Prioritas & Delegasi ala NCLEX: paket kilat

Lembar rumus, langkah-langkah metode utama untuk setiap topik, dan 14 soal latihan, dengan pembahasan lengkap di bagian belakang.

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1Rumus dan metode

Prioritas & delegasi

Metode

  1. Tanyakan apa yang akan paling cepat membahayakan pasien bila tidak dilakukan apa-apa.
  2. Terapkan ABC (C-A-B pada henti jantung), lalu Maslow: kebutuhan fisiologis sebelum keselamatan, keselamatan sebelum kebutuhan psikologis.
  3. Bandingkan pilihannya: akut sebelum kronis, tidak stabil sebelum stabil, tak terduga sebelum yang diharapkan, sistemik sebelum lokal, dan periksa setiap temuan terhadap kondisi dasar pasien.
  4. Lakukan pengkajian sebelum bertindak kecuali dalam keadaan darurat; lalu pilih langkah yang menjadi dasar langkah lainnya.
  5. Untuk delegasi, periksa lima benar: tugas, keadaan, orang, arahan, dan supervisi. Pengkajian, edukasi, dan evaluasi tetap pada perawat terdaftar (RN).

Pengendalian infeksi & keselamatan pasien

Metode

  1. Mulailah dengan kewaspadaan standar untuk setiap pasien: kebersihan tangan, APD sesuai pajanan yang diperkirakan, benda tajam yang aman.
  2. Tambahkan kewaspadaan menurut jalur: kontak (gaun, sarung tangan), droplet (masker bedah), udara (N95, ruang bertekanan negatif).
  3. Jaga barang steril tetap steril: bila ragu, anggap tidak steril; ganti, jangan pernah dilap.
  4. Cegah bahaya di lingkungan: tindakan pencegahan jatuh, restrain hanya sebagai pilihan terakhir, RACE dan PASS untuk kebakaran.
  5. Periksa prinsip benar dalam pemberian obat, dua identitas, dan pengaman tambahan untuk obat berisiko tinggi; laporkan kesalahan dan nyaris cedera.

Nilai laboratorium & elektrolit

Metode

  1. Bandingkan nilainya dengan rentang rujukan laboratorium itu sendiri, lalu dengan kondisi dasar dan tren pasien.
  2. Periksa sampelnya: hemolisis, keterlambatan, atau darah yang diambil dekat jalur IV dapat memberi hasil palsu.
  3. Hubungkan nilai itu dengan tanda khasnya serta obat dan kondisi yang menyebabkannya.
  4. Cari interaksi: kalium atau magnesium yang rendah meningkatkan toksisitas digoksin; dehidrasi menaikkan litium.
  5. Bertindaklah untuk pasien: lakukan pengkajian, tahan obat bila kadarnya tidak aman, bacakan kembali nilai kritis, dan beri tahu penulis resep.

Medikal-bedah: kardiovaskular & respirasi

Metode

  1. Namai masalahnya: kegagalan pompa, arteri tersumbat, irama, bekuan, penyempitan jalan napas, infeksi, atau masalah alat.
  2. Periksa tanda bahaya lebih dulu: hipoksia, hipotensi, nyeri dada, kebingungan baru, anggota gerak yang dingin tanpa denyut.
  3. Sesuaikan oksigen dengan pasien: 94–98% untuk sebagian besar, 88–92% untuk yang berisiko retensi CO₂.
  4. Hubungkan setiap obat dengan tesnya dan risikonya: warfarin dan INR, heparin dan aPTT serta trombosit, diuretik dan kalium.
  5. Pilih tindakan pertama yang aman, lalu lakukan eskalasi dan nilai ulang.

Medikal-bedah: saraf, endokrin & ginjal

Metode

  1. Periksa glukosa pada setiap pasien dengan kebingungan baru, kelemahan, atau kejang.
  2. Gunakan tingkat kesadaran sebagai peringatan paling awal gangguan otak; pupil dan trias Cushing muncul belakangan.
  3. Untuk kegawatan diabetes, bedakan KAD (keton, asidosis) dari HHS (osmolalitas sangat tinggi, dehidrasi); berikan cairan lebih dulu.
  4. Untuk natrium dan air, tentukan apakah ADH berlebih (SIADH) atau kurang (DI), dan koreksi perubahan kronis secara perlahan.
  5. Untuk masalah ginjal, golongkan penyebabnya menjadi prarenal, intrinsik, atau pascarenal, dan pantau kalium dan cairan.

