Prioritas & Delegasi ala NCLEX: paket kilat

Two nursing assistants argue loudly at the station about their assignments. What is the charge nurse’s best first step?

1. AIgnore it and hope they sort it out
2. BReport them to human resources at once
3. CMeet both of them privately to hear each side
4. DChange both of their assignments without any discussion

A patient with suspected sepsis has four prescribed orders. Which should usually be done first?

1. AArrange a chest X-ray for later today
2. BGive the IV antibiotic
3. CRepeat the lactate in six hours
4. DTake blood cultures

Seorang pasien dengan dugaan tuberkulosis berada di ruang bertekanan negatif. Praktik mana yang benar?

1. AMembiarkan pintu terbuka agar petugas dapat melihat pasien setiap saat
2. BMembiarkan pengunjung masuk tanpa perlindungan apa pun
3. CMematikan ventilasi ruangan pada malam hari
4. DMenjaga pintu tetap tertutup kecuali saat masuk atau keluar

A patient on airborne precautions for tuberculosis wants to walk in the hallway. What is the best response?

1. AExplain that they must stay in the room, and offer ways to stay active inside it
2. BAllow it, as long as the patient wears an N95 respirator in the corridor
3. CAllow it, if they avoid the nurses’ station
4. DAllow it, as long as they walk quickly

Kumpulan temuan mana yang sesuai dengan hiperkalsemia?

1. AHaus dengan urine sangat encer sebagai satu-satunya tanda
2. BTetani, kram otot, dan tanda Chvostek positif
3. CGelombang T runcing dan kelemahan otot saja
4. DKonstipasi, kelelahan, kebingungan, dan batu ginjal

A patient on warfarin with an INR of 3,6 fell and hit their head an hour ago. They now report a worsening headache and drowsiness. What is the priority?

1. AHold warfarin for one dose and observe at home
2. BEncourage rest in a dark room to settle the pain
3. CReport urgently for imaging and possible reversal
4. DGive acetaminophen (paracetamol) and recheck the INR tomorrow

Which lifestyle advice helps a patient with gastro-oesophageal reflux disease?

1. AAvoid large meals late in the evening and raise the head of the bed
2. BEat one very large meal a day rather than several small ones
3. CWear tight belts to support the stomach
4. DLie down straight after each meal to let the food settle

Which patient should the nurse assess first?

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

A patient has exercise-induced asthma. Which advice is most appropriate?

1. ATake a beta-blocker before exercise
2. BUse the reliever inhaler shortly before exercise and warm up
3. CExercise only in cold, dry air to toughen the airways
4. DAvoid all forms of exercise permanently to prevent attacks

A patient with severe COPD has increasing ankle oedema and a raised JVP, but no crackles and a normal left ventricle on echocardiography. Which condition is most likely?

1. ALeft ventricular failure
2. BDeep vein thrombosis
3. CCor pulmonale
4. DAortic stenosis

A patient has acute glomerulonephritis with oedema and high blood pressure. Which nursing care is most appropriate?

1. AMonitor BP, fluid balance and daily weight
2. BEncourage a high-salt diet to balance the fluids
3. CGive large amounts of IV fluid
4. DCheck the weight once a week

Why may HbA1c be unreliable in a patient with haemolytic anaemia or a recent large blood transfusion?

1. ABlood transfusions contain large amounts of glucose
2. BAnaemia always makes the HbA1c very high
3. CIt depends on how long red blood cells survive in the blood
4. DThe test only measures the glucose in the plasma, not in the cells

A day after a spinal anaesthetic, a patient has a headache that is worse when sitting up and better when lying flat. What is the most likely cause?

1. ARaised blood pressure from pain
2. BA side effect of the antibiotic
3. CPost-dural puncture headache
4. DMigraine caused by hospital lighting

Four patients from a house fire arrive in the emergency department. Which should the nurse assess first?

1. AA blistered forearm burn and a small cut on the knee
2. BPartial-thickness burns to both legs, with pain rated 8/10
3. CRedness on the backs of both hands, and very anxious
4. DCircumferential chest burns, with breathing becoming shallow and laboured