Prioritas & Delegasi ala NCLEX: paket kilat

Seorang perawat meminta asisten keperawatan menggunakan lift mekanis. Asisten mengatakan belum pernah dilatih menggunakannya. Hak pendelegasian mana yang dilanggar bila perawat berkeras?

1. ATugas yang benar
2. BPengawasan dan evaluasi yang benar
3. CArahan dan komunikasi yang benar
4. DOrang yang benar

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

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

A newly hired nurse had BCG vaccine as a child. Which TB screening test is usually preferred?

1. AAn interferon-gamma release assay (IGRA) blood test
2. BA chest x-ray every month for the first year
3. CA tuberculin skin test, which is read 24 hours after it is placed
4. DNo screening, because BCG prevents all TB

A patient on an anticoagulant falls and hits their head but says they feel fine. What should the nurse do?

1. AGive the next anticoagulant dose early to prevent clots from forming after the fall
2. BHelp the patient back to bed and do nothing more if they feel fine
3. CNotify the provider and start neurological observations, because a brain bleed may develop
4. DWait until the next day to see if a headache develops

Seorang pasien dengan infus heparin memiliki aPTT 110 detik; target protokol adalah 1,5–2,5 kali kontrol 30 detik. Apa yang harus dilakukan perawat?

1. AMengikuti protokol heparin, memeriksa perdarahan, dan memberi tahu pemberi layanan
2. BMenaikkan kecepatan infus, karena hasilnya di atas rentang target
3. CMemberikan vitamin K sesuai resep dan melanjutkan infus
4. DMelanjutkan tanpa perubahan dan mengulang aPTT besok pagi

A patient has fever, chills, flank pain and costovertebral angle tenderness. Urinalysis shows many white cells and white cell casts. Which condition is most likely?

1. AGlomerulonephritis
2. BSimple cystitis
3. CAcute pyelonephritis
4. DNephrotic syndrome

Why is an ankle–brachial pressure index (ABPI) measured before applying compression bandages to a leg ulcer?

1. ATo check for a urinary tract infection that could delay ulcer healing
2. BTo work out the patient's fluid needs
3. CTo exclude significant arterial disease, as compression could cut off blood flow
4. DTo measure how deep the ulcer is and how much exudate it produces

A patient with myasthenia gravis develops increasing difficulty swallowing and weak, shallow breathing. What is the main danger?

1. ARespiratory failure from a myasthenic crisis
2. BA urinary tract infection
3. CSevere hypertension from anxiety
4. DA sudden rise in blood glucose from the stress

A patient on theophylline develops nausea, vomiting, a fast heart rate and restlessness. What should the nurse suspect?

1. AHypoglycaemia caused by the drug
2. BAn expected sign that the drug is working
3. CTheophylline toxicity
4. DA theophylline allergy causing a rash

A patient who injects drugs has a fever, a new heart murmur and splinter haemorrhages. Before antibiotics are started, what is most important?

1. ATake a single blood culture from the cannula
2. BTake several sets of blood cultures from separate sites
3. CArrange an exercise ECG test
4. DWait for an echocardiogram before taking any samples

Why is propranolol given to a patient with hyperthyroidism?

1. ATo replace the hormone lost from the thyroid gland
2. BTo stop the thyroid gland from making any more hormones
3. CTo ease tremor and palpitations while other treatment starts
4. DTo destroy overactive thyroid tissue over a few weeks

A patient with a long-term catheter has fever and rigors, and a catheter UTI is suspected. Which action is recommended before starting antibiotics?

1. AFlush the catheter with saline and continue
2. BRemove the catheter and leave it out permanently
3. CReplace the catheter and take a sample from the new one
4. DTake a sample from the drainage bag and send it to the lab

Pengkajian di sisi tempat tidur mana yang digunakan untuk memantau asites?

1. ABerat badan harian dan lingkar perut
2. BUkuran pupil dan reaksinya dua kali sehari
3. CArus puncak dan saturasi oksigen
4. DGlukosa kapiler sebelum setiap makan

An older patient on regular opioids has small amounts of liquid stool leaking all day, but has not had a formed bowel movement for 6 days. What is the most likely cause?

1. AA flare of ulcerative colitis
2. BAcute infective gastroenteritis
3. CFaecal impaction with overflow
4. DNormal stool pattern on opioids