Prioritas & Delegasi ala NCLEX: paket kilat

A patient has a nasogastric tube on suction. Which task can the nurse delegate to a nursing assistant?

1. AAssessing the drainage for blood
2. BIrrigating the tube when it blocks
3. CGiving mouth care
4. DChecking the tube’s position

A patient with known abdominal aortic aneurysm suddenly has severe back pain, a pulsing mass in the abdomen and a falling blood pressure. What should the nurse do?

1. AGive an oral analgesic and reassess the patient in about one hour
2. BEncourage the patient to walk to ease the back pain
3. CCall for emergency help at once and prepare for urgent surgery
4. DPalpate the mass firmly to check its size and spread

Which PPE does a nurse wear when giving an IV chemotherapy drug?

1. AOne pair of standard latex gloves, changed after the infusion is started
2. BA reusable cloth gown and one pair of gloves
3. CA surgical mask and no gloves
4. DTwo pairs of chemotherapy-tested gloves and a disposable impermeable gown

A patient has signed a surgical consent form but tells the nurse, “I don’t really understand what they are going to do.” What should the nurse do?

1. AReassure the patient that the surgeon knows best and continue with the preparation
2. BInform the surgeon so the procedure can be explained again before any sedation
3. CGive the preoperative sedative so the patient relaxes
4. DExplain the risks and benefits in place of the surgeon

A patient's potassium is 7,0 mEq/L. Which ECG change would the nurse expect?

1. ADelta waves before the QRS
2. BTall, peaked T waves
3. CFlattened T waves
4. DProminent U waves

Seorang pasien malnutrisi mulai makan kembali dan, pada hari ke-3, memiliki fosfat 1,2 mg/dL (0,39 mmol/L) dengan kelemahan otot dan sesak napas. Apa risiko utamanya?

1. AOtot pernapasan lemah dan gagal jantung akibat fosfat rendah
2. BHiperkalemia akibat sel melepaskan kalium
3. CBatu ginjal akibat kalsium yang dilepaskan tulang
4. DKenaikan berat badan cepat, tetapi tanpa bahaya serius

Which of these is a non-drug measure that can help relieve pain?

1. ARepositioning and distraction
2. BRestricting visitors completely
3. CKeeping the patient awake all night
4. DTelling the patient that the pain is not real

A patient with known prostate cancer reports new back pain, leg weakness and difficulty passing urine. What should be suspected?

1. ASimple mechanical back pain
2. BA urinary tract infection spreading to the back
3. CMetastatic spinal cord compression
4. DHypokalaemia

A patient on ramipril is to start sacubitril/valsartan for heart failure. What is the key safety point?

1. ASacubitril/valsartan is safe to start on the same morning
2. BThe ACE inhibitor must be stopped first, with a gap before starting
3. CBoth drugs should be taken together each day for the best effect
4. DThe ACE inhibitor dose should be doubled during the change

Seorang pasien dengan TVD betis yang terkonfirmasi telah memulai antikoagulasi terapeutik dan bertanya apakah ia harus tetap di tempat tidur. Jawaban paling akurat apa?

1. ATungkai harus dipijat sebelum setiap berjalan
2. BTirah baring ketat diperlukan setidaknya dua minggu
3. CBerjalan sesuai toleransi biasanya dianjurkan setelah diobati
4. DBerjalan tidak diperbolehkan sampai bekuan larut sepenuhnya

Which nursing action helps most to prevent and manage delirium in an older inpatient?

1. AMove the patient to a different room each day for variety
2. BUse glasses and hearing aids and reorient the patient often
3. CKeep the lights on all night so the patient can see clearly
4. DRestrain the patient so that they do not wander off the ward

A patient on carbamazepine is admitted confused, with a sodium of 121 mmol/L. Which explanation is most likely?

1. AConfusion is a normal, expected effect of carbamazepine and is unrelated to sodium
2. BCarbamazepine can cause hyponatraemia through an SIADH-like effect
3. CThe low sodium proves the patient has stopped taking the drug
4. DCarbamazepine causes salt loss through severe diarrhoea

Which wound drain observation should be reported immediately?

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

Seorang pasien dengan PCA opioid menerima oksigen melalui masker. SpO₂ 97% dan laju napas 11/menit, tetapi kini sulit dibangunkan. Apa kesimpulan perawat?

1. AToksisitas opioid kemungkinan besar; oksigen mungkin menutupi hipoventilasi
2. BPasien hanya tidur nyenyak, karena nyeri terkontrol
3. CPasien aman, karena saturasi oksigen normal
4. DDosis PCA harus dinaikkan agar pasien tetap nyaman