Prioritas & Delegasi ala NCLEX: paket kilat

On a pediatric unit, which child does the nurse assess first?

1. AA child in a new arm cast with pink, warm fingers and pain of 5/10
2. BA child with asthma who is now quiet with very little air movement
3. CA child with croup who has a barking cough but no stridor at rest
4. DA child with a temperature of 38,2 °C after vaccination

The charge nurse overhears four instructions from an RN to a nursing assistant. Which one needs to be corrected?

1. A“Check his glucose before lunch and tell me the number straight away.”
2. B“Help him wash and change, and tell me at once if you see any red or broken skin.”
3. C“Walk him to the bathroom and back, and stay with him the whole time.”
4. D“Check his glucose and give the insulin according to the sliding scale.”

A family member will visit a patient on contact precautions. What should the nurse do?

1. AShow them how to use the gown and gloves and how to clean their hands
2. BTell them visits are not allowed at all
3. CAsk them to wear an N95 respirator only, with no gown or gloves
4. DTell them precautions only apply to staff

A patient on contact precautions for MRSA has become withdrawn and says, “Everyone avoids me.” What is the best nursing action?

1. AStop the precautions for a few days so the patient feels less isolated and alone
2. BKeep visits short to limit the risk of spreading MRSA
3. CExplain why the precautions are needed and plan regular, unhurried time in the room
4. DAsk the provider for a sedative to help the patient cope

Seorang pasien yang mengonsumsi fenitoin memiliki kadar 28 mcg/mL (rentang biasa sekitar 10–20 mcg/mL). Temuan mana yang diharapkan perawat?

1. ARasa lapar dan kenaikan berat badan
2. BGelombang T tinggi dan runcing
3. CNistagmus, gaya berjalan tidak stabil, dan bicara pelo
4. DPerilaku hiperaktif dan insomnia saja

A woman with preeclampsia is receiving IV magnesium sulfate. Her urine output has fallen and her creatinine is rising. Why is this a concern?

1. AMagnesium is excreted by the kidneys, so it can build up to toxic levels
2. BPoor kidney function makes the magnesium level fall quickly
3. CMagnesium is broken down by the liver, so it will stop working soon
4. DMagnesium causes potassium loss, so the kidneys release more fluid

What is one advantage of a direct oral anticoagulant (DOAC) such as apixaban compared with warfarin?

1. AIt does not need routine INR monitoring
2. BIt never interacts with other drugs
3. CIt has no risk of bleeding
4. DIt is safe in all patients with severe kidney failure

A patient taking dapagliflozin is vomiting and unwell, with high blood ketones and a blood glucose of only 11 mmol/L (198 mg/dL). What should be suspected?

1. AEuglycaemic diabetic ketoacidosis
2. BSimple gastroenteritis with no further concern
3. CHypoglycaemia
4. DHyperosmolar hyperglycaemic state

Seorang pasien gagal jantung memulai spironolakton selain penghambat ACE. Hasil darah mana yang memerlukan pemantauan ketat?

1. AHemoglobin, karena kedua obat dapat menyebabkan perdarahan
2. BGlukosa, karena kedua obat dapat menyebabkan hipoglikemia
3. CKalsium, karena kedua obat dapat menurunkannya
4. DKalium, karena kedua obat dapat meningkatkannya

An older ex-smoker has a dry cough and worsening breathlessness over a year, finger clubbing and fine "Velcro-like" crackles at both bases at the end of inspiration. Which condition is most likely?

1. ASpontaneous pneumothorax
2. BCommunity-acquired pneumonia
3. CIdiopathic pulmonary fibrosis
4. DAn acute asthma attack

A patient has just started levetiracetam. Which side effect should the nurse teach them to report?

1. AA persistent dry cough at night
2. BSwelling and overgrowth of the gums around the teeth
3. CChanges in mood, such as irritability, low mood or anger
4. DOrange discoloration of the urine

A nurse teaches a patient with Hashimoto's thyroiditis about levothyroxine. Which statement shows a need for further teaching?

1. A"I can stop the tablets once I feel back to normal."
2. B"I will have regular blood tests to check my dose."
3. C"I will report palpitations or chest pain."
4. D"I will take the tablets at the same time each day."

Which lung problem is a known toxicity of bleomycin?

1. APneumothorax from coughing
2. BAsthma from pollen
3. CLung cancer within weeks
4. DPulmonary fibrosis

Just after extubation in recovery, a patient develops a high-pitched noise on breathing in, with falling SpO₂. What should the nurse do first?

1. AWait a few minutes to see if it passes
2. BCall for help, give 100% oxygen and use a jaw thrust
3. CGive an opioid to calm the patient's breathing and reduce anxiety
4. DSit the patient up and give a drink of water