Medikal-bedah: saluran cerna, perioperatif & onkologi

Metode

  1. Tanyakan apa yang mungkin tersembunyi: perdarahan dalam, infeksi tanpa demam, hipoventilasi di balik SpO₂ yang normal.
  2. Gunakan waktu setelah operasi untuk mempersempit komplikasi: perdarahan dalam hitungan jam, masalah dada dalam hitungan hari, masalah luka dan kebocoran belakangan.
  3. Untuk nyeri, kaji, tangani dengan analgesia multimodal, nilai ulang, dan pantau sedasi pada setiap opioid.
  4. Untuk pasien kanker, perlakukan setiap penyakit selama nadir sebagai sepsis neutropenik dan ketahui kegawatan onkologi.
  5. Untuk luka bakar, hitung hanya area derajat sebagian dan seluruh ketebalan kulit, mulai jam Parkland pada waktu luka bakar, dan titrasi menurut produksi urine.

2Soal latihan

1.Prioritas & delegasiSedang

An anxious patient is breathing very fast and has tingling fingers. The blood gas shows pH 7,51 and PaCO₂ 29 mmHg (3,9 kPa). What should the nurse do first?

  1. AGive IV sodium bicarbonate as soon as it can be found
  2. BEncourage the patient to breathe even faster
  3. CStay with the patient and coach slow, calm breathing
  4. DGive oxygen at the highest flow and leave the room
2.Prioritas & delegasiSulit

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

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

A patient is receiving opioids for pain. Which sign usually comes before opioid-induced respiratory depression?

  1. ADilated pupils
  2. BIncreasing sedation
  3. CRising blood pressure
  4. DDiarrhea
4.Pengendalian infeksi & keselamatan pasienSulit

A nurse often skips barcode scanning to save time, as many colleagues do. In a just culture, how is this behavior classed?

  1. ASimple human error, managed only by consoling the nurse and moving on
  2. BAcceptable behavior, because it is common on the unit
  3. CReckless behavior, managed by immediate dismissal and reporting to the licensing board
  4. DAt-risk behavior, managed by coaching and fixing the system pressures behind it
5.Nilai laboratorium & elektrolitSedang

A patient taking empagliflozin (an SGLT2 inhibitor) has glucose in the urine but a normal blood glucose. What is the best interpretation?

  1. AUncontrolled diabetes needing insulin
  2. BA sign of kidney failure
  3. CA urinary tract infection
  4. DAn expected effect of the drug
6.Nilai laboratorium & elektrolitSulit

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 insulin infusion because the glucose is near normal
  2. BGive an IV bolus of sodium bicarbonate at once
  3. CAdd dextrose to the IV fluids and continue the insulin
  4. DStop the IV fluids and start oral fluids only
7.Keperawatan klinisSedang

Why are patients encouraged to use an incentive spirometer after abdominal surgery?

  1. ATo measure their lung function so the result can go in the discharge letter
  2. BTo lower their heart rate before mobilising
  3. CTo encourage deep breaths that prevent atelectasis and chest infection
  4. DTo strengthen the abdominal muscles around the wound
8.Keperawatan klinisSulit

A patient rescued from a house fire has soot around the mouth, singed nasal hairs and a hoarse voice. What is the main concern?

  1. AAirway swelling from inhalation injury
  2. BHypothermia from the fire service water
  3. CA minor throat infection
  4. DDehydration from sweating
9.Medikal-bedah: kardiovaskular & respirasiSedang

Why is a higher level of HDL cholesterol considered protective?

