4. DTirah baring ketat diperlukan setidaknya dua minggu

Mengapa metformin biasanya ditahan selama cedera ginjal akut atau di sekitar kontras beryodium pada pasien berisiko?

1. ADapat menumpuk dan meningkatkan risiko asidosis laktat
2. BMenyebabkan hipoglikemia berat bila diberikan bersama kontras
3. CMenyebabkan hiperkalemia saat ginjal cedera
4. DMenghalangi kontras sehingga pemindaian tidak dapat dibaca

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

1. AUnderdrainage, so the drain should be lowered further
2. BOverdrainage of CSF, so act per protocol and inform the team
3. CAn infected drain, so the dressing should be removed
4. DNo concern, because more drainage always lowers the ICP safely

Pengkajian di sisi tempat tidur mana yang digunakan untuk memantau asites?

1. ABerat badan harian dan lingkar perut
2. BUkuran pupil dan reaksinya dua kali sehari
3. CGlukosa kapiler sebelum setiap makan
4. DArus puncak dan saturasi oksigen

A patient with a PICC line develops swelling and aching of the same arm and prominent veins on the chest. What should the nurse suspect?

1. ANormal swelling after line insertion
2. BLymphoedema from a previous operation
3. CA catheter-related deep vein thrombosis
4. DAn allergy to the dressing