Prioritas & Delegasi ala NCLEX: paket kilat

An anxious patient is breathing very fast and has tingling fingers. The blood gas shows pH 7,51 and PaCO₂ 29 mmHg (3,9 kPa). What should the nurse do first?

1. AStay with the patient and coach slow, calm breathing
2. BEncourage the patient to breathe even faster
3. CGive oxygen at the highest flow and leave the room
4. DGive IV sodium bicarbonate as soon as it can be found

A day after a femur fracture, a young patient becomes confused and breathless, with small red spots on the chest. What should the nurse suspect?

1. ANormal pain after a fracture
2. BFat embolism syndrome
3. CAn allergic reaction to the cast
4. DAlcohol withdrawal

A patient is booked for an MRI scan. What must the nurse check beforehand?

1. AWhether the patient’s blood glucose has been in the normal range today
2. BWhether the patient has any metal implants or devices, such as a pacemaker
3. CWhether the patient has eaten a large meal recently
4. DWhether the patient has had a hearing test this year

Over a few hours, the emergency department sees many previously healthy people with the same unusual severe symptoms. What should the nurse do?

1. ATell only the patients’ families about the pattern
2. BReport it to infection prevention and public health authorities promptly
3. CTreat each patient and wait to see if more arrive next week
4. DSend the patients home quickly to avoid crowding the emergency department

When should a blood specimen tube be labeled?

1. AIn the laboratory, by the staff who receive the unlabeled sample
2. BAt the bedside, in the patient's presence, using two identifiers
3. CAt the nurses' station, after all samples for the shift are drawn
4. DBefore entering the room, so tubes are ready for the next patients

A patient on IV gentamicin has a trough level above the target, and the creatinine has risen since yesterday. The next dose is due. What is the best action?

1. AGive half of the dose and document the reason for it
2. BGive the dose now and recheck the levels next week
3. CHold the dose and report the results to the prescriber
4. DGive the dose with extra oral fluids to protect the kidneys

Which group of symptoms suggests hypothyroidism?

1. AWeight loss, heat intolerance and tremor
2. BFever, neck stiffness and photophobia
3. CExcessive thirst and passing large volumes of urine
4. DTiredness, weight gain and feeling cold

A patient faints during cannulation, with a slow pulse and pallor, and recovers quickly when laid flat. There is no rash, wheeze or swelling. What is most likely?

1. AA stroke
2. BA hypoglycaemic coma
3. CAnaphylaxis
4. DVasovagal syncope

After coronary artery bypass surgery through a median sternotomy, which instruction is usually given for the first several weeks?

1. AAvoid walking until the stitches are removed
2. BLift the arms above the head often to stretch the chest
3. CSleep only on the stomach to protect the wound
4. DAvoid heavy lifting and pushing up with the arms

A nurse has four cardiac patients. Which one should be seen first?

1. AA patient with heart failure whose weight is 0,3 kg up on yesterday's morning weight
2. BA patient with AF and a heart rate of 86/min who is due an apixaban dose this morning
3. CA patient with angina whose chest pain has not eased with rest and who is sweating
4. DA patient after a radial angiogram asking when they can eat

Temuan urine mana yang paling membedakan diabetes insipidus dari SIADH?

1. AKedua kondisi menghasilkan urine sangat pekat
2. BDI menghasilkan urine pekat; SIADH menghasilkan urine encer
3. CDI menghasilkan urine encer; SIADH menghasilkan urine pekat
4. DDI menghasilkan glukosa dalam urine; SIADH menghasilkan protein

A patient on a variable rate IV insulin infusion is nil by mouth. Why is a glucose-containing IV fluid usually given alongside it?

1. ATo prevent hypoglycaemia while insulin is running
2. BTo stop the insulin sticking to the IV tubing
3. CTo replace the potassium lost from the cells
4. DTo speed up the action of the insulin in the muscles

When is cold therapy most useful for pain?

1. AFor long-term muscle stiffness, applied continuously for several hours
2. BOver numb areas where sensation is lost
3. CSoon after an acute soft tissue injury, to reduce swelling
4. DDirectly on skin with poor circulation

An immobile patient on opioids drinks very little. Which laxative choice is least appropriate?

1. AA bulk-forming laxative used on its own
2. BA stool softener with a stimulant laxative
3. CAn osmotic laxative such as a macrogol
4. DA stimulant laxative taken regularly