  1. AHDL thins the blood in the same way as an anticoagulant
  2. BHDL carries cholesterol from the tissues back to the liver
  3. CHDL lowers the blood pressure directly
  4. DHDL is converted into vitamin D in the walls of the arteries
10.Medikal-bedah: kardiovaskular & respirasiSulit

Four hours after abdominal surgery, a patient's heart rate has risen from 84 to 122/min and they are restless and pale. BP is still 118/76 mmHg, and the surgical drain is filling with blood. What should the nurse conclude?

  1. AThe patient is stable because the blood pressure is normal
  2. BEarly haemorrhagic shock is likely, so escalate urgently
  3. CThe drain is working well, so no action is needed
  4. DThe tachycardia is from pain and needs only analgesia
11.Medikal-bedah: saraf, endokrin & ginjalSedang

What does a positive pronator drift test show?

  1. ALoss of hearing on one side
  2. BA normal response in older adults
  3. CSubtle weakness in one arm
  4. DWeakness of the eye muscles
12.Medikal-bedah: saraf, endokrin & ginjalSulit

A patient with a head injury now has a blood pressure of 190/70 mmHg, a pulse of 48/min and irregular breathing. How should the nurse interpret this?

  1. AA normal stress response to pain, anxiety and the noise of the ward
  2. BHypovolaemic shock from internal bleeding
  3. CNeurogenic shock from a spinal cord injury
  4. DCushing's triad, a late sign of raised intracranial pressure
13.Medikal-bedah: saluran cerna, perioperatif & onkologiSedang

How should pancreatic enzyme replacement capsules usually be taken?

  1. AOne hour after meals, on an empty stomach
  2. BOnce a day at bedtime
  3. COnly on days with abdominal pain
  4. DWith every meal and snack
14.Medikal-bedah: saluran cerna, perioperatif & onkologiSulit

During a nerve block, a patient reports a metallic taste and ringing in the ears, then has a seizure. Besides calling for help and supporting the airway, which specific treatment is given?

  1. AIV naloxone
  2. BIV glucose 50%
  3. CIV lipid emulsion
  4. DIV dantrolene

3Larutan

1.Prioritas & delegasi

Jawaban: C · Stay with the patient and coach slow, calm breathing

Mengapa ini jawabannya

These results show respiratory alkalosis caused by hyperventilation. Calming the patient and coaching slower breathing lets carbon dioxide return to normal; the nurse also looks for physical causes.

Jawaban

C · Stay with the patient and coach slow, calm breathing
2.Prioritas & delegasi

Jawaban: C · Pasien infeksi saluran kemih yang baru bingung, dengan frekuensi napas 26/menit dan tekanan darah sistolik 94 mmHg

Mengapa ini jawabannya

Kebingungan baru, frekuensi napas 22/menit atau lebih, dan tekanan darah sistolik 100 mmHg atau kurang (kriteria qSOFA) pada pasien dengan infeksi menunjukkan kemungkinan sepsis dengan risiko perburukan yang tinggi. Pasien memerlukan eskalasi segera, kultur, dan antibiotik dini. Skor peringatan dini seperti NEWS2 memberikan sinyal yang sama. Pasien lain stabil.

Jawaban

C · Pasien infeksi saluran kemih yang baru bingung, dengan frekuensi napas 26/menit dan tekanan darah sistolik 94 mmHg
3.Pengendalian infeksi & keselamatan pasien

Jawaban: B · Increasing sedation

Mengapa ini jawabannya

Sedation increases before respiratory depression occurs, so sedation levels are checked regularly along with breathing. A patient who is getting harder to wake needs the opioid held and the prescriber informed.

Jawaban

B · Increasing sedation
4.Pengendalian infeksi & keselamatan pasien

Jawaban: D · At-risk behavior, managed by coaching and fixing the system pressures behind it

Mengapa ini jawabannya

At-risk behavior is a choice whose risk is not recognized or is believed to be justified, often because shortcuts have become normal. It is managed by coaching and removing the pressures behind it, while reckless behavior may need disciplinary action.

