Prioritas & Delegasi ala NCLEX: paket kilat

A nurse cannot read part of a medication order. What should the nurse do?

1. AGive the usual dose of the drug the nurse thinks was meant
2. BAsk another nurse to guess what the order most likely says, then give it
3. CSkip the drug and not tell anyone until the next ward round
4. DContact the prescriber to clarify the order before giving the drug

Pasien mana yang harus pertama kali dieskalasi perawat ke tim respons cepat?

1. APasien selulitis dengan suhu 38,1 °C, dengan tanda vital lainnya normal
2. BPasien infeksi saluran kemih yang baru bingung, dengan frekuensi napas 26/menit dan tekanan darah sistolik 94 mmHg
3. CPasien setelah operasi lutut dengan nyeri 6/10 dan tanda vital normal
4. DPasien hipertensi yang diketahui dengan tekanan darah 152/94 mmHg dan merasa sehat

Which technique is used for suctioning a tracheostomy in hospital?

1. AClean technique, with the catheter rinsed in tap water
2. BNo gloves at all, because the airway already contains bacteria
3. CClean technique, reusing the catheter during the shift
4. DSterile technique, with a sterile catheter and sterile glove

A patient on oxygen needs an MRI scan. Which plan is safe?

1. ALeave the steel cylinder on the patient’s bed during the scan
2. BRemove the oxygen for the scan without telling anyone
3. CUse only MRI-safe equipment, and never take a standard steel oxygen cylinder into the scanner room
4. DTake the usual steel cylinder into the room if it is tightly strapped to the trolley frame

Why is a blood β-hydroxybutyrate level often preferred to a urine ketone dipstick in DKA?

1. AIt measures the main ketone in DKA, and the dipstick may miss it
2. BIt is the only test that can measure glucose and ketones together
3. CThe urine dipstick only detects ketones in people without diabetes
4. DIt shows the average ketone level over the past three months

A patient in DKA is receiving IV fluids and insulin. The glucose has fallen to about 220 mg/dL (12,2 mmol/L), but the anion gap is still high. What change would the nurse expect?

1. AStop the IV fluids and start oral fluids only
2. BStop the insulin infusion because the glucose is near normal
3. CAdd dextrose to the IV fluids and continue the insulin
4. DGive an IV bolus of sodium bicarbonate at once

Which is a first-line nursing measure to help prevent constipation in hospital?

1. AKeeping the patient in bed
2. BGiving an enema to every patient on admission
3. CEncouraging fluids, fibre and mobility
4. DRestricting fluids to reduce urine output

A patient has a full-thickness burn all the way round the forearm. Which complication must be watched for closely?

1. AExcessive bleeding from the burn surface needing an urgent blood transfusion
2. BHypoglycaemia caused by the body using glucose to heal the burn
3. CLoss of circulation to the hand as swelling builds under tight burned skin
4. DDelayed hair growth on the arm

After repair of an abdominal aortic aneurysm, which regular assessment helps detect a blocked graft or clots in the legs?

1. AChecking leg pulses, colour, warmth and sensation
2. BTesting the gag reflex every four hours after surgery
3. CMeasuring the blood glucose every hour through the night
4. DChecking the pupils' response to light

A patient on a morphine PCA after surgery is very drowsy, with a respiratory rate of 7/min and pinpoint pupils. SpO₂ is 89%. What should the nurse do first?

1. AEncourage the patient to keep pressing the PCA button for comfort
2. BGive a sedative to keep the patient comfortable
3. CStop the PCA, support breathing, give oxygen and get naloxone
4. DLeave the patient to sleep and recheck the observations in an hour

Tindakan keperawatan mana yang membantu mencegah peningkatan tekanan intrakranial?

1. AMendorong batuk keras setiap jam
2. BMencegah konstipasi dan menjarangkan perawatan
3. CMelakukan semua perawatan dan pengisapan dalam satu sesi panjang
4. DMembaringkan pasien datar dengan pinggul ditekuk tajam

During haemodialysis, a patient suddenly becomes breathless with chest pain, and air is seen in the line. What should the nurse do first?

1. AContinue the session and recheck in 30 minutes
2. BSit the patient upright and give a drink of water
3. CSpeed up the pump to clear the air into the patient
4. DClamp the lines and lay the patient left side down, head low

A patient had an upper GI endoscopy with a local anaesthetic throat spray. What must the nurse check before giving a drink?

1. AThat the patient has passed urine since the procedure
2. BThat swallowing and the gag reflex have returned
3. CThat bowel sounds are present in all four quadrants
4. DThat the patient's blood glucose is above normal

After surgery, a patient says they have "no pain" but grimaces, breathes shallowly and refuses to move or cough. What should the nurse do?

1. ATell the patient firmly that they must stop hiding their pain from staff
2. BInsist they walk without any analgesia
3. CAccept the statement and record a pain score of 0
4. DExplore their beliefs and explain how analgesia aids recovery