Prioritas & Delegasi ala NCLEX: paket kilat

A patient’s peripheral IV site is swollen, pale and cool, and the infusion has slowed. What should the nurse do first?

1. AIncrease the infusion rate to overcome the resistance
2. BFlush the cannula hard to clear the blockage
3. CApply a tight bandage over the site to reduce swelling
4. DStop the infusion and remove the cannula

Setelah serah terima, pasien mana yang harus dikaji perawat lebih dulu?

1. AHari ke-2 setelah operasi kandung empedu: nyeri 6/10, analgesik berikutnya dijadwalkan 30 menit lagi
2. BDiabetes tipe 2: glukosa 210 mg/dL (11,7 mmol/L) sebelum makan siang, tanpa gejala
3. C1 jam setelah kateterisasi jantung melalui femoralis: nyeri punggung baru, nadi 118/menit, TD 92/58 mmHg
4. DPPOK dengan oksigen 2 L/menit: SpO₂ 90%, frekuensi napas 22/menit, pada kondisi dasarnya

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. BStand next to the patient and hold the film without protection
3. CLook directly at the x-ray tube during the exposure to check its position
4. DStay close to the patient to keep them still without protection

In a mass-casualty incident with limited resources, why may a critically injured patient with little chance of survival receive care after others?

1. AResources go first to those most likely to survive with treatment
2. BThe most severely injured are never given comfort care
3. CCritical patients are always treated last in every situation, even outside disasters
4. DPatients are treated in the order they arrive

An older adult with chronic kidney disease takes glyburide (glibenclamide, a sulfonylurea) and has repeated low glucose readings. Why is this a concern?

1. AThe drug causes high potassium that lowers the glucose
2. BThe drug makes the glucose meter read falsely low
3. CThe drug stops working entirely when the kidneys fail
4. DThe drug and its metabolites build up and cause long lows

Hasil pasien mana yang harus dilaporkan perawat lebih dulu?

1. AHbA1c 7,4% (57 mmol/mol) pada pasien diabetes tipe 2
2. BKolesterol total sedikit di atas target
3. CGlukosa 42 mg/dL (2,3 mmol/L) pada pasien yang berkeringat dan bingung
4. DKreatinin 1,6 mg/dL (141 µmol/L) pada pasien PGK stabil yang sudah diketahui

Long-term amiodarone treatment can affect which of the following?

1. AThyroid function, the lungs and the skin's sensitivity to sunlight
2. BThe sense of smell and taste only, with no other effects
3. CBlood glucose and cholesterol only
4. DHair colour and nail growth only, with no effect on organs

A patient with suspected appendicitis says the pain suddenly eased, but an hour later has pain all over the abdomen, a rigid abdomen and a fever. What is most likely?

1. AThe patient has developed gastroenteritis
2. BThe analgesia has started working
3. CThe appendicitis has resolved without treatment
4. DThe appendix has perforated, causing peritonitis

A patient stops ramipril because of a troublesome dry cough. Which drug class is a common alternative?

1. AAn angiotensin II receptor blocker such as losartan
2. BA non-selective beta-blocker such as propranolol
3. CA nitrate such as isosorbide mononitrate
4. DA loop diuretic such as furosemide

Seorang pasien yang memulai penghambat ACE kemarin mengalami pembengkakan bibir dan lidah serta suara serak. Apa yang harus dilakukan perawat pertama kali?

1. AMengkaji jalan napas, meminta bantuan segera, dan menahan dosis berikutnya
2. BMengompres es pada bibir dan meninjau lagi besok pagi
3. CMenjelaskan bahwa ini adalah efek samping yang diharapkan dan tidak berbahaya
4. DMemberikan dosis berikutnya lebih awal, karena ini akan meredakan pembengkakan dengan cepat

A patient with Alzheimer's disease starts donepezil. Which side effects should the nurse look for?

1. ANausea, diarrhoea and a slow heart rate
2. BA persistent dry cough and a raised potassium
3. CDry mouth, constipation and a fast heart rate
4. DWeight gain, high glucose and swollen ankles

Seorang perempuan dengan epilepsi yang mengonsumsi valproat mengatakan ia merencanakan kehamilan. Respons mana yang paling tepat?

1. AMeyakinkannya bahwa valproat aman selama kehamilan
2. BMenyarankan menggandakan dosis untuk melindungi bayi dari kejang
3. CMenyarankan tidak menghentikannya mendadak dan tinjauan spesialis segera
4. DMenyuruhnya berhenti total mengonsumsi valproat mulai hari ini

Suplemen herbal mana yang umum ditanyakan sebelum operasi karena dapat meningkatkan perdarahan?

1. AGinkgo biloba
2. BMinyak peppermint
3. CChamomile
4. DCranberry

Seorang pasien dengan ileostomi tidak memiliki keluaran selama 6 jam, dengan nyeri kram, distensi, mual, dan stoma bengkak. Apa yang harus dicurigai perawat?

1. ARuam kulit ringan di sekitar stoma
2. BSumbatan stoma, sering akibat makanan, yang perlu ditinjau
3. CDehidrasi akibat keluaran ileostomi yang sangat tinggi
4. DPeriode tenang normal untuk ileostomi baru