Prioritas & Delegasi ala NCLEX: paket kilat

Which patient is most suitable for the nurse to assign to a nurse who has just finished orientation?

1. AA patient with stable cellulitis on scheduled IV antibiotics
2. BA patient on a continuous heparin infusion with rising aPTT values
3. CA patient with a new tracheostomy who needs frequent suctioning
4. DA patient with sepsis whose blood pressure is falling

Two weeks after birth, a mother says she hears voices telling her the baby is evil. What is the priority?

1. AReassure her that this is normal “baby blues”
2. BLeave her alone with the baby to bond
3. CAdvise more sleep and book a routine follow-up visit for next month
4. DKeep the mother and baby safe and arrange urgent psychiatric care

A portable x-ray is taken at the bedside. Which action protects the nurse?

1. AStep away from the patient or wear a lead apron during the exposure
2. BStay close to the patient to keep them still without protection
3. CStand next to the patient and hold the film without protection
4. DLook directly at the x-ray tube during the exposure to check its position

A nurse cannot find a confused patient who was in their room 15 minutes ago. What should the nurse do first?

1. ADocument the absence at the end of the shift
2. BCall the family to ask whether the patient has gone home on their own
3. CAlert staff and security at once, following the missing-patient procedure
4. DWait an hour in case the patient comes back

A patient with type 1 diabetes has the flu, is eating little and has a glucose of 290 mg/dL (16,1 mmol/L). Which advice is correct?

1. AKeep taking insulin and check blood or urine ketones
2. BWait 3 days before checking the glucose again
3. CStop all insulin until you are eating normally again
4. DDrink only water and avoid all carbohydrate foods

A 68-year-old man has fatigue, a hemoglobin of 9,8 g/dL (98 g/L), an MCV of 72 fL and a low ferritin. He eats a normal diet. What is the most important next step?

1. AGive iron and do no further tests at all
2. BStart vitamin B₁₂ injections
3. CLook for a source of blood loss in the gut
4. DRepeat the blood count in one year

Seorang pasien gagal jantung memiliki sputum merah muda berbusa dan ronki di seluruh kedua paru. Apa yang terjadi?

1. APerdarahan saluran cerna atas
2. BEdema paru akut
3. CSerangan asma
4. DPneumotoraks

Why must blood samples for a cross-match be labelled at the bedside immediately after they are taken?

1. ATo prevent "wrong blood in tube" errors that can cause fatal reactions
2. BTo let the patient sign the label
3. CTo keep the sample warm so the cells do not break down in transit
4. DTo speed up the laboratory's computer system and reduce the waiting time

Menurut pedoman terkini, kapan oksigen diberikan kepada pasien dengan sindrom koroner akut?

1. ATidak pernah, karena oksigen merusak otot jantung
2. BSelalu 15 L/menit, berapa pun saturasinya
3. CHanya bila SpO₂ di bawah rentang target
4. DHanya setelah hasil troponin tersedia

After positive end-expiratory pressure (PEEP) is increased on a ventilated patient, the blood pressure falls. What is the most likely reason?

1. AHigher chest pressure reduces venous return to the heart
2. BPEEP causes immediate blood loss from the alveolar capillaries
3. CPEEP directly weakens the heart muscle and its contraction
4. DPEEP lowers the blood oxygen level

A patient is starting lamotrigine. Which teaching point is most important?

1. ADouble the dose if a seizure happens
2. BExpect an orange tint to tears and urine
3. CTake it with a glass of grapefruit juice to improve its absorption
4. DReport any skin rash promptly, especially in the first weeks

A patient on haemodialysis is on a medical ward. Which task can the registered nurse delegate to a healthcare assistant (nursing assistant)?

1. ATeaching the patient about fluid restriction
2. BWeighing the patient before they go to dialysis
3. CAssessing the thrill and bruit of the fistula
4. DDeciding which morning medicines to hold

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

1. AGlukosa kapiler sebelum setiap makan
2. BArus puncak dan saturasi oksigen
3. CBerat badan harian dan lingkar perut
4. DUkuran pupil dan reaksinya dua kali sehari

A patient with a toe ulcer says the leg pain is worse at night and eases when they hang the leg over the side of the bed. What does this suggest?

1. ALymphoedema
2. BVenous insufficiency
3. CArterial insufficiency
4. DNeuropathic itching