Prioritas & Delegasi ala NCLEX: paket kilat

A patient’s peripheral IV site is swollen, pale and cool, and the infusion has slowed. What should the nurse do first?

1. AStop the infusion and remove the cannula
2. BIncrease the infusion rate to overcome the resistance
3. CApply a tight bandage over the site to reduce swelling
4. DFlush the cannula hard to clear the blockage

An adult choking on food is coughing forcefully and can speak a little. What should the nurse do?

1. AGive the patient water to wash the food down
2. BGive abdominal thrusts straight away until the food comes out
3. CEncourage the patient to keep coughing and stay with them
4. DSweep the mouth blindly with a finger

How should the urethral meatus be cared for in a patient with an indwelling urinary catheter?

1. ABy sliding the catheter in and out a little to clean it
2. BWith routine hygiene, using soap and water during daily washing
3. CWith daily bladder irrigation using an antibiotic solution through the catheter
4. DWith antiseptic cream applied to the meatus every shift

A nurse caring for a patient with influenza on droplet precautions will assist with an aerosol-generating procedure, such as bronchoscopy. What change in PPE is needed?

1. AWear a fit-tested respirator (N95 or FFP3) and eye protection instead of a surgical mask
2. BWear gloves only, because the procedure is short
3. CWear two surgical masks, one on top of the other, for the length of the procedure
4. DNo change, because influenza only needs droplet precautions

Seorang pasien sirosis memiliki albumin 2,2 g/dL (22 g/L). Temuan mana yang paling mungkin berkaitan?

1. ATekanan darah tinggi
2. BKeluaran urine meningkat
3. CEdema dan asites
4. DHiperkalemia

A young adult has fatigue, bruising and fever. The white cell count is 85 × 10³/µL with many blasts, the hemoglobin is 7,9 g/dL (79 g/L) and the platelets are 22 × 10³/µL. What is the most likely diagnosis?

1. APolycythemia vera
2. BAcute viral infection
3. CIron-deficiency anemia
4. DAcute leukemia

What should a patient be told before using sublingual glyceryl trinitrate (GTN, nitroglycerin) spray for angina?

1. ASwallow the spray rather than leaving it under the tongue
2. BUse it only after the pain has lasted over an hour, with the patient lying flat
3. CSit down before using it, as it can cause dizziness and low blood pressure
4. DTake it with a large glass of milk to protect the stomach lining

Dua hari setelah reseksi usus, seorang pasien mengalami nyeri yang makin bertambah, demam, takikardia, dan cairan yang tampak seperti tinja di drain luka. Apa yang paling mungkin?

1. AKonstipasi
2. BPemulihan pascaoperasi yang normal
3. CKebocoran anastomosis
4. DRetensi urine

After varicose vein surgery, which advice is usually given?

1. AStand still for long periods to help the veins heal
2. BAvoid all walking until the bruising has gone
3. CStay in bed for two weeks with the legs hanging down
4. DWear the compression stockings as advised and walk regularly

Why is the cuff pressure of an endotracheal or tracheostomy tube checked regularly?

1. AThe cuff must be kept fully deflated in every ventilated patient
2. BThe cuff pressure directly controls the patient's oxygen saturation
3. CToo high a pressure damages the trachea; too low allows aspiration
4. DThe cuff pressure sets the ventilator's breathing rate

A patient with multiple sclerosis says their symptoms get worse after a hot bath. What should the nurse explain?

1. AThis shows that the disease has entered a new progressive stage
2. BThey should take very cold baths to reverse the damage
3. CHot baths cause new areas of damage in the brain
4. DHeat can briefly worsen MS symptoms, which settle when they cool down

The nurse has four renal patients. Which one needs to be seen first?

1. AA patient with a creatinine slightly above their usual level
2. BA patient with mild itching from uraemia who wants a cream
3. CA patient with CKD asking about their phosphate binder
4. DA patient with a potassium of 6,8 mmol/L who reports palpitations

Why are urinary catheters removed as early as possible after surgery?

1. ABecause patients cannot drink normally while a catheter is in place
2. BBecause catheters always cause kidney stones
3. CTo reduce the risk of catheter-associated infection
4. DBecause the catheter stops the bowel working

A patient has an implanted port for chemotherapy. Which needle is used to access it?

1. AA standard hollow needle used for venepuncture
2. BA wide-bore cannula with a steel stylet
3. CA non-coring (Huber) needle
4. DAn intramuscular injection needle