Prioritas & Delegasi ala NCLEX: paket kilat

A patient receiving IV magnesium sulfate for pre-eclampsia has absent knee reflexes and a respiratory rate of 10/min. What does the nurse do first?

1. AGive oral fluids to help clear the drug faster
2. BIncrease the infusion to prevent a seizure
3. CTurn the patient onto her back and recheck later
4. DStop the magnesium infusion and call for help

After handover on a medical unit, which patient should the nurse see first?

1. ANew atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
2. BDeep vein thrombosis on a heparin infusion, aPTT in the target range
3. CPneumonia on 2 L/min oxygen, SpO₂ 93%, talking in full sentences
4. DDay 2 after a hernia repair, pain 6/10, oral analgesic due in 20 minutes, wants it now

A patient on oxygen is being taken to another department by wheelchair. What should the nurse check first?

1. AThat the cylinder is placed on the patient’s lap
2. BThat the portable cylinder has enough oxygen for the whole trip
3. CThat the cylinder is the largest size available
4. DThat the oxygen is turned off during the transfer to save the supply in the tank

Saat masuk rumah sakit, daftar obat dari rumah mencakup pengencer darah yang tidak ada dalam instruksi rumah sakit yang baru. Apa yang harus dilakukan perawat?

1. AMenyuruh pasien diam-diam meminum persediaannya sendiri
2. BMengabaikannya, karena instruksi rumah sakit menggantikan obat rumahan
3. CMemberikan dosis rumahan tanpa instruksi
4. DMengklarifikasi ketidaksesuaian dengan pemberi resep

A patient's potassium is unexpectedly 5,8 mEq/L. The sample was taken after the tourniquet was on for several minutes while the patient pumped their fist. What is the best interpretation?

1. AFist pumping lowers potassium, so the true level is even higher
2. BThe result confirms true hyperkalemia and needs no further checking
3. CThe result may be falsely high and should be repeated with better technique
4. DTourniquet time affects only the glucose result, not the potassium

A patient with diabetes had a glucose of 58 mg/dL (3,2 mmol/L), took 15 g of fast-acting carbohydrate and, 15 minutes later, the glucose is 64 mg/dL (3,6 mmol/L). The patient is alert. What should the nurse do next?

1. AGive a protein snack only and recheck tomorrow
2. BGive another 15 g of fast carbohydrate and recheck
3. CGive a long-acting insulin dose to stabilize it
4. DWait until the next meal before giving anything

A nurse suspects that an older patient is being financially abused by a relative. What should the nurse do?

1. AKeep it secret because it is a family matter
2. BWait until the patient has been discharged
3. CConfront the relative directly at the bedside about it
4. DRaise the concern through the local safeguarding (adult protection) procedure

A patient going home with a leg cast is taught about cast care. Which statement shows a need for further teaching?

1. A"I will keep the cast dry."
2. B"I can push a knitting needle down the cast to scratch an itch."
3. C"I will keep my leg raised on pillows for the first few days."
4. D"I will come back if my toes go numb or turn blue."

A peripheral cannula site is red, warm, tender and swollen along the vein. What should the nurse do?

1. AFlush the cannula hard to clear it
2. BRemove the cannula, document and monitor the site
3. CCover the site and keep using it until it blocks
4. DLeave it in place, as this is normal after 24 hours

Seorang pasien yang mengonsumsi dabigatran mengalami perdarahan saluran cerna serius. Agen pembalik spesifik mana yang dapat digunakan?

1. AProtamin sulfat
2. BAsam traneksamat saja
3. CFitomenadion (vitamin K)
4. DIdarusizumab

Which group of problems is typical of primary hyperparathyroidism?

1. AKidney stones, bone pain, abdominal pain and low mood
2. BHeat intolerance, tremor, weight loss and diarrhoea
3. CHair loss, weight gain and feeling cold
4. DMuscle cramps, tingling lips and seizures

Seorang pasien yang mengonsumsi litium mengalami poliuria dan haus, dan urine tidak memekat setelah desmopresin. Apa penyebab yang paling mungkin?

1. ADI sentral setelah cedera kepala
2. BDiabetes tipe 1 yang baru muncul
3. CSIADH akibat litium
4. DDI nefrogenik akibat litium

Which factor can precipitate hepatic encephalopathy in a patient with cirrhosis?

1. AConstipation
2. BA low-salt diet
3. CRegular gentle walking
4. DA high fluid intake

A nurse teaches a patient going home between chemotherapy cycles. Which statement shows a need for further teaching?

1. A"I'll keep the emergency number and call if I feel shivery."
2. B"If I get a fever, I'll take paracetamol and see if it settles."
3. C"I'll check my temperature whenever I feel hot, shivery or unwell."
4. D"I'll wash my hands often and avoid people with infections."