Prioritas & Delegasi ala NCLEX: paket kilat

Pada triase START, seorang dewasa yang tidak dapat berjalan bernapas 36 kali per menit. Kategori mana yang diberikan kepada korban?

1. AMerah (segera)
2. BKuning (tertunda)
3. CHitam (ekspektan)
4. DHijau (ringan)

A patient with raised intracranial pressure is being nursed on the ward. Which position is best?

1. ASitting forward with the chin on the chest
2. BFlat on the back with the head turned well over to one side
3. CHead down with the legs raised above the heart
4. DHead of the bed at about 30 degrees with the neck straight

Which room lighting is safest at night for a patient at high risk of falls?

1. AComplete darkness so the patient sleeps more deeply
2. BOnly the light from the television screen
3. CBright overhead lights left on all night in the room
4. DA low night light that lights the path to the bathroom

A visitor becomes very agitated and starts shouting at the nurse in a patient’s room. What should the nurse do first?

1. ATurn away from the visitor and continue with the patient’s care as normal
2. BTouch the visitor’s arm to help them calm down
3. CKeep a safe distance and a clear exit, speak calmly and call security if needed
4. DRaise the voice to show who is in charge

A patient with diabetes also takes propranolol. Why is regular glucose monitoring especially important?

1. AThe drug causes very high glucose in all patients
2. BThe drug stops the meter from reading correctly
3. CThe drug can mask warning signs of hypoglycemia
4. DThe drug blocks the insulin injection site

Seorang pasien dengan muntah hebat memiliki kalium 3,0 mEq/L, klorida 88 mEq/L, dan bikarbonat tinggi. Pola apa yang ditunjukkan ini?

1. AKalium tinggi dengan asidosis metabolik akibat dehidrasi
2. BKetoasidosis diabetik dengan anion gap tinggi
3. CKehilangan asam lambung: kalium dan klorida rendah, alkalosis metabolik
4. DHasil normal yang tidak memerlukan tindak lanjut

A dying patient can no longer drink and has a dry mouth. What is the most appropriate nursing care?

1. ALeaving the mouth alone to avoid disturbing them
2. BInserting a nasogastric tube for fluids
3. CStarting a fast intravenous infusion to correct the dryness
4. DFrequent mouth care that keeps the lips and mouth moist

Three days after bowel surgery, a patient has a distended abdomen, vomiting and absent bowel sounds, without colicky pain. What is most likely?

1. AAcute cholecystitis
2. BA urinary tract infection
3. CNormal recovery after surgery
4. DParalytic ileus

A 70 kg patient has passed 20 mL of urine per hour for the last three hours. How should this be interpreted?

1. AHigh, suggesting fluid overload that needs a diuretic
2. BNormal, because any measurable urine output is reassuring
3. CBelow 0,5 mL/kg/h, suggesting poor kidney perfusion
4. DNormal, because the target is 0,1 mL/kg/h

A patient with severe sepsis becomes increasingly breathless over 24 hours. SpO₂ stays low despite high-flow oxygen, and the chest X-ray shows bilateral infiltrates. The heart function is normal. Which condition is most likely?

1. ASpontaneous pneumothorax
2. BAcute respiratory distress syndrome
3. CAn acute asthma attack
4. DAcute left ventricular failure after an MI

Seorang pasien SIADH memiliki natrium 126 mmol/L dan gejala ringan. Pengobatan mana yang biasanya lini pertama?

1. ADesmopresin
2. BPembatasan cairan
3. CInfus glukosa 5% IV
4. DTambahan air oral

A patient taking amiodarone has gained weight and feels tired and cold. Which blood test is most relevant?

1. ASerum ferritin
2. BBlood alcohol level
3. CThyroid function tests
4. DSerum amylase and lipase levels

How are skin staples usually removed from a healed incision?

1. AThe staples are left in permanently under the skin
2. BAlternate staples first, then the rest if the wound holds
3. COnly the staples at each end, leaving the others for good
4. DAll staples at once by pulling each one straight up from the skin

A patient who takes NSAIDs suddenly develops severe epigastric pain, a rigid abdomen and shoulder-tip pain. Which finding would most support the likely diagnosis?

1. AA raised serum lipase three times the upper limit
2. BTall, peaked T waves on a 12-lead ECG
3. CFluid levels in the bladder on an ultrasound scan
4. DFree air under the diaphragm on an erect chest X-ray