Prioritas & Delegasi ala NCLEX: paket kilat

A patient is receiving opioids after surgery. Which finding usually comes before opioid-induced respiratory depression?

1. AIncreased appetite and thirst
2. BA sudden rise in pain scores
3. CA rise in blood pressure with flushed cheeks
4. DIncreasing sleepiness that is hard to rouse

An older patient has bruises of different ages and seems frightened when a relative visits. What is the nurse’s priority?

1. ATell the patient she must leave home and go to live somewhere else
2. BEnsure the patient’s safety, document the findings and report as required
3. CIgnore it, because older people bruise easily
4. DAsk the relative directly in front of the patient whether they hit her

When should a nurse call the rapid response team?

1. AOnly when the provider has written an order for a rapid response call in the chart
2. BOnly when the patient’s family makes a complaint
3. CWhen a patient shows an acute decline, such as new confusion or a sharp change in vital signs
4. DOnly after a patient has had a cardiac or respiratory arrest on the ward

A patient sitting in a chair starts to have a generalized seizure. What should the nurse do?

1. ALeave to get the provider, then return
2. BPut a padded tongue blade between the teeth to protect the tongue and airway
3. CEase the patient to the floor, protect the head and turn them on their side
4. DHold the patient firmly in the chair until the seizure stops

A patient scheduled for surgery this morning has a potassium of 3,0 mEq/L on pre-operative tests. What should the nurse do?

1. AGive an oral potassium dose without a prescription
2. BSend the patient to surgery without comment
3. CRepeat the test after the surgery is finished
4. DReport it to the surgical team before surgery

A patient has macrocytic anemia with low vitamin B₁₂ and antibodies to intrinsic factor. What does this suggest, and how is it usually treated?

1. AHemolytic anemia, treated with blood transfusion
2. BIron deficiency, treated with oral iron tablets
3. CFolate deficiency, treated with folic acid only
4. DPernicious anemia, treated with B₁₂ injections

Seorang pasien di bangsal mengalami mengi dan sesak napas setelah dosis pertama penyekat beta. Riwayat mana yang membuat hal ini paling mungkin?

1. AHipotiroidisme
2. BAsma
3. CMigrain
4. DOsteoartritis

Seorang pasien cedera kepala memiliki GCS yang turun dari 14 menjadi 10, dan satu pupil menjadi lebih besar serta lambat bereaksi. Apa yang harus dilakukan perawat?

1. APeriksa ulang GCS pada putaran observasi rutin berikutnya
2. BAnjurkan pasien untuk tidur
3. CSegera lakukan eskalasi sebagai kegawatdaruratan neurologis
4. DBerikan sedatif untuk menenangkan pasien

After an acute coronary syndrome, a patient with a normal cholesterol level is prescribed a high-intensity statin. Why?

1. AStatins are given after an ACS mainly to lower the blood pressure
2. BStatins reduce further events whatever the starting cholesterol
3. CStatins work as painkillers for chest pain
4. DStatins are needed only if the cholesterol level is very high

A patient's blood gas shows pH 7,26, PaCO₂ 9,0 kPa (68 mmHg) and bicarbonate 25 mmol/L. What does this show?

1. AAcute respiratory acidosis
2. BMetabolic acidosis with compensation
3. CMetabolic alkalosis
4. DRespiratory alkalosis

A patient has taken metformin for many years and now has tingling feet and a low haemoglobin. Which blood test is most relevant?

1. ABlood alcohol level
2. BVitamin B12 level
3. CThyroid antibodies
4. DSerum amylase

Seorang pasien dengan cedera medula spinalis T4 mengalami sakit kepala berdenyut, TD 210/110 mmHg, kulit memerah dan berkeringat di atas cedera, dan nadi 50/menit. Setelah mendudukkan pasien, apa prioritas berikutnya?

1. AMemberikan bolus cairan IV cepat untuk menunjang sirkulasi
2. BMencari dan menyingkirkan pemicu, dimulai dari kandung kemih
3. CMembaringkan pasien datar lagi dan mengangkat tungkai di atas bantal
4. DMemberikan sedatif dan memeriksa ulang tekanan darah dalam satu jam

Which wound drain observation should be reported immediately?

1. ADrainage slowly falling each day
2. BA little dried blood around the drain site
3. CSmall amounts of pink serous fluid
4. DA sudden large volume of fresh red blood

A patient has a category (stage) 2 pressure ulcer on the sacrum. Which plan is most appropriate?

1. AOffload the area, manage moisture, support nutrition and dress it
2. BLeave it uncovered and dry it with a hair dryer
3. CMassage around the wound every hour to stimulate blood flow to the skin
4. DSit the patient upright in a chair for most of the day