Prioritas & Delegasi ala NCLEX: paket kilat

Seorang kepala ruangan perlu mengosongkan tempat tidur. Pasien mana yang paling tepat dipulangkan atau dipindahkan ke tingkat perawatan yang lebih rendah?

1. AHari ke-1 setelah operasi usus dengan suhu baru 38,5 °C
2. BPneumonia, dengan kebutuhan oksigen yang naik semalam dari 2 menjadi 4 L/menit
3. CDirawat dua jam yang lalu dengan nyeri dada; hasil troponin masih menunggu
4. DHari ke-3 setelah apendektomi tanpa komplikasi, sudah makan, dengan analgesik oral

A patient was knocked out briefly in a fall, then woke and talked normally. Two hours later the patient becomes drowsy and one pupil is larger. What is the most likely cause?

1. AA mild concussion that is settling
2. BLow blood sugar from missing a meal
3. CAn epidural hematoma
4. DNormal tiredness after a fall

A patient is on seizure precautions. Which equipment should be ready at the bedside?

1. AA tongue blade to put between the teeth
2. BAn ice pack to place on the forehead
3. CRestraints ready for all four limbs
4. DWorking suction and oxygen equipment

Sebuah instruksi tulisan tangan berbunyi "10U insulin reguler subkutan sekarang". Tindakan terbaik perawat apa?

1. AMengklarifikasi instruksi, karena "U" dapat salah dibaca
2. BMemberikan 100 unit, seperti yang tampaknya tertulis
3. CMeminta asisten perawat menafsirkan tulisan tangan
4. DMemberikan 10 unit tanpa bertanya, sesuai yang tertulis

A patient with iron-deficiency anemia started oral iron. Which result is usually the earliest sign that treatment is working?

1. AA rise in the platelet count
2. BA fall in the mean cell volume (MCV)
3. CA rise in the reticulocyte count
4. DA fall in the white cell count

A patient has a continuous heparin infusion for a pulmonary embolism. A new nurse plans to adjust the infusion using today's INR of 1,1. What should the experienced nurse explain?

1. AHeparin is adjusted using the aPTT or anti-Xa level, not the INR
2. BHeparin needs no laboratory monitoring once the infusion is started
3. CThe INR is the correct test, and 1,1 means heparin is therapeutic
4. DThe INR of 1,1 means the heparin rate must be doubled at once

How does CPAP help a patient with obstructive sleep apnoea?

1. AIt strengthens the breathing muscles during the day
2. BIt delivers bronchodilator drugs deep into the lungs overnight
3. CIt removes excess carbon dioxide from the lungs by gentle suction
4. DIt keeps the upper airway open during sleep with continuous air pressure

Perubahan EKG apa yang secara klasik terkait dengan hiperkalemia berat?

1. AGelombang T tinggi dan runcing
2. BInterval PR memendek
3. CGelombang U yang menonjol
4. DHanya depresi ST

Seorang pasien penyakit arteri perifer mengalami nyeri tungkai pada malam hari. Posisi mana yang dapat meredakannya?

1. AMenggantungkan tungkai ke bawah di tepi tempat tidur
2. BMengangkat tungkai di atas bantal di atas level jantung
3. CMenempelkan botol air panas langsung pada kaki
4. DMembungkus tungkai dengan perban kompresi

A 74-year-old with atrial fibrillation, hypertension and diabetes asks why she needs an anticoagulant when she feels well. Which reply is best?

1. AHer risk of stroke is high, and an anticoagulant lowers it
2. BIt is given to lower her blood pressure
3. CIt is needed only while she has palpitations
4. DThe anticoagulant will stop the irregular heartbeat for good

Setelah operasi hipofisis, seorang pasien mengeluarkan 400 mL urine per jam selama tiga jam dengan berat jenis rendah. Apa yang harus dicurigai perawat?

1. ADiuresis normal
2. BSIADH
3. CDiabetes insipidus
4. DCedera ginjal akut

A patient with motor neurone disease reports morning headaches, poor sleep and sleepiness during the day. What do these symptoms suggest?

1. AWeak breathing at night, so a review for ventilation support
2. BLow mood, which should be treated with an antidepressant first
3. CNormal tiredness that needs no specific action
4. DA side effect of riluzole, which should be stopped straight away by the nurse

How does sucralfate help a peptic ulcer heal?

1. AIt kills H. pylori in the stomach lining
2. BIt forms a protective coating over the ulcer base
3. CIt speeds up emptying of the stomach
4. DIt blocks histamine receptors on parietal cells

A patient with cirrhosis and ascites has a falling urine output and a rising creatinine. They have not received nephrotoxic drugs and are not dehydrated. Which complication is likely?

1. ANephrotic syndrome
2. BPolycystic kidney disease
3. CUrinary tract infection
4. DHepatorenal syndrome