Prioritas & Delegasi ala NCLEX: paket kilat

Before giving a scheduled dose of metoprolol, which assessment is most important?

1. ABlood glucose and weight
2. BTemperature and the latest pain score
3. CApical pulse and blood pressure
4. DBowel sounds and urine color

Which patient finding after a total knee replacement needs the nurse’s action first?

1. ASudden calf pain and swelling in the operated leg, with new breathlessness
2. BPain of 4/10 when the physiotherapist bends the knee during the morning session
3. CAsks for an ice pack to help with swelling around the knee
4. DA small amount of dried blood on the dressing

A patient has fallen, and the nurse completes an incident report. Which statement about this report is correct?

1. AA copy of it is placed in the patient’s chart so all staff know about the fall
2. BIt is written factually and does not replace documenting the fall in the patient’s record
3. CIt replaces the need to document the fall in the patient’s record
4. DIt is only needed when the patient is injured

A patient who speaks little English is being discharged with new medications. The patient’s 12-year-old child offers to interpret. What should the nurse do?

1. AUse a professional medical interpreter
2. BGive written instructions in English only
3. CLet the child interpret, because the family prefers it
4. DUse simple English and many hand gestures

Seorang pasien yang mengonsumsi warfarin untuk fibrilasi atrium memiliki INR 5,2 dan tidak ada perdarahan. Apa tindakan terbaik perawat?

1. AMemberikan dosis biasa dan memeriksa ulang dalam sebulan
2. BMemberikan dosis ganda
3. CMenahan dosis warfarin dan memberi tahu penulis resep
4. DMenyarankan pasien berhenti makan sayuran hijau mulai hari ini

Seorang pasien yang mengonsumsi apiksaban bertanya mengapa tidak perlu tes INR rutin seperti tetangganya yang mengonsumsi warfarin. Penjelasan mana yang terbaik?

1. AApiksaban sebenarnya tidak mengencerkan darah
2. BINR diperiksa secara diam-diam bersama pemeriksaan darah rutin lainnya
3. CEfeknya dapat diprediksi, sehingga tes pembekuan rutin tidak diperlukan
4. DApiksaban dipantau dengan aPTT setiap hari sebagai gantinya

How does ulcerative colitis differ from Crohn's disease?

1. AUlcerative colitis can affect any part of the gut from mouth to anus
2. BUlcerative colitis always affects the full thickness of the bowel wall
3. CUlcerative colitis affects only the colon, continuously from the rectum
4. DUlcerative colitis typically causes patchy "skip" lesions

Which patient should the nurse assess first?

1. AA patient with asthma who can only speak in single words
2. BA patient with diabetes whose glucose is 11 mmol/L (198 mg/dL) before lunch
3. CA postoperative patient who rates their pain as 6/10
4. DA patient with COPD whose SpO₂ is 89% and within their target range

A patient has a prosthetic heart valve. Which teaching best reduces the risk of infective endocarditis?

1. ATake a daily antibiotic tablet indefinitely
2. BKeep teeth and gums healthy with regular dental check-ups
3. CAvoid eating dairy products and raw vegetables
4. DAvoid all physical exercise for the rest of their life

Seorang pasien eksaserbasi akut PPOK yang meretensi CO₂ diresepkan bronkodilator nebulisasi. Bagaimana nebulizer biasanya digerakkan?

1. ADengan oksigen 6–8 L/menit tanpa pemantauan saturasi
2. BDengan oksigen 15 L/menit selama mungkin
3. CTanpa aliran gas, dengan meminta pasien bernapas dalam
4. DDengan udara terkompresi, ditambah oksigen terkontrol melalui kanula hidung

After transsphenoidal pituitary surgery, which advice should the patient follow?

1. ABlow the nose often to clear any clots
2. BDrink through a straw to keep the nose clean
3. CAvoid blowing the nose, straining and bending forward
4. DLie completely flat for at least a week after surgery

Seorang pasien hemodialisis bertanya mengapa cairan di antara sesi harus dibatasi. Penjelasan mana yang benar?

1. ACairan berlebih menumpuk, menaikkan TD dan menyebabkan sesak napas serta kram saat dialisis
2. BMinum air membuat dialisis mengeluarkan terlalu banyak kalium dari darah
3. CPembatasan cairan terutama untuk mempersingkat waktu di mesin
4. DCairan tambahan melemahkan dinding fistula dan membuatnya lebih mungkin pecah

Which is correct when caring for a patient with a PICC line?

1. ALeave the external length unchecked once it is placed
2. BFlush the line only when it blocks
3. CUse the PICC arm for heavy lifting to keep it flexible
4. DAvoid taking blood pressure on the arm with the line

A patient admitted for an elective general anaesthetic mentions that they ate a slice of toast 3 hours ago. What should the nurse do?

1. AGive a large drink to wash the food through
2. BAsk the patient to try to vomit to empty the stomach
3. CSay nothing, since toast is a light food
4. DInform the anaesthetist, as surgery may be delayed