Prioritas & Delegasi ala NCLEX: paket kilat

Pada henti jantung di bangsal, tindakan mana yang pertama setelah memastikan pasien tidak responsif dan tidak bernapas normal?

1. AMemanggil bantuan dan memulai kompresi dada
2. BMemberikan dua napas buatan, lalu memeriksa nadi selama satu menit
3. CMengukur tekanan darah
4. DMencari rekam medis pasien untuk memeriksa status resusitasi sebelum memanggil bantuan

A patient in acute mania paces constantly, has lost weight and will not sit down to eat. Which intervention is most helpful?

1. ALeave meals in the room and let the patient eat whenever and whatever they choose
2. BWait until the mania settles before worrying about nutrition
3. CInsist that the patient sits at the table until the meal is finished
4. DOffer high-calorie finger foods and drinks the patient can take while moving

A nurse who never had BCG vaccine has a positive tuberculin skin test for the first time. The chest x-ray is clear and there are no symptoms. What does this most likely mean?

1. AA failed test that must be repeated next year
2. BLatent TB infection, which is not contagious
3. CActive TB, which needs airborne isolation
4. DImmunity to TB from a past exposure

A patient in a vest restraint has slid down in bed, and the vest is pressing against the neck. What should the nurse do first?

1. ACall the provider to ask about a different restraint
2. BWrite a note about the event in the chart
3. CTighten the vest so the patient cannot slide down again
4. DRelease the restraint at once and reposition the patient

Hemoglobin seorang pasien adalah 7,8 g/dL (78 g/L). Temuan mana yang diharapkan perawat?

1. ASakit kepala, mimisan, dan wajah merah
2. BDenyut jantung lambat, kulit memerah, dan tekanan darah tinggi
3. CKelelahan, pucat, denyut jantung cepat, dan sesak napas saat beraktivitas
4. DGatal, kulit kuning, dan urine gelap

A child with sickle cell disease and a recent viral illness is pale and tired. The hemoglobin has fallen sharply, and the reticulocyte count is very low. What is the most likely problem?

1. AAn aplastic crisis, often caused by parvovirus B19
2. BIron deficiency from a poor diet over months
3. CA vaso-occlusive pain crisis in the bones
4. DA normal finding in sickle cell disease

When a patient returns to the ward from theatre, what should the nurse assess first?

1. AWhether visitors are waiting to see the patient
2. BAirway, breathing, circulation and level of consciousness
3. CThe patient's dietary preferences for the next meal
4. DThe discharge date

Which route and site are recommended for the first dose of adrenaline (epinephrine) in anaphylaxis on a ward?

1. AIntravenous bolus given by the nurse without monitoring
2. BOral tablet dissolved under the tongue
3. CIntramuscular injection into the anterolateral thigh
4. DSubcutaneous injection into the upper arm

A patient with a mechanical heart valve asks to switch from warfarin to apixaban. What is the correct response?

1. ADirect oral anticoagulants are not used for mechanical valves
2. BAspirin alone can replace warfarin once the valve has healed
3. CAny anticoagulant works equally well once the valve is in place
4. DMechanical valves do not need anticoagulation after the first month

Setelah operasi pinggul, seorang pasien tiba-tiba sesak napas dan cemas dengan denyut jantung 124/menit, SpO₂ 86% pada udara ruangan, dan nyeri tajam saat bernapas. Dada terdengar bersih. Apa yang harus dilakukan perawat pertama kali?

1. AMembaringkan pasien datar dan mengangkat kedua tungkai di atas bantal
2. BMengajak pasien berjalan keliling bangsal untuk memperbaiki pernapasan
3. CMemberikan sedatif untuk kecemasan dan memeriksa ulang dalam satu jam
4. DMemberikan oksigen, mendudukkan pasien, meminta tinjauan segera, dan tetap mendampingi

A bladder scan straight after voiding shows 450 mL of urine still in the bladder. What does this show?

1. AThe patient is passing urine normally
2. BThe patient has drunk too little fluid
3. CThe kidneys are making too little urine
4. DThe bladder is not emptying properly

The nurse has four endocrine patients. Which one needs to be seen first?

1. AA patient after thyroidectomy with mild pain on swallowing
2. BA patient with hypothyroidism who has been constipated for three days
3. CA patient with hyperthyroidism who is confused, with a temperature of 39,5 °C (103,1 °F)
4. DA patient with Graves' disease asking about radioactive iodine

Which group of findings suggests obstruction of the bile duct?

1. AJaundice, dark urine, pale stools and itching
2. BNormal skin colour with diarrhoea and fever
3. CPale urine, dark stools and a flapping tremor
4. DRed urine, black stools and a high blood glucose

An incontinent patient has diffuse, shiny, red and broken skin in the natal cleft and buttocks with irregular edges, not over a bony prominence. What is most likely?

1. AA category 4 pressure ulcer over the sacrum
2. BAn arterial ulcer caused by poor circulation
3. CIncontinence-associated dermatitis
4. DA full-thickness burn