Jawaban

D · At-risk behavior, managed by coaching and fixing the system pressures behind it
5.Nilai laboratorium & elektrolit

Jawaban: D · An expected effect of the drug

Mengapa ini jawabannya

SGLT2 inhibitors block glucose reabsorption in the proximal tubule, so glycosuria is expected even with normal blood glucose. Urine glucose cannot be used to monitor control in these patients. The drugs also raise the risk of genital infections and DKA.Diperiksa dengan: Ketones blood test · MedlinePlus (NIH) (2025)

Jawaban

D · An expected effect of the drug
6.Nilai laboratorium & elektrolit

Jawaban: C · Add dextrose to the IV fluids and continue the insulin

Mengapa ini jawabannya

The glucose usually falls before the ketoacidosis resolves. Dextrose is added so insulin can continue, clearing ketones without causing hypoglycemia, until the anion gap closes. Stopping insulin too early lets ketoacidosis return.

Jawaban

C · Add dextrose to the IV fluids and continue the insulin
7.Keperawatan klinis

Jawaban: C · To encourage deep breaths that prevent atelectasis and chest infection

Mengapa ini jawabannya

Shallow breathing after surgery lets alveoli collapse, causing atelectasis and pneumonia. Deep-breathing exercises with an incentive spirometer help keep the lungs expanded.

Jawaban

C · To encourage deep breaths that prevent atelectasis and chest infection
8.Keperawatan klinis

Jawaban: A · Airway swelling from inhalation injury

Mengapa ini jawabannya

These signs suggest inhalation injury, which can cause rapid airway swelling and obstruction. Early senior anaesthetic review is needed, as early intubation may be required. Carbon monoxide poisoning must also be considered.

Jawaban

A · Airway swelling from inhalation injury
9.Medikal-bedah: kardiovaskular & respirasi

Jawaban: B · HDL carries cholesterol from the tissues back to the liver

Mengapa ini jawabannya

HDL transports cholesterol from the tissues and artery walls to the liver for removal (reverse cholesterol transport), so higher levels are linked with lower cardiovascular risk. LDL carries cholesterol to tissues and drives atherosclerosis.

Jawaban

B · HDL carries cholesterol from the tissues back to the liver
10.Medikal-bedah: kardiovaskular & respirasi

Jawaban: B · Early haemorrhagic shock is likely, so escalate urgently

Mengapa ini jawabannya

Rising heart rate, restlessness, pallor and visible bleeding are signs of compensated haemorrhagic shock. Waiting for hypotension delays treatment. The nurse escalates urgently, gives oxygen, ensures IV access and anticipates bloods, fluids or blood products and surgical review.

Jawaban

B · Early haemorrhagic shock is likely, so escalate urgently
11.Medikal-bedah: saraf, endokrin & ginjal

Jawaban: C · Subtle weakness in one arm

Mengapa ini jawabannya

When a weak arm drifts down and turns palm-down (pronates), it suggests a mild upper motor neuron weakness, for example from a stroke. It can detect weakness that is not obvious on routine testing.

Jawaban

C · Subtle weakness in one arm
12.Medikal-bedah: saraf, endokrin & ginjal

Jawaban: D · Cushing's triad, a late sign of raised intracranial pressure

Mengapa ini jawabannya

Cushing's triad is hypertension with a widening pulse pressure, bradycardia and irregular respiration. It shows that the brainstem is being compressed and herniation may be imminent, so it is an emergency.

Jawaban

D · Cushing's triad, a late sign of raised intracranial pressure
13.Medikal-bedah: saluran cerna, perioperatif & onkologi

Jawaban: D · With every meal and snack

Mengapa ini jawabannya

Pancreatic enzymes digest fat, protein and carbohydrate, so they are taken with meals and snacks. The dose is adjusted to reduce steatorrhoea and support weight gain.

Jawaban

D · With every meal and snack
14.Medikal-bedah: saluran cerna, perioperatif & onkologi

Jawaban: C · IV lipid emulsion

Mengapa ini jawabannya

These are signs of local anaesthetic systemic toxicity. The injection is stopped, help is called, the airway is secured and seizures are treated. IV lipid emulsion is the specific treatment, especially if the circulation is affected.

Jawaban

C · IV lipid emulsion

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