Prioritas & Delegasi ala NCLEX: paket kilat

Pasien mana yang harus ditemui perawat lebih dulu setelah serah terima?

1. APasien yang ingin dibantu mandi sebelum tamu tiba
2. BPasien dengan gips baru yang mengatakan kakinya terasa kebas dan jari kakinya dingin
3. CPasien yang mengonsumsi diuretik dan mengeluarkan 400 mL urine sejak pukul 08,00
4. DPasien osteoartritis yang melaporkan kekakuan setiap pagi

A day after a femur fracture, a young patient becomes confused and breathless, with small red spots on the chest. What should the nurse suspect?

1. AAn allergic reaction to the cast
2. BNormal pain after a fracture
3. CFat embolism syndrome
4. DAlcohol withdrawal

Dua pasien yang terinfeksi organisme yang sama dirawat, dan tidak ada ruang tunggal yang tersedia. Apa pilihan yang dapat diterima?

1. AMenempatkan mereka di koridor
2. BMenempatkan mereka dalam satu ruangan (kohorting), sesuai saran pengendalian infeksi
3. CMenghentikan kewaspadaan kontak
4. DMenempatkan masing-masing bersama pasien yang daya tahan tubuhnya lemah

A nurse teaches new parents how to cope with an infant’s crying. Which statement shows a need for further teaching?

1. A“If he won’t stop crying, a quick shake will get his attention.”
2. B“I will check whether he is hungry, wet or too warm.”
3. C“If I get frustrated, I will put him safely in the crib and take a short break.”
4. D“I can call a friend or family member to help when I am tired.”

After surgery for colon cancer, a patient's CEA had fallen to normal, but it has been rising over the last two checks. What does this most likely suggest?

1. APossible recurrence that needs further assessment
2. BA normal change after surgery that needs no follow-up
3. CA sure sign that the cancer has been fully cured
4. DA sign of iron deficiency from the earlier bleeding

A patient recovering from acute tubular necrosis now passes 4–5 L of urine a day. Which electrolyte changes should the nurse watch for?

1. ANo changes, because the kidneys are now normal
2. BLow potassium and low sodium from urine losses
3. CHigh calcium and high phosphate from bone loss
4. DHigh potassium and high sodium from retention

A patient with pneumonia is breathless and coughing up thick sputum. Which nursing measure helps most with breathing?

1. ARestricting all oral fluids
2. BSitting the patient upright and supporting them to clear secretions
3. CLying the patient flat so that they can rest and conserve energy
4. DDiscouraging coughing to save energy

A patient due a blood transfusion is not wearing an identity band. What should the nurse do?

1. AAsk the patient to state their name and date of birth, then start straight away
2. BAsk another patient to confirm who the patient is
3. CCheck the name on the bed and proceed
4. DNot start until a correct identity band is in place and identity is confirmed

How should a patient breathe in when using a dry powder inhaler?

1. AQuickly and deeply, after breathing out away from the device
2. BSlowly and gently over about ten seconds
3. CThrough the nose with the mouthpiece in the mouth
4. DSeveral times, breathing out into the device between breaths

A patient with an inferior myocardial infarction develops complete heart block with a heart rate of 38/min. What is the most likely reason?

1. AThe right coronary artery usually supplies the AV node
2. BInferior infarcts always destroy the bundle of His permanently
3. CThe left anterior descending artery supplies the SA node only
4. DHeart block is caused by the thrombolytic drug

Why is IV calcium gluconate given in severe hyperkalaemia?

1. AIt binds potassium in the gut
2. BIt removes potassium through the kidneys
3. CIt protects the heart from arrhythmias
4. DIt moves potassium into the cells

A patient with an insulin pump is admitted with nausea, a glucose of 19 mmol/L (342 mg/dL) and blood ketones of 3,1 mmol/L. What is the priority?

1. AGive an antiemetic only, because nausea is causing the high glucose
2. BIncrease the pump rate and recheck the ketones in 12 hours
3. CDisconnect the pump and give no insulin until the ketones clear
4. DSuspect failed insulin delivery and give insulin by another route

Why should antacids usually be taken at a different time from other medicines?

1. AThey make all other drugs much more toxic
2. BThey destroy other drugs before they are swallowed
3. CThey can reduce the absorption of many other drugs
4. DThey stop the kidneys from clearing other drugs

A patient with a severe flare of ulcerative colitis develops abdominal distension, fever and tachycardia, and the stool frequency has dropped. What should the nurse suspect?

1. AThe flare is getting better
2. BSimple constipation from low intake
3. CHaemorrhoids caused by diarrhoea
4. DToxic megacolon