Prioritas & Delegasi ala NCLEX: paket kilat

Which newborn finding needs prompt reporting?

1. AJaundice that appears within the first 24 hours
2. BBluish hands and feet in the first hours
3. CMilia (small white spots) on the nose
4. DMild jaundice that first appears on the third day

A patient who is 7 weeks pregnant has one-sided lower abdominal pain, pain in the shoulder tip, a heart rate of 120/min and a blood pressure of 88/54 mmHg. What is most likely?

1. AA ruptured ectopic pregnancy
2. BSevere morning sickness
3. CA urinary tract infection
4. DA normal early pregnancy

How should a newborn be moved through hospital corridors?

1. ACarried in the nurse’s arms for comfort
2. BOn the mother’s lap in a wheelchair, without staff
3. CIn a bassinet, not carried in the arms
4. DIn the arms of any visitor who offers to help

Seorang pasien bingung dengan restrain pergelangan tangan memiliki jari yang dingin dan pucat pada satu tangan dan nadi radialis lemah pada sisi tersebut. Apa yang pertama kali harus dilakukan perawat?

1. AMengangkat tangan di atas bantal, membiarkan restrain apa adanya
2. BMendokumentasikan temuan dengan cermat dan memeriksa ulang dalam dua jam
3. CMelonggarkan restrain tersebut dan mengkaji sirkulasi tangan
4. DMengencangkan restrain yang lain agar pasien berhenti menarik

When should a blood sample for a digoxin level be drawn to be interpreted correctly?

1. AAt any time, because digoxin levels do not change during the day
2. BWithin 30 minutes after an oral dose to show the peak level
3. COnly after a meal, because food is needed for absorption
4. DAt least 6–8 hours after a dose, often just before the next one

Ten days after chemotherapy, a patient has a platelet count of 9 × 10³/µL and reports a sudden severe headache and blurred vision. What is the priority?

1. AEncourage the patient to drink more fluids and check the blood pressure later
2. BGive acetaminophen (paracetamol) for the headache and reassess in 1 hour
3. CDim the lights and encourage rest, as headaches are common after chemotherapy
4. DAssess neurological status and report it at once as possible brain bleeding

Which blood results are typical of Addison's disease (primary adrenal insufficiency)?

1. ALow haemoglobin and high platelets
2. BHigh sodium and low potassium
3. CHigh glucose and high calcium
4. DLow sodium and high potassium

Hasil tes darah seorang pasien menunjukkan kalium 6,8 mmol/L dan EKG menunjukkan gelombang T runcing. Pengobatan mana yang paling cepat melindungi jantung?

1. AKalsium glukonat IV
2. BHanya diet rendah kalium
3. CTablet furosemid keesokan harinya
4. DSuplemen kalium oral

A patient is on a short course of oral prednisolone for an asthma exacerbation. Which effect should the nurse monitor for?

1. ASlow heart rate
2. BLow blood sodium
3. CRaised blood glucose
4. DLow blood pressure

During drainage of a large pleural effusion, a patient starts coughing and feels tight in the chest. What should the nurse do?

1. ALie the patient flat until the drainage is complete
2. BSpeed up the drainage to finish quickly
3. CAsk the patient to cough harder to help the flow
4. DStop or clamp the drainage and inform the doctor

Komplikasi hemodialisis mana yang menyebabkan sakit kepala, mual, gelisah, dan kadang kejang, terutama pada sesi-sesi pertama?

1. AEmboli udara vena melalui selang
2. BHipoglikemia akibat dialisat
3. CPeritonitis bakteri
4. DSindrom disekuilibrium dialisis

A nurse teaches a carer to give buccal midazolam for prolonged seizures. Which statement shows a need for further teaching?

1. A"I will write down the time the seizure started and the time I gave the dose."
2. B"I will call an ambulance if the care plan tells me to."
3. C"I will give it into the space between his gum and cheek."
4. D"I will put something between his teeth so he does not bite his tongue."

How should a patient use an incentive spirometer after surgery?

1. ABreathe in slowly and deeply, then hold briefly
2. BBlow out as hard and as fast as possible
3. CUse it once a day, just before going to sleep at night
4. DBreathe quickly in and out ten times in a row

Seorang pasien obstruksi usus halus memiliki selang nasogastrik yang mengalirkan 2 L sehari. Fokus keperawatan mana yang paling penting?

1. AMengklem selang dalam waktu lama untuk menghemat cairan lambung
2. BKeseimbangan cairan yang akurat dengan penggantian IV dan pemeriksaan elektrolit
3. CMelepas selang setelah 1 L mengalir untuk mencegah kehilangan
4. DMemberikan cairan oral secara bebas untuk mengganti yang dikeluarkan selang